Application of dynamic contrast enhanced ultrasound in the assessment of kidney diseases.

PURPOSE OF REVIEW: Many forms of acute and chronic disease are linked to changes in renal blood flow, perfusion, vascular density and hypoxia, but there are no readily available methods to assess these parameters in clinical practice. Dynamic contrast enhanced ultrasound (DCE-US) is a method that provides quantitative assessments of organ perfusion without ionising radiation or risk of nephrotoxicity. It can be performed at the bedside and is suitable for repeated measurements. The purpose of this review is to provide updates from recent publications on the utility of DCE-US in the diagnosis or assessment of renal disease, excluding the evaluation of benign or malignant renal masses. RECENT FINDINGS: DCE-US has been applied in clinical studies of acute kidney injury (AKI), renal transplantation, chronic kidney disease (CKD), diabetic kidney disease and to determine acute effects of pharmacological agents on renal haemodynamics. DCE-US can detect changes in renal perfusion across these clinical scenarios and can differentiate healthy controls from those with CKD. In sepsis, reduced DCE-US measures of perfusion may indicate those at increased risk of developing AKI, but this requires confirmation in larger studies as there can be wide individual variation in perfusion measures in acutely unwell patients. Recent studies in transplantation have not provided robust evidence to show that DCE-US can differentiate between different causes of graft dysfunction, although it may show more promise as a prognostic indicator of graft function 1 year after transplant. DCE-US can detect acute haemodynamic changes in response to medication that correlate with changes in renal plasma flow as measured by para-aminohippurate clearance. SUMMARY: DCE-US shows promise and has a number of advantages that make it suitable for the assessment of patients with various forms of kidney disease. However, further research is required to evidence its reproducibility and utility before clinical use can be advocated.

Perioperative dental injury at a tertiary care health system: An eight-year audit of 816,690 anesthetics.

Among all complications of airway management, dental injury is the most common cause of patient complaints with medicolegal consequences. Over an 8-year period, data on dental injury were collected within a large university hospital system that included community, tertiary, and quaternary care centers. Patient characteristics were compared among all patients receiving anesthesia care using billing data collected from the same period. Of the 816,690 patients who received anesthesia care, there were 360 dental injuries, giving an overall incidence of 1:2,269 (0.044%). Patients receiving general anesthesia were at an increased risk for dental injuries, with an incidence of 1:1,754 (0.057%) compared with patients receiving monitored anesthesia care in whom the incidence was 1:12,500 (0.008%). Patients in the age group 18 to 65 years had a higher incidence of dental injuries of 1:1,818 (0.055%) compared with pediatric patients, who had an incidence of 1:7,692 (0.013%). Emergency procedures were not associated with an increased risk of dental injury in the 816,690 cases. However, of the 360 patients who sustained a dental injury, emergency procedures were associated with a higher incidence of injuring multiple teeth.

The value of ambulatory care measures: a review of clinical and financial impact from an employer/payer perspective.

To understand the value for payers and purchasers of primary care quality measures in an insured population, we conducted a 2-part analysis. In the first part, we reviewed the economic and clinical literature supporting 62 quality metrics spanning primary care that had been proposed for use in a physician recertification program and in a pay-for-performance program. We then ranked these metrics by both economic and clinical evidence of effectiveness. For many of the metrics, there was little clinical or economic support for inclusion in a pay-for-performance program. For the 20 with both clinical and economic evidence of effectiveness, we constructed actuarial models to understand the potential financial effect that attainment of these metrics would have in an insured population, from the perspective of a payer. Of those, 16 were found to be cost-saving in the short term with respect to direct medical costs incurred by payers. This analysis suggests that many recommended primary care quality measures may have little clinical evidence of effectiveness beyond expert opinion, and may provide scant clinical or economic benefit to payers if achieved. A minority, however, may deliver substantial savings in the short term. Given the current emphasis on pay-for-performance and pay-for-reporting programs, and recent studies showing a lack of relationship between measures and clinical/economic value, this analysis informs payers, purchasers, providers, and policymakers about the importance of choosing the right metrics and the methods for collecting them.

The prevalence and characteristics of incentive plans for clinical productivity among academic anesthesiology programs.

Performance-based compensation is encouraged in medical schools to improve faculty productivity. Medical specialties other than anesthesiology have used financial incentives for clinical work. The goal of this study was to determine the prevalence and the types of clinical incentive plans among academic anesthesiology departments. We performed an electronic survey of the members of the Society of Academic Anesthesiology Chairs and the Association of Anesthesiology Program Directors in the spring of 2003. The survey included questions about departmental size, presence of a clinical incentive plan, characteristics of existing incentive plans, primary quantifiers of productivity, and factors used to modify productivity measurements. An incentive plan was considered to be present if the department measured clinical productivity and varied compensation according to the measurements. The plans were grouped by the primary measure used into the following categories: None, Charges, Time, Shift, Late/Call (only late rooms and call), and Other. Eighty-eight (64%) of 138 programs responded to the survey, and 5 were excluded for incomplete data. Of the responding programs, 29% had no system, 30% used a Late/Call system, 20% used a Shift system, 11% used a Charges system, 6% used a Time system, and 3% fit in the Other category. Larger groups (>40 faculty members) had a significantly more frequent prevalence of incentive plans compared with smaller groups (<20 faculty members). Incentives were paid monthly or quarterly in 85% of the groups. In 90% of groups, incentive payments accounted for <25% of total compensation. Adjustments for operating room schedule supervisors, personally performed cases, day surgery preoperative clinics, pain-management services, and critical care services were included in less than half of the programs that reported incentive plans. Call and late room compensation was based on varied formulas. Sixty-nine percent of academic anesthesiology departments did not vary compensation according to clinical activity during regular hours. Most did vary payments on the basis of call and/or late rooms worked. Larger departments were more likely to use clinical incentive plans.

