A cost comparison study to review community versus acute hospital models of nursing care delivered to oncology patients.

PURPOSE: Ireland's Sláintecare health plan is placing an increased focus on primary care. A community oncology nursing programme was developed to train community nurses to deliver care in the community. While the initial pilot was proven to be clinically safe, no cost evaluation was carried out. This study aims to compare the costs of providing cancer support services in a day-ward versus in the community. METHODS: 183 interventions (40 in day-ward and 143 in community) were timed and costed using healthcare professional salaries and the Human Capital method. RESULTS: From the healthcare provider perspective, the day-ward was a significantly cheaper option by an average of €17.13 (95% CI €13.72 - €20.54, p < 0.001). From the societal perspective, the community option was cheaper by an average of €2.77 (95% CI -€3.02 - €8.55), although this was a non-significant finding. Sensitivity analyses indicate that the community service may be significantly cheaper from the societal perspective. CONCLUSIONS: Given the demand for cost-viable options for primary care services, this programme may represent a national option for cancer care in Ireland when viewed from the societal perspective.

Surgical, Economic, and Psychological Impacts of SARS-COV-2 on a Kansas Community Hospital System.

The chief of surgery of a 264-bed acute care facility and clinic system in Topeka, KS, USA, gives a chronology that illustrates the rapid and profound clinical, economic, and emotional impact of the SARS-CoV-2 outbreak on his hospital and community. In his view, the pandemic has laid bare the weaknesses of several factors basic to the modern US health care system and the resulting economic crisis: just-in-time supply chain technology; foreign sourcing of masks, gowns, and critical equipment, all at critical shortages during the crisis; rural hospital closings; lack of excess capacity through maximization of utilization for efficiency; and an overreliance on high revenue elective procedures and tests. His team was tested by an emergency operation for bowel obstruction that put all the isolation protocols into action. Despite their readiness and the success of the operation and the potential for telemedicine as an alternative to in-person evaluations and outpatient visits, the forced cancellation of all elective operations have led to the loss of revenue for both hospital system and providers, furlough and termination of workers, and financial hardship and uncertainty.

Communities as 'renewable energy' for healthcare services? a multimethods study into the form, scale and role of voluntary support for community hospitals in England.

OBJECTIVE: To examine the forms, scale and role of community and voluntary support for community hospitals in England. DESIGN: A multimethods study. Quantitative analysis of Charity Commission data on levels of volunteering and voluntary income for charities supporting community hospitals. Nine qualitative case studies of community hospitals and their surrounding communities, including interviews and focus groups. SETTING: Community hospitals in England and their surrounding communities. PARTICIPANTS: Charity Commission data for 245 community hospital Leagues of Friends. Interviews with staff (89), patients (60), carers (28), volunteers (35), community representatives (20), managers and commissioners (9). Focus groups with multidisciplinary teams (8 groups across nine sites, involving 43 respondents), volunteers (6 groups, 33 respondents) and community stakeholders (8 groups, 54 respondents). RESULTS: Communities support community hospitals through: human resources (average=24 volunteers a year per hospital); financial resources (median voluntary income = £15 632); practical resources through services and activities provided by voluntary and community groups; and intellectual resources (eg, consultation and coproduction). Communities provide valuable supplementary resources to the National Health Service, enhancing community hospital services, patient experience, staff morale and volunteer well-being. Such resources, however, vary in level and form from hospital to hospital and over time: voluntary income is on the decline, as is membership of League of Friends, and it can be hard to recruit regular, active volunteers. CONCLUSIONS: Communities can be a significant resource for healthcare services, in ways which can enhance patient experience and service quality. Harnessing that resource, however, is not straight forward and there is a perception that it might be becoming more difficult questioning the extent to which it can be considered sustainable or 'renewable'.

The Use of Procalcitonin as a Sepsis Marker in a Community Hospital.

