CRRT in the area of cost containment: is it justified?

Intensive care accounts for at least 25% of health care costs. One third of this goes to 10% of patients who, in general, have combined respiratory and renal failure. The cost of renal replacement therapy is, therefore, of major importance. Continuous renal replacement therapy (CRRT) has many potential advantages over intermittent hemodialysis (IHD). These include better nutritional support, better volume maintenance, reduction of extravascular lung water, and potential clearance of inflammatory mediators. To date, noncomparative trials have suggested a trend toward decreased mortality. Randomized trials have suggested a CRRT mortality and morbidity benefit, but only when comparing long-term renal recovery. Acute mortality benefit has not been clearly established and, as such, cost comparison is of increased interest. Cost comparison trials are complicated, but some recent studies have led to the conclusion that costs are comparable. Others have concluded that CRRT is slightly more expensive. When comparing randomized patients in a recent prospective trial, aggregate costs for renal replacement therapy were comparable. The advantages of better nutrition, better fluid balance, easier management of hemodynamics, and more complete renal recovery, as suggested by this study, should continue to make it valuable. Physician acceptance of CRRT advantages has been established and suggests clinical benefit despite any potential increased cost.

Clinical practice guidelines.

Clinical practice guidelines are becoming an important determinant of how we practice medicine and surgery. They are the strategy of our federal agencies to reduce variability in care, improve quality, measure outcomes, and reduce costs. The payors and entrepreneurs of medicine have endorsed the use of practice guidelines as the most efficacious way to manage costs, and variability. This economic force alone will perpetuate their development in the foreseeable future. It could be tempting to recoil from these pressures that may seem outside the realm of the individual surgeon trying to do the best for the individual patient. However, when viewed as a way to work with our colleagues and use scientific evidence and expert opinion to achieve consensus about best practice, this effort is very much in line with the way we practice surgery. The surgical community should not be concerned with participating but, in fact, should lead. The surgical tradition with outcomes assessment-the Morbidity and Mortality Conference-is a fundamental principle used to improve care. The process of practice guideline development is designed to do the same to continuously improve care.

MAST 96.

The Military Anti-Shock Trouser, or MAST suit, is a controversial device that has been used to support blood pressure in hypotensive trauma patients. Most studies on humans have shown that the device has limited clinical utility. In this study, a telephone survey of all 50 State Emergency Medical Services was conducted to determine the nature and extent of MAST suit usage in the United States. The trend in MAST suit usage in San Diego County over the last 7 years was also analyzed. Thirty (60%) states still require MAST suits to be carried on ambulances. In San Diego County, MAST suit inflations for adult, hypotensive (systolic blood pressure < 90 mmHg,) blunt trauma patients has declined from 37% in 1987, to 2% in 1993. Despite a lack of data supporting efficacy in areas of severe hypotensive shock, blunt trauma, long transport times, and pelvic fractures, states continue to expend resources on the MAST suit. It is for this reason that we believe that the clinical use of the MAST suit should be based upon medical control philosophy rather than legislation.

High-risk behavior and the public burden for funding the costs of acute injury.

OBJECTIVE: To determine if high-risk behavior is associated with increased injury severity and cost and if public agencies bear a disproportionate burden of that cost. DESIGN: Case comparison study utilizing patient data collected over a 10-year period. SETTING: Five level 1 and 2 trauma centers in an urban-suburban community with a population of 2.4 million. PARTICIPANTS: Trauma registry data from 37,304 consecutive hospitalized adult patients with trauma. Financial data were reported and analyzed on 28,842 of these. MAIN OUTCOME MEASURES: Incidence of alcohol intoxication, other drug use, use of vehicular protective devices, and firearm violence injuries in patients with private vs public health care sponsorship. Length of hospital stay, injury severity, and hospital unit charges were assessed for high-risk behavior. RESULTS: High-risk behavior was more prevalent among trauma patients relying on public funding to cover the costs of their injuries (P < .001). Total hospital unit charges were 28% and 35% higher for motorists not wearing seat belts and motorcyclists not wearing helmets, respectively. Injury severity and length of stay were also higher (P < .001). CONCLUSIONS: High-risk behavior is associated with increased injury severity and cost. Trauma victims exhibiting high-risk behavior more often depend on public agencies to cover the cost of acute injury. Failure to establish and enforce laws and policies designed to reduce or prevent injury may generate enormous trauma care costs, borne to a large extent by public agencies. Further restriction of certain types of high-risk behavior and the institution of "users' fees," taxes, or penalties may be necessary to reduce the disproportionate public agency cost generated by this activity.

