Suture material use and procurement: an audit of a public hospital surgical system in Gauteng, South Africa.

BACKGROUND: Surgical systems are integral to successful, safe and cost effective clinical practice and must balance surgical demands on consumable items and their costs. Suture material is a key consumable resource, and was evaluated in an audit of consumable use and cost as well as the procurement systems within the South African Gauteng public health care sector. AIMS: To determine suture use and cost in the four commonest general surgical procedures - abdominal wall closure, mastectomy, appendicectomy and inguinal hernia repair - in three academic Gauteng hospitals. Performance and availability were evaluated as a secondary aim in suture material use. METHOD: A prospective observational study. Suture use was documented by the surgeon at the time of the procedure and qualitative investigation at relevant hospital departments determined suture material procurement and expenditure. RESULTS: The surgeons in three facilities documented consistent material type and average number of units used; however, in some cases there was a lack of availability of appropriate material and breakage of generic material intraoperatively. There is no consistent and consolidated electronic record-keeping of suture stock and cost in all three hospitals, therefore cost of suture material used was not obtainable. CONCLUSION: Clinical deficiencies in availability and quality of material may have adverse implications for patient health, healthcare costs and budgets through procedure-related complications and should be investigated. There is a lack of communication between the financial management, procurement officers, hospital and theatre stores and theatre staff. It is suggested that clinical protocols and system-based strategies be put in place to manage surgical consumables.

The perplexity of prescribing and switching of biologic drugs in rheumatoid arthritis: a UK regional audit of practice.

BACKGROUND: Biologic drugs are expensive treatments used in rheumatoid arthritis (RA). Switching among them is common practice in patients who have had an inadequate response or intolerable adverse events. The National Institute of Health and Clinical Excellence (NICE) UK, which aims to curtail postcode prescribing, has provided guidance on the sequential prescription of these drugs. This study sought to evaluate the extent to which rheumatology centres across the Midlands were complying with NICE guidance on the switching of biologic drugs in RA, as well as analyse the various prescribing patterns of these drugs. METHODS: Data was collected via a web-based tool on RA patients who had undergone at least one switch of a biologic drug during 2011. The standards specified in NICE technology appraisals (TA130, TA186, TA195, TA198, and TA225) were used to assess compliance with NICE guidance. Descriptive statistical analysis was performed. RESULTS: There were 335 biologic drug switches in 317 patients. The most common reason given for switching to a drug was NICE guidelines (242, 72.2%), followed by Physician's choice (122, 33.4%). Lack of effect was the most common reason for discontinuing a drug (224, 67%). For patients on Rituximab, Methotrexate was used in 133 switches (76.9% of the time). Overall NICE compliance for all units was 65% (range 50 to 100%), with anti-TNFα to anti-TNFα switches for inefficacy making up the majority of non-compliant switches. CONCLUSION: This study draws attention to the enigma and disparity of commissioning and prescribing of biologic drugs in RA. Currently the evidence would not support switching of a biologic drug for non-clinical purposes such as economic pressures. Flexibility in prescribing should be encouraged: biologic therapy should be individualised based on the mode of action and likely tolerability of these drugs. Further work should focus on the evidence for using particular sequences of biologic drugs.

Condition Code 44 or Condition Code W2?

When hospitals determine after discharge that a patient did not meet inpatient criteria, they can file a provider liable claim using Condition Code W2 and be reimbursed for all services as if the patient were an outpatient, according to Deborah Hale, CCS, CCDS. The claims must be filed within 12 months after discharge. The medical record must be reviewed by the physician advisor and the utilization review committee before the claim is submitted. It is still advantageous to get the patient status right up front.

Antibiotic surveillance on a paediatric intensive care unit: easy attainable strategy at low costs and resources.