BACKGROUND: Procalcitonin (PCT) is a biomarker that shows good sensitivity and specificity in identifying septic patients. METHODS: This study investigated the diagnostic accuracy of PCT in a community hospital setting and how it compared to that of lactic acid. It explored the impact on patient care before and after PCT implementation regarding costs and length of stay. Two comparative groups were analyzed using an exploratory descriptive case-control study with data from a 19-month period after PCT implementation and a retrospective quasi-experimental study using a control group of emergency department patients diagnosed with sepsis using data before PCT implementation. RESULTS: Post-procalcitonin implementation samples included 165 cases and pre-procalcitonin implementation sample included 69 cases. From the 165 sepsis cases who had positive blood cultures, PCT had a sensitivity of 89.7%. In comparison, lactic acid's sensitivity at the current cutoff of 18.02 mg/dL (2.0 mmol/L) was 64.9%. There was a 32% decrease in median cost before and after PCT implementation, even with the length of stay remaining at 5 days in both time periods. CONCLUSIONS: There was a significant decrease after the implementation of PCT in cost of hospitalization compared to costs before implementation. This cost is highly correlated with length of stay; neither the hospital nor the intensive care unit length of stay showed a difference with before and after implementation. There was a positive correlation between lactic acid and PCT values. PCT values had a higher predictive usefulness than the lactic acid values.

Effect of Standardized Infliximab Dose Rounding on an Outpatient Infusion Center.

BACKGROUND: Infliximab dose rounding is a commonly accepted practice at many institutions to contain costs. Currently, there is limited data on the clinical and financial implications of infliximab dose rounding standardization. OBJECTIVE: To determine whether standardized infliximab dose rounding is comparable with nonstandardized dosing in patients with Crohn's disease or ulcerative colitis in terms of cost and efficiency, using a cost comparison between the 2 dosing methods at an outpatient infusion center attached to a community teaching hospital. METHODS: A retrospective electronic chart review was conducted to identify patients who received infliximab for ulcerative colitis or Crohn's disease over a 6-month period. The primary endpoint was cost comparison between the 2 dosing methods. The secondary outcomes were estimated time taken for order verification, number of order clarifications, increase in dose or frequency of infliximab, number of patients who switched to alternative therapy, and use of medications for adverse drug effects. Descriptive statistics and Fisher's exact test were used for data analysis. RESULTS: 72 patients met the inclusion criteria. Because of patient overlap during the study period, 45 patients (62.5%) were in the standardized rounding arm, and 69 patients (95.8%) were in the nonstandardized rounding arm. One patient in each arm required an increased dose or frequency of infusion (2.2% vs. 1.5%, P = 1.000). Standardized infliximab dose rounding had a theoretical cost savings of at least $104,640 per year (based on our rough annual census of 480 patients) compared with the nonstandardized method that had been used previously. The cost savings can also be translated as $218 per patient per month on average. The mean times to order verification were 10 vs. 12 minutes in the nonstandardized and standardized groups, respectively. Two patients in the nonstandardized group switched to alternative therapy. There was no difference in usage of rescue medications for adverse drug effects. CONCLUSIONS: Standardization of infliximab dose rounding resulted in increased efficiency in the pharmacy workflow by reducing time for order verification. Furthermore, standardized dose rounding resulted in a significant reduction in expenditure for infliximab for the institution. DISCLOSURES: No outside funding supported this research. The authors have nothing to disclose. This research was presented as a poster at the ASHP Midyear Clinical Meeting & Exhibition 2017; December 3-7, 2017; Orlando, FL.

Clinical, operational, and financial impact of an ultraviolet-C terminal disinfection intervention at a community hospital.

BACKGROUND: Hospital-acquired infections (HAIs) are a significant contributor to adverse patient outcomes and excess cost of inpatient care. Adjunct ultraviolet-C (UV-C) disinfection may be a viable strategy for reducing HAIs. This study aimed to measure the clinical, operational, and financial impact of a UV-C terminal disinfection intervention in a community hospital setting. METHODS: Using a pre-post study design, we compared the HAI rates of 5 multidrug-resistant bacteria (Acinetobacter baumannii, Klebsiella pneumoniae, methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus, and Pseudomonas aeruginosa) from 6 culture sites before and after a 12-month facility-wide UV-C intervention. To measure impact of UV-C disinfection on hospital operations, mean inpatient emergency room wait time was calculated. Finally, we conducted a cost saving analysis to evaluate the financial benefits of the intervention. RESULTS: Overall, 245 HAIs among 13,177 inpatients were observed during a 12-month intervention period, with an incidence rate of 3.94 per 1,000 patient days. This observed HAIs incidence was 19.2% lower than the preintervention period (4.87 vs 3.94 per 1,000 patient days; P = .006). The intervention did not adversely impact emergency department admissions (297.9 vs 296.2 minutes; P = .18) and generated a direct cost savings of $1,219,878 over a 12-month period. CONCLUSIONS: The UV-C disinfection intervention was associated with a statistically significant facility-wide reduction of multidrug-resistant HAIs and generated substantial direct cost savings without adversely impacting hospital operations.

