National analysis of in-hospital resource utilization in choledocholithiasis management using propensity scores.

BACKGROUND: Two treatment options exist for choledocholithiasis (CDL): endoscopic retrograde cholangiopancreatography (ERCP) and common bile duct exploration (CBDE). Resource utilization measured by total in-hospital charges (THC) and length of stay (LOS) was compared using the propensity score (PS). In this study, PS was the probability that a patient received CBDE based on comorbidities and demographics. The power of this method lies in balancing groups on variables by PS, resulting in 90% bias reduction and improved inferential validity compared to traditional analytic techniques. METHODS: Laparoscopic cholecystectomy (LC) patients with CDL who had ERCP or CBDE were identified in the 2002 U.S. Nationwide Inpatient Sample. Patients were ordered into five PS balanced strata. Mean THC, LOS, and estimated costs were compared. A linear regression model was used to estimate the contribution that LOS had on estimated costs. Monetary values were adjusted to 2004 dollars. RESULTS: A total of 40,982 patients underwent LC with CDL in 2002; 27,739 had either ERCP (93%) or CBDE (7%). Mean age was 52.7 +/- 0.4 years, with 74% women. Mean THC were less for CBDE (25,200 dollars +/- 1,800 dollars) than for ERCP (29,900 dollars +/- 800 dollars, p < 0.05). Mean LOS was less for CBDE (4.9 +/- 0.2 days) than for ERCP (5.6 +/- 0.1 days, p < 0.05). PS adjusted analysis revealed an estimated overall cost savings of 4,500 dollars +/- 1,600 dollars and reduced LOS (0.6 +/- 0.2 days) per hospitalization for CBDE. Mean THC, LOS, and estimated costs across PS score balanced strata were generally higher in the ERCP group compared to the CBDE group. LOS contributed 53% to increased THC and 62% of estimated costs. A higher cumulative incidence of complications was evident with CBDE (0.5-4.6%) compared to ERCP (0.3-3.6%). CONCLUSIONS: Based on this PS analysis, CBDE incurs less THC, reduces LOS, and has less estimated costs for CDL compared to ERCP. Furthermore, CBDE appears to be dramatically underutilized.

Oral quinolones in hospitalized patients: an evaluation of a computerized decision support intervention.

OBJECTIVE: To determine whether a computerized decision support system could increase the proportion of oral quinolone antibiotic orders placed for hospitalized patients. DESIGN: Prospective, interrupted time-series analysis. SETTING: University hospital in the south-eastern United States. SUBJECTS: Inpatient quinolone orders placed from 1 February 2001 to 31 January 2003. INTERVENTION: A web-based intervention was deployed as part of an existing order entry system at a university hospital on 5 February 2002. Based on an automated query of active medication and diet orders, some users ordering intravenous quinolones were presented with a suggestion to consider choosing an oral formulation. MAIN OUTCOME MEASURE: The proportion of inpatient quinolone orders placed for oral formulations before and after deployment of the intervention. RESULTS: There were a total of 15 194 quinolone orders during the study period, of which 8962 (59%) were for oral forms. Orders for oral quinolones increased from 4202 (56%) before the intervention to 4760 (62%) after, without a change in total orders. In the time-series analysis, there was an overall 5.6% increase (95% CI 2.8-8.4%; P < 0.001) in weekly oral quinolone orders due to the intervention, with the greatest effect on nonintensive care medical units. CONCLUSIONS: A web-based intervention was able to increase oral quinolone orders in hospitalized patients. This is one of the first studies to demonstrate a significant effect of a computerized intervention on dosing route within an antibiotic class. This model could be applied to other antibiotics or other drug classes with good oral bioavailability.