BACKGROUND: Antibiotic surveillance is mandatory to optimise antibiotic therapy. Our objectives were to evaluate antibiotic use in our pediatric intensive care unit (PICU) and to implement a simple achievable intervention aimed at improving antibiotic therapy. METHOD: Prospective, 3 months surveillance of antibiotic use on PICU (phase I) and evaluation according to the CDC 12-step campaign with development of an attainable intervention. 3 months surveillance (phase II) after implementation of intervention with comparison of antibiotic use. RESULTS: Appropriate antibiotic use for culture-negative infection-like symptoms and targeted therapy for proven infections were the main areas for potential improvement. The intervention was a mandatory checklist requiring indication and recording likelihood of infection at start of antibiotic therapy and a review of the continuing need for therapy at 48 h and 5 days, reasons for continuation and possible target pathogen. The percentage of appropriate empiric antibiotic therapy courses for culture-negative infection-like symptoms increased from 18% (10/53) to 74% (42/57; p<0.0001), duration of therapy <3 days increased from 18% (10/53) to 35% (20/57; p=0.05) and correct targeting of pathogen increased from 58% (7/12) to 83% (20/24; p=0.21). CONCLUSIONS: Antibiotic surveillance using the CDC 12-step campaign can help to evaluate institutional antibiotic therapy. Development of an attainable intervention using a checklist can show improved antibiotic use with minimal expense.

Estimating the costs of induced abortion in Uganda: a model-based analysis.

BACKGROUND: The demand for induced abortions in Uganda is high despite legal and moral proscriptions. Abortion seekers usually go to illegal, hidden clinics where procedures are performed in unhygienic environments by under-trained practitioners. These abortions, which are usually unsafe, lead to a high rate of severe complications and use of substantial, scarce healthcare resources. This study was performed to estimate the costs associated with induced abortions in Uganda. METHODS: A decision tree was developed to represent the consequences of induced abortion and estimate the costs of an average case. Data were obtained from a primary chart abstraction study, an on-going prospective study, and the published literature. Societal costs, direct medical costs, direct non-medical costs, indirect (productivity) costs, costs to patients, and costs to the government were estimated. Monte Carlo simulation was used to account for uncertainty. RESULTS: The average societal cost per induced abortion (95% credibility range) was $177 ($140-$223). This is equivalent to $64 million in annual national costs. Of this, the average direct medical cost was $65 ($49-86) and the average direct non-medical cost was $19 ($16-$23). The average indirect cost was $92 ($57-$139). Patients incurred $62 ($46-$83) on average while government incurred $14 ($10-$20) on average. CONCLUSION: Induced abortions are associated with substantial costs in Uganda and patients incur the bulk of the healthcare costs. This reinforces the case made by other researchers--that efforts by the government to reduce unsafe abortions by increasing contraceptive coverage or providing safe, legal abortions are critical.

Conducting a charge description master audit: getting the most value from an internal review.

Periodic audits of the charge description master are a key piece of an organization's compliance program. But they can do more than verify compliance--they can help improve the business.

The forecast for RAC extrapolation: mostly cloudy.

The current statutory and regulatory guidance for recovery audit contractor (RAC) extrapolation leaves providers with minimal protection against the process and a limited ability to challenge overpayment demands. Providers not only should understand the statutory and regulatory basis for extrapolation forecast, but also should be able to assess their extrapolation risk and their recourse through regulatory safeguards against contractor error. Providers also should aggressively appeal all incorrect RAC denials to minimize the potential impact of extrapolation.

A quantity survey of intravenous administration of metronidazole in its different forms in a tertiary teaching hospital.