Economic Impact of Early Inpatient Palliative Care Intervention in a Community Hospital Setting.

BACKGROUND: Inpatient palliative care programs have demonstrated financial benefit for the hospital and improved quality of care for patients with advanced disease. Previous studies on this subject have focused on comparisons between palliative and traditional care. The financial and clinical effects of early versus late palliative care intervention are less well documented. OBJECTIVE: The aims of this study are to review the financial and quality outcomes that early palliative care intervention has on appropriate inpatients in the community hospital setting. MATERIALS AND METHODS: This retrospective study analyzed 449 palliative care patients. The independent variable was days to palliative care consultation, characterized as early palliative care (≤3 days) and late palliative care (>3 days). Dependent variables included length of stay (LOS) and financial considerations. The two groups were further stratified according to case mix index, medical versus surgical, as well as certain disease groups, such as sepsis, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD) exacerbation. The patient's functional status, measured by the Victoria Palliative Performance Scale (PPSv2) was calculated to determine if this variable independently influenced the timing of consultation. RESULTS: Patients in the early intervention group realized a reduction in LOS and a significant cost reduction. In the analysis of the entire group, the average LOS with early intervention was 6.09 days versus 16.5 days with late intervention (p < 0.001). The early intervention group demonstrated an earlier transition to comfort care, earlier referral to outpatient hospice, and did not have a negative effect on mortality. The patient's PPSv2 score did not influence the timing of intervention (p 0.25). CONCLUSION: Early intervention with inpatient palliative care consultation correlated with financial benefit as well as earlier referral to more appropriate levels of care. These effects were achieved with minimal expense in a medium-sized community hospital.

Workforce Issues in Pediatric Surgery.

High salaries indicate a demand for pediatric surgeons in excess of the supply, despite only a slight growth in the pediatric-age population and a sharp increase in numbers of trainees. Top-level neonatal intensive care units require 24-hour-7-day pediatric surgical availability, so hospitals are willing to pay surgeons a premium and engage high-priced locum tenens surgeons to fill vacancies in coverage. With increased supply comes an erosion of the numbers of cases performed by trainees and surgeons in practice. Caseloads may be inadequate to gain expertise and maintain skills. A quality initiative sponsored by the American College of Surgeons and the American Pediatric Surgical Association will discourage underresourced community facilities and surgeons without specialty training from performing operations on children, mostly common conditions such as appendicitis. This will further increase demand for specialty-trained practitioners. Receiving less attention are considerations of value, the ratio of quality per dollar cost. Cost concerns, paramount among buyers of health care (businesses, insurance companies, and governmental health agencies), will prefer community hospitals that have lower cost structures than specialty children's facilities. Less recognized are the costs to families, who for a myriad of reasons would prefer closer alternatives. Cost considerations support providing pediatric surgical services in local facilities. Quality considerations may be addressed by a tiered system where top centers would care for conditions that require technical expertise and advanced modalities. Evidence indicates that pediatric surgeons already direct such cases to more specialized centers.

Cost-Effectiveness Analysis of Initial Treatment Strategies for Nonembolic Acute Limb Ischemia Using Real-Word Data.