Functional limitation after major trauma: a more sensitive assessment using the Quality of Well-being scale--the trauma recovery pilot project.

Little is known about the degree of disability and quality of life of patients after major trauma. We conducted a prospective study to examine the incidence and predictors of functional limitation (FL). Between January 1, 1990 and March 30, 1990, 61 eligible trauma patients were enrolled in the study (admission GCS score > or = 12, LOS > 24 hours). Functional limitation after trauma was measured at discharge and 3 months after discharge using the Quality of Well-being (QWB) scale, a more sensitive index to the well end of the functioning continuum (range, 0 = death to 1.000 = optimum functioning). Functional limitation was also measured using a standard ADL scale (range, 17 = full function to 41 = maximum dysfunction). Risk factors measured were injury severity, body region, depression (CES-D) scale, and social support. Follow-up was achieved in 42 patients (70%). The mean age was 30 years, 74% were male, 52% white, 41% hispanic, and 3% other. The mean ISS was 15, with 69% blunt injuries and a mean LOS of 12 days. The QWB scores improved between discharge and follow-up; discharge mean = 0.457 (+/- 0.048), follow-up mean = 0.613 (+/- 0.118), but the mean QWB score at follow-up still reflected a significant degree of functional limitation. The mean percentage of change in QWB scores was 34.5% (+/- 25.5%) with a range of -6.34% to 103.8%. The discharge mean FDS was 29 (+/- 6.2) while the follow-up FDS mean was 17 (+/- 3.8), reflecting that most patients at follow-up reported near-perfect ADL functioning.(ABSTRACT TRUNCATED AT 250 WORDS)

The clinical utility of computed tomographic scanning and neurologic examination in the management of patients with minor head injuries.

The evaluation and management of patients with minor head injury (MHI: history of loss of consciousness or posttraumatic amnesia and a GCS score greater than 12) remain controversial. Recommendations vary from routine admission without computed tomographic (CT) scanning to mandatory CT scanning and admission to CT scanning without admission for selected patients. Previous reports examining this issue have included patients with associated non-CNS injuries who confound the interpretation of the data and affect outcome. We hypothesized that patients with MHI and no other reason for admission with normal neurologic examinations and normal CT scans would have a negligible risk of neurologic deterioration requiring surgical intervention. To validate this hypothesis we studied 2766 patients with an isolated MHI admitted to seven trauma centers between January 1, 1988, and December 31, 1991. There were 1898 male patients and 868 female patients; injury was blunt in 99%. A neurologic examination and a CT scan were performed on 2166 patients; 933 patients had normal neurologic examinations and normal CT scans and none required craniotomy; 1170 patients had normal CT scans and none required craniotomy; 2112 patients had normal neurologic examinations and 59 required craniotomy. The sensitivity of the CT scan was 100%, with positive predictive value of 10%, negative predictive value of 100%, and specificity of 51%. The use of CT alone as a diagnostic modality would have saved 3924 hospital days, including 814 ICU days, and $1,509,012 in hospital charges. Based on these data, we believe that CT scanning is essential in the management of patients with MHI and that if the neurologic examination is normal and the scan is negative patients can be safely discharged from the emergency room.

The impact of in-house surgeons and operating room resuscitation on outcome of traumatic injuries.

As trauma systems develop, more patients can potentially benefit from immediate surgery. With in-house surgeons available, enthusiasm for direct transfer from the scene to the operating room (OR) has developed in many institutions. The purpose of this study was to define precisely which patients should be taken to the OR for resuscitation. Three hundred twenty-three patients were taken to the OR directly from the field during a 4-year period (6.9% of trauma activations). Indications included the following: (1) cardiac arrest--one vital sign present, (2) persistent hypotension despite field intravenous fluid, and (3) uncontrolled external hemorrhage. A board-certified surgeon and resuscitation team met the field transport team in the OR in all cases. Cardiopulmonary resuscitation for patients with blunt trauma was not accompanied by survival even with immediate surgery by a trained surgeon and it wastes valuable OR resources. Patients with prehospital hypotension unresponsive to fluid resuscitation indicate the need for rapid surgery. Patients with blunt injuries even with hypotension infrequently undergo operations in less than 20 minutes and can be resuscitated in traditional areas where better roentgenograms are obtained. Penetrating injuries to the chest and abdomen with hypotension are the primary indications for OR resuscitation. It can be anticipated with field communication and accompanied by enhanced survival.