The aim of this paper is to examine the prescribing patterns and cost of various formulations of metronidazole in a hospital setting over a 3-month period. Oral metronidazole has high bioavailability (98.9%) with peak plasma concentrations averaged at 2.3 h after dosing. Despite the high bioavailability of oral metronidazole, many patients continue to receive metronidazole intravenously when they are suitable for oral preparation. An audit of 120 consecutive patients prescribed metronidazole was conducted at the Liverpool Hospital, NSW, from March to July 2005. There were 65 men and 55 women (age 18-93). Of the 120 patients, 16 were on oral, 1 on rectal and 103 were on intravenous metronidazole. Treatment was initiated based on clinical diagnoses. Potential pathogens were subsequently identified on only 21 occasions. The use of metronidazole as an oral preparation was contraindicated in 27 patients (22.5%) who were nil-by-mouth. Of these, rectally administered metronidazole was contraindicated in only eight patients. The average course of intravenous metronidazole was 8.0 +/- 9.7 days (mean +/- SD). The total number of intravenous metronidazole treatment days was 824. Oral metronidazole would have been possible in 618 out of the 824 days. The estimated cost to administer each dose of oral, suppository and intravenous forms of metronidazole is $A0.11, $A1.34 and $A6.09 respectively. Thus, substantial savings could be achieved if oral metronidazole were to be administered whenever possible. The early use of oral or rectal metronidazole should be encouraged when there are no clinical contraindications.

Financial and clinical governance implications of clinical coding accuracy in neurosurgery: a multidisciplinary audit.

Clinical coding is the translation of documented clinical activities during an admission to a codified language. Healthcare Resource Groupings (HRGs) are derived from coding data and are used to calculate payment to hospitals in England, Wales and Scotland and to conduct national audit and benchmarking exercises. Coding is an error-prone process and an understanding of its accuracy within neurosurgery is critical for financial, organizational and clinical governance purposes. We undertook a multidisciplinary audit of neurosurgical clinical coding accuracy. Neurosurgeons trained in coding assessed the accuracy of 386 patient episodes. Where clinicians felt a coding error was present, the case was discussed with an experienced clinical coder. Concordance between the initial coder-only clinical coding and the final clinician-coder multidisciplinary coding was assessed. At least one coding error occurred in 71/386 patients (18.4%). There were 36 diagnosis and 93 procedure errors and in 40 cases, the initial HRG changed (10.4%). Financially, this translated to pound111 revenue-loss per patient episode and projected to pound171,452 of annual loss to the department. 85% of all coding errors were due to accumulation of coding changes that occurred only once in the whole data set. Neurosurgical clinical coding is error-prone. This is financially disadvantageous and with the coding data being the source of comparisons within and between departments, coding inaccuracies paint a distorted picture of departmental activity and subspecialism in audit and benchmarking. Clinical engagement improves accuracy and is encouraged within a clinical governance framework.

Family tracing to identify patients with familial hypercholesterolaemia: the second audit of the Department of Health Familial Hypercholesterolaemia Cascade Testing Project.

BACKGROUND: Family tracing is a method recognized to find new patients with familial hypercholesterolaemia (FH). We have implemented family tracing led by FH Nurses and have determined acceptability to patients, feasibility and costs. METHODS: Nurses were located at five National Health Service (NHS) Trusts; they identified FH patients and offered them family tracing. Responses and test results were recorded on a database and summarized on a family pedigree. RESULTS: The majority ( approximately 70%) of index cases participated; the proportion was lower when patients had been discharged from the clinics and in metropolitan areas. On average, 34% (range 13-50%) of relatives lived outside the catchment area of the clinics and could not attend the nurse-led FH clinics. Of the previously untested relatives, 76% who lived in the catchment area of the clinic came forward to be tested. One-third of the relatives who came forward for testing were children

Improving supply of safe blood and reducing cost of transfusion service through haemovigilance.

Availability of safe blood remains a major challenge for many developing countries. Unnecessary discontinuation of scarce blood is a major conduit of wastage of scarce blood, as well as man hours and funds. Haemovigilance is a national system of surveillance and alarm, from blood collection to the follow-up of the recipients, gathering and analysing all untoward effects of blood transfusion in order to correct their cause and prevent recurrence. A prospective study to audit discontinuation of blood transfusion at the Obafemi Awolowo University Teaching Hospital Ile-Ife over a period of one and half years was done. Simple febrile non-haemolytic transfusion reaction (FNHTR) was the leading indication for such discontinuation (66.7%). More than half of discontinued transfusion due to FNHTR (58%) was successfully completed on review by trained personnel in transfusion medicine. A system of haemovigilance if incorporated into the blood transfusion service will promote effective monitoring of blood transfusion and reduce wastage of scarce blood/blood products.