BACKGROUND: Nonembolic acute limb ischemia (ALI) is a condition characterized by a sudden decrease in limb perfusion and requires immediate interventions. There are multiple treatment options available including surgery, catheter-directed thrombolysis (CDT), endovascular procedures, and hybrid treatment (a combination of open and endovascular techniques). Randomized trials provide information only on clinical efficacy, but not on economic outcomes. The objective of the study was to perform the cost-effective analysis comparing different treatment alternatives of ALI. METHODS: The data were collected from 4r ProMedica community hospitals in the Northwest Ohio from January 2009 to December 2012. Patients were included if they were treated within 14 days of onset of symptoms for nonembolic ALI and were divided into groups of receiving CDT, surgery, endovascular, or hybrid treatments. Demographics, comorbidities, medications taken before admission, and smoking status were collected at baseline for all patients and were compared among the treatment groups. A cost-effectiveness decision tree was developed to calculate expected costs and life years gained associated with available treatment options. A probabilistic sensitivity analysis was also performed to check the robustness of the model. RESULTS: A population of 205 patients with the diagnosis of ALI was included and divided into different treatment groups. There was no major significant difference in baseline characteristics among the studied groups (P > 0.05). The total costs were $17,163.47 for surgery, $20,620.39 for endovascular, $21,277.61 for hybrid, and $30,675.42 for CDT. The life years gained were 17.25 for surgery, 18 for endovascular, 18 for hybrid, and 17 for CDT. CDT was dominated because of the high cost and the low effectiveness, while hybrid treatment was dominated when compared with endovascular treatment because these 2 treatments have similar outcomes. The incremental cost-effectiveness ratio of the endovascular group over the surgery group was found to be $4,609.23 per life year gained. The sensitivity analysis showed that the endovascular treatment was found to be cost-effective under willingness to pay $50,000. CONCLUSIONS: This study provides economic evaluation of ALI treatments for a defined clinical population in the real-world setting. Compared with other available alternatives, the endovascular treatment showed to be a cost-effective use of healthcare resources.

Impact of Hospital-Employed Physician Assistants on a Level II Community-Based Orthopaedic Trauma System.

OBJECTIVES: The American Academy of Orthopedic Surgeons and the Orthopedic Trauma Association have released guidelines for the provision of orthopedic trauma services such as adequate stipends, designated operating rooms, ancillary staff, and guaranteed reimbursement for indigent care. One recommendation included a provision for hospital-based physician assistants (PAs). Given current reimbursement arrangements, PA collections for billable services may not meet their salary and benefit expenses. However, their actions may indirectly affect emergency room, operating room, and hospital reimbursement and patient care itself. The purpose of our study is to define the true impact of hospitalbased PAs on orthopaedic trauma care at a level II community hospital. DESIGN: Retrospective case series. SETTING: Level II trauma center. PATIENTS/PARTICIPANTS: One thousand one hundred four trauma patients with orthopaedic injuries. INTERVENTION: PA involvement. MAIN OUTCOME MEASUREMENTS: Emergency room data such as triage time, time until seen by the orthopedic service, and total emergency room time was recorded. Operating room data such as time to surgery, set-up time, total operating time, and out of room time was entered as well. Charts were reviewed to determine if patients were given postoperative antibiotics and Deep Venous Thrombosis (DVT) prophylaxis. Intraoperative and postoperative complications were noted, and lengths of stay were calculated for all patients. RESULTS: At our institution, PA collections from patient care cover only 50% of their costs for salary and benefits. However, with PA involvement, trauma patients with orthopedic injuries were seen 205 minutes faster (P = 0.006), total Emergency Room (ER) time decreased 175 minutes (P = 0.0001), and time to surgery improved 360 minutes (P . 0.03). Operating room parameters were minimally improved, but postoperative DVT prophylaxis increased by a mean of 6.73% (P = 0.0084), postoperative antibiotic administration increased by 2.88% (P = 0.0302), and there was a 4.67% decrease in postoperative complications (P = 0.0034). Average length of stay decreased by 0.61 days (P = 0.27). CONCLUSIONS: Although the PA's collections do not cover their costs, the indirect economic and patient care impacts are clear. By increasing emergency room pull through and decreasing times to Operating Room (OR), operative times, lengths of stay, and complications, their existence is clearly beneficial to hospitals, physicians, and patients as well. LEVEL OF EVIDENCE: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Evaluation of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in a community setting: A cost-utility analysis of a hospital's initial experience and reflections on the health care system.

