Cost of Immediate Surgery Versus Non-operative Treatment for Trigger Finger in Diabetic Patients.

PURPOSE: As health care costs continue to rise, providers must increasingly identify and implement cost-effective practice measures without sacrificing quality of care. Corticosteroid injections are an established treatment for trigger finger; however, numerous clinical trials have documented the limited efficacy of these injections in the diabetic population. Furthermore, the most cost-effective treatment strategy for diabetic trigger finger has not been determined. The purpose of this study was to perform a decision analysis to identify the least costly strategy for effective treatment of diabetic trigger finger using existing evidence in the literature. METHODS: Four treatment strategies for diabetic trigger finger were identified: (1) 1 steroid injection followed by surgical release, (2) 2 steroid injections followed by surgical release, (3) immediate surgical release in the operating room, and (4) immediate surgical release in the clinic. A literature review was conducted to determine success rates of the different treatment strategies. Costing analysis was performed using our institutional reimbursement from Medicare. One-way sensitivity and threshold analysis was utilized to determine the least costly treatment strategy. RESULTS: The least costly treatment strategy was immediate surgical release in the clinic. In patients with insulin-dependent diabetes mellitus, this strategy results in a 32% and a 39% cost reduction when compared with treatment with 1 or 2 corticosteroid injections, respectively. For 1 or 2 corticosteroid injections to be the most cost-effective strategy, injection failure rates would need to be less than 36% and 34%, respectively. The overall cost of care for immediate surgical release in the clinic was $642. CONCLUSIONS: Diabetic trigger finger is a common problem faced by hand surgeons, with a variety of acceptable treatment algorithms. Management of diabetic trigger finger with immediate surgical release in the clinic is the most cost-effective treatment strategy, assuming a corticosteroid injection failure rate of at least 34%. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic/decision III.

Quality improvement and cost savings after implementation of the Leapfrog intensive care unit physician staffing standard at a community teaching hospital.

BACKGROUND: Prior studies have shown that implementation of the Leapfrog intensive care unit physician staffing standard of dedicated intensivists providing 24-hr intensive care unit coverage reduces length of stay and in-hospital mortality. A theoretical model of the cost-effectiveness of intensive care unit physician staffing patterns has also been published, but no study has examined the actual cost vs. cost savings of such a program. OBJECTIVE: To determine whether improved outcomes in specific quality measures would result in an overall cost savings in patient care DESIGN: Retrospective, 1 yr before-after cohort study SETTING: A 15-bed mixed medical-surgical community intensive care unit PATIENTS: A total of 2,181 patients: 1,113 patients preimplementation and 1,068 patients postimplementation. INTERVENTION: Leapfrog intensive care unit physician staffing standard MEASUREMENTS: Intensive care unit and hospital length of stay, rates for ventilator-associated pneumonia and central venous access device infection, and cost of care. RESULTS: Following institution of the intensive care unit physician staffing, the mean intensive care unit length of stay decreased significantly from 3.5±8.9 days to 2.7±4.7 days, (p<.002). The frequency of ventilator-associated pneumonia fell from 8.1% to 1.3% (p<.0002) after intervention. Ventilator-associated pneumonia rate per 100 ventilator days decreased from 1.03 to 0.38 (p<.0002). After intervention, the frequency of the central venous access device infection events fell from 9.4% to 1.1% (p<.0002). Central venous access device infection rate per 1000 line days decreased from 8.49 to 1.69. The net savings for the hospital were $744,001. The 1-yr institutional return on investment from intensive care unit physician staffing was 105%. CONCLUSIONS: Implementation of the Leapfrog intensive care unit physician staffing standard significantly reduced intensive care unit length of stay and lowered the prevalence of ventilator-associated pneumonia and central venous access device infection. A cost analysis yielded a 1-yr institutional return on investment of 105%. Our study confirms that implementation of the Leapfrog intensive care unit physician staffing model in the community hospital setting improves quality measures and is economically feasible.