Effect of Patient Care Coordination on Hospital Encounters and Related Costs.

Given high costs of hospital encounters, providers have increasingly turned to patient-centered health care programs to improve cost-effectiveness and population health for patients with high needs. Yet, evidence is mixed about program effectiveness. This pre-post comparative analysis assessed whether the number of hospital encounters and related costs decreased for patients who received care coordination services funded through Texas's 1115(a) Medicaid waiver incentive-based payment model, under which providers created new programs to improve care quality, population health, and cost-effectiveness. This study compared hospital records for patients who were frequent emergency department users at 4 urban safety net hospitals in Texas and state data for hospital encounters for the calendar years 2013 through 2015. The study included 9061 patients who frequently used emergency departments: 4117 patients who received waiver-funded care coordination services at 2 hospitals and 4944 patients who received usual care at 2 comparison hospitals. Regression models compared changes in patients' hospital use and length of stay for the 2 groups. Patients receiving waiver-funded care coordination had a 19% lower probability of hospitalization after receiving care coordination relative to patients who received usual care, for a mean savings of approximately $1500 per year per patient. Receiving care coordination was not associated with a change in length of stay. Care coordination developed by hospitals to meet the needs of their most vulnerable patients can reduce their use of hospital resources through better preventive care. These findings bolster the business case for care coordination, which may help ensure service continuation.

Management patterns and healthcare costs for hospitalized patients with cerebral infarction.

OBJECTIVES: Although evidence shows the importance of specialized intensive care of patients with cerebral infarction, it is not well known whether resources are generously applied in the initial period and how patterns of medical resource utilization are associated with characteristics of providers and patient outcomes. In this study, we analyzed changing patterns of daily medical cost using administrative healthcare claim data and identified a management pattern in each case. METHODS: We used Japan's administrative data to identify medical costs on a day-to-day basis. Data of 3136 patients with acute cerebral infarction from 14 medical institutions were included in the analyses. Using the data, we calculated the costs from the perspective of the third-party payer. Institutions were divided into three groups according to the distribution of medical costs in the first 2 days, and patient background, treatment process, and outcomes were compared across the groups. RESULTS: Medical cost was not necessarily intensively allocated during the early hospitalization period. Wide variations were observed in medical cost utilization patterns across institutions. The differences in medical cost for the initial hospitalization period appears to be more influenced by ICU utilization and management policies of institutions than the clinical condition of patients. CONCLUSIONS: We proposed a methodology that uses administrative claim data to examine management patterns of ischemic stroke. We believe that the use of our method, in conjunction with accurate and detailed clinical data, can help elucidate the relationship among acute-period medical resource utilization, process of care, and patient outcomes.

Auditing the frequency and the clinical and economic impact of testing for Fabry disease in patients under the age of 70 with a stroke admitted to Saint Vincent's University Hospital over a 6-month period.

BACKGROUND: Fabry disease is an X-linked recessive lysosomal storage disorder that provokes multi-organ morbidity, including early-onset stroke. Worldwide prevalence may be greater than previously estimated, with many experiencing first stroke prior to diagnosis of Fabry disease. AIMS: The aim of this study is to screen a cohort of stroke patients under 70 years of age, evaluating the clinical and economic efficacy of such a broad screening programme for Fabry disease. METHODS: All stroke patients under 70 years of age who were entered into the Saint Vincent's University Hospital stroke database over a 6-month period underwent enzyme analysis and/or genetic testing as appropriate for Fabry disease. Patients' past medical histories were analysed for clinical signs suggestive of Fabry disease. Cost-effectiveness analysis of testing was performed and compared to overall economic impact of young stroke in Ireland. RESULTS: Of 22 patients tested for Fabry disease, no new cases were detected. Few clinical indicators of Fabry disease were identified at the time of testing. CONCLUSION: Broad screening programmes for Fabry disease are highly unlikely to offset the cost of testing. The efficacy of future screening programmes will depend on careful selection of an appropriate patient cohort of young stroke patients with multi-organ morbidity and a positive family history.