BACKGROUND: The combination of Cytoreductive Surgery (CRS) plus Hyperthermic Intraperitoneal Chemotherapy (HIPEC) has been gaining a considerable interest by surgeons throughout the United States due to the significant survival improvement it provides for peritoneal surface malignancies and the ability to reproduce comparable clinical results in numerous health care centers. However, CRS plus HIPEC has not been sufficiently investigated from the economic standpoint in the United States where a wide variety of health care insurers exists. This study was conducted to analyze hospital/surgeon cost and reimbursement data at a community hospital offering a new peritoneal surface malignancy program, and expand the discussion to analyze future healthcare implementation on this procedure in the United States. METHODS: This is a retrospective economic analysis of an initial CRS plus HIPEC experience at a community non-teaching medical center. This study was conducted using hospital/surgeon cost and reimbursement based on the Office of Finance data at Edward Hospital Cancer Center (Naperville, IL). All patients who underwent CRS and HIPEC between June 2013 and August 2014 were included in this analysis. We aimed to assess CRS plus HIPEC purely from the financial perspective on the initial admission regardless of the patients' advancement of the disease or postoperative adverse events. RESULTS: Twenty-five patients underwent 26 CRS plus HIPEC procedures. Twelve patients had private insurance plans (PRV) whereas 13 were covered by public insurers (PUB). Median overall length of stay (LOS) was 10 days (PRV 10 days vs. PUB 11 days; P = 0.76.) Average hospital cost was $38,369 (PRV $37,093 vs. PUB $39,463; P = 0.67), and average reimbursement for our patient population was $45,243 (PRV $48,954 vs. PUB $42,062; P = 0.53). It was noted that CRS plus HIPEC generated more net profit in patients with private insurance than in those with public plans, however, not statistically significant ($11,861 vs. $2,599 per patient, respectively; P = 0.38). Evaluating surgeon's data, average surgeon's charge was $29,139 (PRV $28,440 vs. PUB $29,737; P = 0.80), and average patients' payment was $8,126 (PRV 9,234 vs. PUB 7,176; P = 0.47). CONCLUSION: CRS plus HIPEC is profitable in the community setting for both the hospital and surgeon. Both private and public insurers reimbursed profitably, though with a greater profit margin from private insurers. As CRS plus HIPEC is becoming more widely recognized as a standard of care for patients with peritoneal surface malignancy, it is increasingly important to understand and report its associated costs and variability in insurance coverage, especially in light of the current healthcare structure changes in the United States. It is strongly encouraged to report and present a wider scope of CRS plus HIPEC economic experiences in a variety of hospital settings to provide further evidence for future healthcare implementations in the United States. J. Surg. Oncol. 2016;113:544-547. © 2016 Wiley Periodicals, Inc.

Disparities in Colorectal Cancer Treatment Delay Within Appalachia--The Role of For-Profit Hospitals.

BACKGROUND: Appalachian residents have a higher overall cancer burden than the rest of the United States because of the unique features of the region. Treatment delays vary widely within Appalachia, with colorectal cancer patients undergoing median treatment delays of 5 days in Kentucky compared to 9 days for patients in Pennsylvania, Ohio, and North Carolina combined. OBJECTIVE: This study identified the source of this disparity in treatment delay using statistical decomposition techniques. METHODOLOGY: This study used linked 2006 to 2008 cancer registry and Medicare claims data for the Appalachian counties of Kentucky, Pennsylvania, Ohio, and North Carolina to estimate a 2-part model of treatment delay. An Oaxaca Decomposition of the 2-part model revealed the contribution of the individual determinants to the disparity in delay between Kentucky counties and the remaining 3 states. RESULTS: The Oaxaca Decomposition revealed that the higher percentage of patients treated at for-profit facilities in Kentucky proved the key contributor to the observed disparity. In Kentucky, 22.3% patients began their treatment at a for-profit facility compared to 1.4% in the remaining states. Patients initiating treatment at for-profit facilities explained 79% of the observed difference in immediate treatment (<2 days after diagnosis) and 72% of Kentucky's advantage in log days to treatment. CONCLUSIONS: The unique role of for-profit facilities led to reduced treatment delay for colorectal cancer patients in Kentucky. However, it remains unknown whether for-profit hospitals' more rapid treatment converts to better health outcomes for colorectal cancer patients.

Reasons for 30-day postoperative readmissions for Medicare patients at a community-based teaching hospital.

