[Determinants of treatment costs of unstable angina pectoris]. / Determinanten der Behandlungskosten der instabilen Angina pectoris.

BACKGROUND AND AIM: Unstable angina, a common serious clinical entity, is associated with a high rate of complications. The aim of our study was to evaluate treatment costs of patients with uncomplicated and complicated follow-up in order to evaluate the economic consequences of new therapeutic strategies, like the introduction of GPIIb/IIIa blockers at our hospital. METHODOLOGY: All 103 patients who were admitted to the medical intensivecare unit of Johann Wolfgang Goethe-University Hospital, Frankfurt am Main between March 2, 1992 and October 31, 1997 for unstable angina of Braunwald class III B were enrolled in the study. Clinical events were the occurrence of refractory ischemia, nontransmural or transmural myocardial infarction or cardiac death. The following were documented: duration of treatment in the ICU and in the general ward, cardiac catheterizations, balloon angioplasties (PTCA), and bypass operations. Treatment costs were calculated on the basis of daily rates, flat rates, and special fees. RESULTS: Following successful primary treatment, a clinical event occurred in 48 of the 103 patients, recurrent refractory ischemia in 34 patients, nontransmural infarction in eight patients, transmural infarction in three patients, and death in four patients. Patients with events were significantly less likely to have had a history of PTCA (38% vs 60%, p < 0.05) and were significantly less likely to be undergoing long-term treatment with aspirin (63% vs 80%, p < 0.05). Other sociodemographic data as well as the initial treatment strategies were comparable. The occurrence of a complication significantly prolonged the duration of treatment in the ICU from 2.6 days (95%-CI [2.1; 3.0]) to 3.6 days (95%-CI [3.1; 4.1]) and the total duration of treatment from 7.0 days (95%-CI [5.7; 8.4]) to 12.8 days (95%-CI [9.6; 16.1]). The total treatment costs rose accordingly from DM 14,360 (95%-CI [12,360; 16,360]) to DM 26,690 (95%-CI [23,150; 30,240]). CONCLUSION: The data show that ischemic complications following successful primary treatment of unstable angina constitute a common problem. Such complications are associated with significantly more intensive treatment and significantly longer hospitalization times, resulting in a near doubling of treatment costs.

[Treatment costs in a medical intensive care unit: a comparison of 1992 and 1997]. / Behandlungskosten auf einer medizinischen Intensivstation. Ein Vergleich von 1992 und 1997.

BACKGROUND AND OBJECTIVE: Treatment in an intensive care unit (ICU) is very expensive. Aim of this study was to determine the exact composition of costs and to analyse what factors are responsible for the rise in costs over the last 5 years. METHODS: In a prospective investigation all 790 patients who had been treated at the ICU of the Medical Department of Frankfurt University during 1992 were included, findings being compared with data on all 208 patients treated in the ICU in May and June 1997. All important diagnostic and therapeutic measures were quantitatively determined each day. RESULTS: The mean age of the ICU patients rose in the 5 years from 55 to 59 years (P < 0.001). Mean period of stay in the ICU remained unchanged (4.1 days), total duration of hospital stay (15 and 12 days, respectively), and treatment intensity (sum of points according to the "Therapeutic Intervention Scoring System" per ICU stay: 96 and 77, respectively). The mortality rate in the ICU fell from 16.3% to 10.6% (P = 0.02), hospital mortality rate from 23% to 14% (P = 0.01). Total cost rose from DM 797,860 to DM 1,148,945 per 100 patients (+44%). Of this total, personnel costs were DM 286,885 in 1992 and 356,091 in 1997 (+24%), costs for apparatus-based diagnostic and therapeutic tests were DM 169,743 and 245,156, respectively (+44%), DM 98,496 and 129,222 for drugs (+31%), and DM 60,399 and 186,671 (+209%) for blood and clotting products (in each category per 100 patients). Per case costs rose from DM 7970 to 11,489, per day costs from DM 1943 to 2831. 90% of cost increases were due to new strategies in the treatment of patients with myocardial infractions and those with severe clotting disorders and a rise in personnel costs. CONCLUSION: The costs of a stay in the ICU has greatly increased over the last 5 years, the main causes being a change to new forms of treatment, especially in patients with myocardial infarction and those with haemophilia.

[Electronic data processing in a surgical and medical intensive care unit]. / EDV-Dokumentation auf einer chirurgischen und einer medizinischen Intensivstation.