A medicolegal analysis of malpractice claims involving anesthesiologists in the gastrointestinal endoscopy suite (2007-2016).

STUDY OBJECTIVE: Gastrointestinal endoscopy cases make up the largest portion of out of operating room malpractice claims involving anesthesiologists. To date, there has been no closed claims analysis specifically focusing on the claims from the endoscopy suite. We aim to identify associated case characteristics and contributing factors. DESIGN: Retrospective review of closed claims. SETTING: Multi-institutional setting of hospitals that submit data to the Controlled Risk Insurance Company (CRICO) Comparative Benchmarking System, a database representing approximately 30% of annual malpractice cases in the United States. PATIENTS: A total of 58 claims in the gastrointestinal endoscopy suite between January 1, 2007 and December 31, 2016. INTERVENTIONS: Gastrointestinal endoscopy procedures. MEASUREMENTS: We analyzed associated factors for each case as well as payments, and severity scores. MAIN RESULTS: There was a difference in the percent of cases that resulted in payment by procedure type, with 91% of endoscopic retrograde cholangiopancreatography (ERCP) cases resulting in payment compared with 37.5% of colonoscopy cases, 25% of combined esophagogastroduodenoscopy (EGD)/colonoscopy cases, 21.4% of EGD cases and 0.0% of endoscopic ultrasound cases (P = 0.0008). Oversedation was a possible contributing factor in 62.5% of cases. The mean payment for all claims involving anesthesiologists in the endoscopy suite was $99,754. CONCLUSIONS: There are differences in the rates of payment of malpractice claims between procedures. ERCPs made up a disproportionate percentage of the total amount paid to patients. While a significant percent of cases involved possible oversedation, these errors were compounded by other factors, such as failure to resuscitate or recognize the acute clinical change. With medically complex patients undergoing endoscopic procedures, it is critical to have well prepared anesthesia providers.

Clinical audits: why and for whom.

Every surgical activity poses some element of risk to the public and should include a quality control initiative. Surgical audit is one strategy used to maintain and/or improve standards in surgical care. The Royal Australasian College of Surgeons is committed to ensuring best practice in surgical care and strongly endorses the use of audits to achieve this. This review provides an overview of clinical audit and its role in surgical practice.

Semi-Automatic Electronic Stent Register: a novel approach to preventing ureteric stents lost to follow up.

BACKGROUND: Ureteric stents are indispensable tools in modern urology; however, the risk of them not being followed-up once inserted poses medical and medico-legal risks. Stent registers are a common solution to mitigate this risk; however, manual registers are logistically challenging, especially for busy units. METHODS: Western Sydney Local Health District developed a novel Semi-Automatic Electronic Stent Register (SAESR) utilizing billing information to track stent insertions. To determine the utility of this system, an audit was conducted comparing the 6 months before the introduction of the register to the first 6 months of the register. RESULTS: In the first 6 months of the register, 457 stents were inserted. At the time of writing, two of these are severely delayed for removal, representing a rate of 0.4%. In the 6 months immediately preceding the introduction of the register, 497 stents were inserted, and six were either missed completely or severely delayed in their removal, representing a rate of 1.2%. A non-inferiority analysis found this to be no worse than the results achieved before the introduction of the register. CONCLUSION: The SAESR allowed us to improve upon our better than expected rate of stents lost to follow up or severely delayed. We demonstrated non-inferiority in the rate of lost or severely delayed stents, and a number of other advantages including savings in personnel costs. The semi-automatic register represents an effective way of reducing the risk associated with a common urological procedure. We believe that this methodology could be implemented elsewhere.