Healthcare reform initiatives have proposed reducing reimbursement for certain 30-day readmissions among Medicare patients. Our objective was to evaluate the incidence and reasons for 30-day postoperative readmissions at our institution. The medical records of Medicare patients who underwent surgery from January 1, 2010, through May 16, 2011, were reviewed. Statistical analysis included χ(2), Wilcoxon rank sum, and t tests. Two thousand eight hundred sixty-five patients were included; 199 (7%) had a 30-day readmission. The readmission group included a higher proportion of men (53.8 vs 43.6%, P = 0.005), and patients with an American Society of Anesthesiologists (ASA) Class 3 or greater (84 vs 66%, P < 0.001) versus the nonreadmission group. Mean index length of stay and operative time were longer in the readmitted versus nonreadmitted group (4.8 vs 2.8 days, P < 0.001; 122.8 vs 98.2 minutes, P < 0.001). Readmission reasons were surgically related (53%), surgically unrelated (35%), planned (7%), and patient-related (5%). Higher 30-day postoperative readmission rates were associated with male sex, higher ASA class, and longer index length of stay and operative time. Reasons for readmission included surgical- and patient-related factors. Decreased reimbursement should be discouraged for readmissions directly related to patient noncompliance.

Retrospective analysis of community hospital red blood cell recovery procedures: improved utilization needed for effectiveness.

BACKGROUND: Perioperative blood recovery (PBR) is an important component of patient blood management. We analyzed our experience providing PBR for community hospitals to determine procedure types and clinical variables associated with efficacy and cost-effectiveness. STUDY DESIGN AND METHODS: PBR cases (>25,000) from January 2008 through December 2012 were analyzed. For each procedure type, the median number of returned red blood cell units (rRBCs) and ratio of cases with at least 1 to less than 1 rRBC unit were calculated. Clinical predictors of rRBC were identified by linear and logistic regression. RESULTS: The overall median rRBC was 0.29 units despite median estimated blood loss (EBL) of 350 mL. Only three of 31 common procedure types had ≥1:<1 rRBC ratios near to or higher than 1. In nine of 31 common procedure types, at least 50% of cases had no rRBC return. Linear regression demonstrated significant association of rRBCs with increased EBL, longer operative duration, surgeon, PBR device type (autoLog vs. CS5), and decreasing age. EBL, autoLog use, high surgeon case volume, vascular procedures, and emergent versus elective procedures associated with higher odds of at least 1 rRBC. CONCLUSION: Discrepancy between rRBC and EBL and high percentages of cases with no rRBC suggests that PBR technique and case selection need optimization. Identification of procedure types and variables associated with PBR efficacy (≥1 rRBC) should improve utilization of PBR. Association of autoLog use with higher rRBC warrants further investigation.

Yield of diagnostic tests and its impact on cost in adult patients with syncope presenting to a community hospital.

OBJECTIVES: Total annual costs for syncope-related hospitalizations were $2.4 billion in 2000. The aim of this study was to examine the type and number of tests ordered for patients admitted with syncope and whether these tests helped establish the cause. METHODS: We studied the records of 1038 patients coded as "syncope" in billing records, and 167 fulfilled the eligibility criteria. The main outcome measures were the diagnostic yield of the ordered tests, the incremental cost/incremental benefit, and the number of admissions that can be averted if risk stratification were used in the evaluation. RESULTS: The etiology of the syncope was identified in 48.3% of the patients. Postural blood pressure measurement has the highest diagnostic yield at 58.7%, whereas history taking diagnosed 19.7% of cases. The diagnostic yields of telemetry, electrocardiogram, radionuclide stress test, echocardiography, and troponin measurement were 4.76%, 4.24%, 3.44%, 0.94%, and 0.62%, respectively. Chest x-ray, carotid ultrasonography, 24-hour Holter monitoring, brain computed tomography, and brain magnetic resonance imaging did not yield the diagnosis in any of the patients. Only 1.9% of the money spent in the evaluation of syncope was effective in leading to a definitive diagnosis. The orthostatic blood pressure measurement was ranked first in the incremental cost/incremental benefit ratio and the radionuclide stress test was ranked last (17.03 vs 42,369.0, respectively). Approximately 6% of the patients did not meet the admission criteria. CONCLUSIONS: Physicians ordered unnecessary tests that have a low yield and are not cost-effective. A standardized algorithmic approach should be the cornerstone in the evaluation of syncope.

Hospital diversification strategy.