A prospective documentation of patients data on an internal and a surgical intensive care unit (ICU) has been transacted. The physician and nursing staff used an online electronic documentation program, which has been developed in Frankfurt. Main emphasis has been placed on the epidemiological data, clinical diagnoses as well as diagnostically and therapy costs. The medical ICU of university hospital of Frankfurt has been analysed since 1992 and the surgical ICU of Städtisches Krankenhaus of Lüneburg since 1994. Up to now data from 2001 patients from Frankfurt are available. Period spent on the ICU was 4.7 +/- 0.16 days (average +/- SEM), mortality was 15%. 47% of the whole group suffered from cardiac disease, of which 211 had an acute myocardial infarction (10.6%), 156 patients a serious ventricular arrhythmia (7.8%) as well as 88 patients an unstable angina (4.4%). Long-term observation revealed a rise of the duration spent on the ICU (from 4.1 +/- 0.17 to 5.5 +/- 0.38 days, P < 0.0002), an increasing number of technical examinations (for example: chest x-ray from 2.25 +/- 0.13 to 4.52 +/- 0.4/patient, P < 0.0001) and a steady mortality between 1992 and 1994. Detailed analysis of patients with acute myocardial infarction showed an impressive reduction of total mortality within the 3 years observed. In Lüneburg data of 1004 patients have been recorded so far. The average time spent on the ICU was 6.4 +/- 0.33 days. 4.1% patients passed away. Neoplasia of gastric intestinal tract (143; 14.2%), femoral neck fracture (64; 6.4%) and ilei (54; 5.4%) have been the most frequent diagnoses. Patients underwent 2.2 +/- 0.12 chest x-rays and 1.4 +/- 0.1 ultrasound investigations. The study shows that an online data processing is practicable and can be integrated in the daily work flow. Furthermore, it can be seen that the collected data play an important role to secure the increasing administrative requisition to the modern medicine in view of costs and quality management.

[Multiparametric analysis using radionuclide ventriculography in the assessment of left ventricular function following heart transplantation]. / Multiparameteranalyse mittels Radionuklidventrikulographie in der Beurteilung der linksventrikulären Funktion nach Herztransplantation.

Left ventricular systolic and diastolic performance was evaluated by radionuclide angiography in 17 patients following cardiac transplantation and compared with normal persons. Both groups performed supine bicycle exercise during the investigation, the control group at 102 +/- 73 W and the transplanted patients at 61.2 +/- 15 W. The ejection fraction increased in the normal persons from 61 +/- 8 to 69 +/- 10% whereas in the transplanted patients it did not increase significantly. There were no relevant changes in systolic parameters during exercise in the transplant recipients. The changes in diastolic parameters were significantly smaller in transplant patients than in normals. After correction for heart rate-induced changes a significantly different time course of the systolic-diastolic sequence during the cardiac cycle became evident in the transplanted group at rest. During exercise the systolic-diastolic sequence during the cardiac cycle became similar in both groups. It is concluded that the reduced exercise capacity of patients in the late phase after cardiac transplantation is partially due to the absence of an EF increase and a limitation of diastolic reserve during exercise.

Noninvasive assessment of left ventricular performance following transluminal coronary angioplasty.

We studied 36 patients with successful transluminal coronary angioplasty (group 1) noninvasively using exercise electrocardiography, exercise T1-201 myocardial scintigraphy and equilibrium radionuclide ventriculography before and 3-5 days after the procedure. Six patients who underwent aortocoronary-bypass surgery (group 2) and 10 patients with stable angina pectoris (group 3) served as controls. All patients had arteriographically documented coronary artery disease at least in one major coronary vessel (stenosis greater than or equal to 70%). In group 1, average coronary stenosis was 81.1 +/- 8.4% before dilatation and 44 +/- 13.7% after the procedure (P less than 0.001). Ischemia score in the exercise electrocardiography decreased from 2.4 +/- 2.7 before dilatation to 0.4 +/- 0.8 after the procedure (P less than 0.001). Myocardial perfusion in computerized T1-201 myocardial scintigraphy 5-10 min after exercise expressed as vitality index (the ratio of T1-201 uptake in the ischemic region to the region of maximal uptake in the same image analyzed carefully in the same view in 2 studies) increased from 72.9 +/- 8.4% before dilatation to 79.9 +/- 11.7% after the procedure (P less than 0.001). Ejection fraction at rest increased from 47.2 +/- 9.2% to 51.0 +/- 9.7% (P less than 0.001) and during exercise from 39.9 +/- 10.5% to 49.4 +/- 10.9% (P less than 0.001) before and after the procedure. In group 2, noninvasive studies showed a tendency to improvement after surgery. In group 3 no significant changes were noted. We conclude that transluminal coronary angioplasty improves both coronary perfusion to ischemic areas supplied by critical coronary artery stenoses and left ventricular function, especially during exercise, if luminal diameter is dilated by greater than 20%.