Economics of nerve block pain management after anterior cruciate ligament reconstruction: potential hospital cost savings via associated postanesthesia care unit bypass and same-day discharge.

BACKGROUND: Anterior cruciate ligament reconstruction is a complex outpatient surgical procedure often associated with pain. Traditionally, the procedure is performed under general anesthesia and often requires the use of the PACU. Refractory pain and/or nausea/vomiting occasionally leads to an unplanned hospital admission. In this study, the authors examine the associations of nerve block analgesia for these patients and its associated reductions in PACU use, hospital admission, and hospital costs. METHODS: This was an observational, nonrandomized study in which existing data regarding patients' day-of-surgery outcomes were merged with hospital cost data. We reviewed a consecutive sample of 948 men and women who were in good health and underwent anterior cruciate ligament reconstruction in an outpatient surgery unit between July 1995 and June 1999. RESULTS: The use of nerve block analgesia was associated with reduced PACU admissions to 18% and decreased unplanned hospital admission rates from 17% to 4%. Multivariate linear regression analysis showed that patients bypassing the PACU had an associated hospital cost reduction of 12% (P = 0.0001), whereas patients who needed hospital admission had an associated hospital cost increase of 11% (P = 0.0003). CONCLUSIONS: The use of nerve blocks for acute pain management in patients undergoing anterior cruciate ligament reconstruction is associated with PACU bypass and reliable same-day discharge. Although the cost savings for this one procedure are unlikely to generate sufficient cost savings via staffing reductions, extrapolating these results to a large volume of all types of invasive outpatient orthopedic procedures may have the potential to create significant hospital cost savings.

New developments in influenza vaccine technology: a potential new prevention strategy for employers and managed care organizations.

Influenza is still one of the most wide-reaching, deadly infectious diseases in the United States, with an estimated 54 million cases and 42,000 deaths in a typical year. At $14 billion, the annual cost of influenza is also enormous. More than 80% of that figure comes from so-called indirect medical costs-eg, the productivity loss that results when a person with influenza misses work. The economic cost makes the disease of special concern to employers, who bear the financial burden of such indirect costs, and to the managed care organizations that serve them. Although several therapies moderate the severity of influenza symptoms, prevention remains the best strategy for reducing the disease's morbidity and mortality, as well as the economic cost. Vaccines composed of inactivated (ie, killed) virus have been available for more than 50 years, and with millions of doses now administered, these inactivated vaccines have earned a strong safety record. When the viral strains contained in the vaccine match those circulating, efficacy against serologically defined infection can be as high as 88%. When the match is not good, however, the inactivated vaccine may have substantially lower efficacy. Another shortcoming is that the inactivated virus vaccine requires injection, which can deter compliance in those who have needle phobia or simply dislike getting shots. These concerns have fueled the development and application for licensing of a cold-adapted, live-attenuated influenza virus vaccine (CAIV), which is administered nasally and is not capable of causing disease. Compared with the inactivated vaccine, the CAIV may have superior efficacy and appears to have similarly minor systemic side effects. In addition, CAIV does not require injection and therefore does not cause local pain or tenderness when administered. This article summarizes recent studies of CAIV indicating that it is effective and safe. With its likelihood of enhanced compliance, its ease of administration, and its potentially superior efficacy, CAIV could play a significant role in influenza prevention.

Immune-mediated inflammatory disorders (I.M.I.D.s): the economic and clinical costs.

Immune-mediated inflammatory disorders (I.M.I.D.s) are a group of diseases that involve an immune response that is inappropriate or excessive, and is caused, signified, or accompanied by dysregulation of the body's normal cytokine milieu. I.M.I.D.s cause acute or chronic inflammatory injury, sometimes severe, in any organ system. Despite strong evidence linking the pathophysiologies and treatments of the diseases that constitute the I.M.I.D. group, providers, payers, employers, and benefits consultants have been slow to adopt the I.M.I.D. concept. As a result, these stakeholders risk underestimating the significant clinical and economic burdens of the I.M.I.D. class. In this review we examine those burdens, specifically analyzing I.M.I.D. prevalence and cost data for a group of large employers. We also describe the scientific rationale for the I.M.I.D. paradigm, examine the cytokine dysregulation that many I.M.I.D.s share, and focus in detail on the pathophysiology of 3 I.M.I.D.s with high morbidity: rheumatoid arthritis, Crohn's disease, and type 1 diabetes mellitus. The review concludes with an evaluation of approved anticytokine I.M.I.D. therapies and those in development.