To determine the impact of health system restructuring on the levels of hospital diversification and operating ratio this article analyzed 94 teaching hospitals and 94 community hospitals during the period 2008-2013. The 47 teaching hospitals are matched with 47 other teaching hospitals experiencing the same financial market position in 2008, but with different levels of preference for risk and diversification in their strategic plan. Covariates in the analysis included levels of hospital competition and the degree of local government planning (for example, highly regulated in New York, in contrast to Texas). Moreover, 47 nonteaching community hospitals are matched with 47 other community hospitals in 2008, having varying manager preferences for service-line diversification and risk. Diversification and operating ratio are modeled in a two-stage least squares (TSLS) framework as jointly dependent. Institutional diversification is found to yield better financial position, and the better operating profits provide the firm the wherewithal to diversify. Some services are in a growth phase, like bariatric weight-loss surgery and sleep disorder clinics. Hospital managers' preferences for risk/return potential were considered. An institution life cycle hypothesis is advanced to explain hospital behavior: boom and bust, diversification, and divestiture, occasionally leading to closure or merger.

Unnecessary head computed tomography scans: a level 1 trauma teaching experience.

The Canadian CT Head Rule attempts to standardize the practice of obtaining head computed tomography (CT) scans in patients with minor head injury. Previous research indicates 10 to 35 per cent of CT scans performed do not meet these guidelines. The purpose of this study was to review our use of CT scans in the evaluation of mild traumatic brain injury and to identify 1) unnecessary head CT scans (UHCT); 2) variables associated with UHCT; and 3) associated costs. Using a trauma registry, inclusion criteria were age older than 18 years, Glasgow Coma Scale of 15, and at least one head CT scan. UHCTs were those without head injury, loss of consciousness, amnesia, or neurologic complaint. The proportion of patients meeting the criteria for UHCT was 24.2 per cent. Univariate analyses revealed ages 41 to 64 years, drug use, vehicular injury, and surgery within 24 hours were associated with UHCT (all P < 0.05). UHCTs were associated with higher Injury Severity Scores (P = 0.008), ventilator days, and length of stay (all P < 0.05). An average cost of $1,413 per CT equals $149,778 in extra costs. This study suggests that current practices at our Level I trauma center result in UHCT. Further investigation into best practices would benefit our center by reducing costs and providing quality patient care.

The return on investment of implementing a continuous monitoring system in general medical-surgical units.

OBJECTIVES: To evaluate the cost savings attributable to the implementation of a continuous monitoring system in a medical-surgical unit and to determine the return on investment associated with its implementation. DESIGN: Return on investment analysis. SETTING: A 316-bed community hospital. PATIENTS: Medicine, surgery, or trauma patients admitted or transferred to a 33-bed medical-surgical unit. INTERVENTIONS: Each bed was equipped with a monitoring unit, with data collected and compared in a 9-month preimplementation period to a 9-month postimplementation period. MEASUREMENTS AND MAIN RESULTS: Two models were constructed: a base case model (A) in which we estimated the total cost savings of intervention effects and a conservative model (B) in which we only included the direct variable cost component for the final day of length of stay and treatment of pressure ulcers. In the 5-year return on investment model, the monitoring system saved between $3,268,000 (conservative model B) and $9,089,000 (base model A), given an 80% prospective reimbursement rate. A net benefit of between $2,687,000 ($658,000 annualized) and $8,508,000 ($2,085,000 annualized) was reported, with the hospital breaking even on the investment after 0.5 and 0.75 of a year, respectively. The average net benefit of implementing the system ranged from $224 per patient (model B) to $710 per patient (model A) per year. A multiway sensitivity analyses was performed using the most and least favorable conditions for all variables. In the case of the most favorable conditions, the analysis yielded a net benefit of $3,823,000 (model B) and $10,599,000 (model A), and for the least favorable conditions, a net benefit of $715,000 (model B) and $3,386,000 (model A). The return on investment for the sensitivity analysis ranged from 127.1% (25.4% annualized) (model B) to 601.7% (120.3% annualized) (model A) for the least favorable conditions and from 627.5% (125.5% annualized) (model B) to 1739.7% (347.9% annualized) (model A) for the most favorable conditions. CONCLUSIONS: Implementation of this monitoring system was associated with a highly positive return on investment. The magnitude and timing of these expected gains to the investment costs may justify the accelerated adoption of this system across remaining inpatient non-ICU wards of the community hospital.