Omega-3 fatty acid-containing parenteral nutrition in ICU patients: systematic review with meta-analysis and cost-effectiveness analysis.

BACKGROUND: Omega-3 (ω-3) fatty acid (FA)-containing parenteral nutrition (PN) is associated with significant improvements in patient outcomes compared with standard PN regimens without ω-3 FA lipid emulsions. Here, we evaluate the impact of ω-3 FA-containing PN versus standard PN on clinical outcomes and costs in adult intensive care unit (ICU) patients using a meta-analysis and subsequent cost-effectiveness analysis from the perspective of a hospital operating in five European countries (France, Germany, Italy, Spain, UK) and the US. METHODS: We present a pharmacoeconomic simulation based on a systematic literature review with meta-analysis. Clinical outcomes and costs comparing ω-3 FA-containing PN with standard PN were evaluated in adult ICU patients eligible to receive PN covering at least 70% of their total energy requirements and in the subgroup of critically ill ICU patients (mean ICU stay > 48 h). The meta-analysis with the co-primary outcomes of infection rate and mortality rate was based on randomized controlled trial data retrieved via a systematic literature review; resulting efficacy data were subsequently employed in country-specific cost-effectiveness analyses. RESULTS: In adult ICU patients, ω-3 FA-containing PN versus standard PN was associated with significant reductions in the relative risk (RR) of infection (RR 0.62; 95% CI 0.45, 0.86; p = 0.004), hospital length of stay (HLOS) (- 3.05 days; 95% CI - 5.03, - 1.07; p = 0.003) and ICU length of stay (LOS) (- 1.89 days; 95% CI - 3.33, - 0.45; p = 0.01). In critically ill ICU patients, ω-3 FA-containing PN was associated with similar reductions in infection rates (RR 0.65; 95% CI 0.46, 0.94; p = 0.02), HLOS (- 3.98 days; 95% CI - 6.90, - 1.06; p = 0.008) and ICU LOS (- 2.14 days; 95% CI - 3.89, - 0.40; p = 0.02). Overall hospital episode costs were reduced in all six countries using ω-3 FA-containing PN compared to standard PN, ranging from €-3156 ± 1404 in Spain to €-9586 ± 4157 in the US. CONCLUSION: These analyses demonstrate that ω-3 FA-containing PN is associated with statistically and clinically significant improvement in patient outcomes. Its use is also predicted to yield cost savings compared to standard PN, rendering ω-3 FA-containing PN an attractive cost-saving alternative across different health care systems. STUDY REGISTRATION: PROSPERO CRD42019129311.

Evaluating the Cost-Effectiveness of the ABCDE Bundle: Impact of Bundle Adherence on Inpatient and 1-Year Mortality and Costs of Care.

OBJECTIVES: Growing evidence supports the Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility (ABCDE) bundle processes as improving a number of short- and long-term clinical outcomes for patients requiring ICU care. To assess the cost-effectiveness of this intervention, we determined the impact of ABCDE bundle adherence on inpatient and 1-year mortality, quality-adjusted life-years, length of stay, and costs of care. DESIGN: We conducted a 2-year, prospective, cost-effectiveness study in 12 adult ICUs in six hospitals belonging to a large, integrated healthcare delivery system. SETTING: Hospitals included a large, urban tertiary referral center and five community hospitals. ICUs included medical/surgical, trauma, neurologic, and cardiac care units. PATIENTS: The study included 2,953 patients, 18 years old or older, with an ICU stay greater than 24 hours, who were on a ventilator for more than 24 hours and less than 14 days. INTERVENTION: ABCDE bundle. MEASUREMENTS AND MAIN RESULTS: We used propensity score-adjusted regression models to determine the impact of high bundle adherence on inpatient mortality, discharge status, length of stay, and costs. A Markov model was used to estimate the potential effect of improved bundle adherence on healthcare costs and quality-adjusted life-years in the year following ICU admission. We found that patients with high ABCDE bundle adherence (≥ 60%) had significantly decreased odds of inpatient mortality (odds ratio 0.28) and significantly higher costs ($3,920) of inpatient care. The incremental cost-effectiveness ratio of high bundle adherence was $15,077 (95% CI, $13,675-$16,479) per life saved and $1,057 per life-year saved. High bundle adherence was associated with a 0.12 increase in quality-adjusted life-years, a $4,949 increase in 1-year care costs, and an incremental cost-effectiveness ratio of $42,120 per quality-adjusted life-year. CONCLUSIONS: The ABCDE bundle appears to be a cost-effective means to reduce in-hospital and 1-year mortality for patients with an ICU stay.

Cost analysis of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy and the risk factors for their increased cost in a public insurance health care system - Single centre study.

INTRODUCTION: This study aimed to evaluate the costs of CRS and HIPEC and treatment of the related postoperative complications in the public healthcare system. We also aimed to identify the risk factors that increase the cost of CRS and HIPEC. MATERIALS AND METHODS: We retrospectively evaluated 80 patients who underwent CRS and HIPEC between February 2016 and November 2018 in the Department of Surgery, University Hospital of Olomouc, Czech Republic. Intraoperative factors and postoperative complications were assessed. The treatment cost included the surgery, hospital stay, intensive care unit (ICU) admission, pharmaceutical charges including medication, hospital supplies, pathology, imaging, and allied healthcare services. RESULTS: The postoperative morbidity rate was 50%, and the mortality rate was 2.5%. The mean length of hospitalisation and ICU admission was 15.44 ± 8.43 and 6.15 ± 4.12 for all 80 patients and 10.73 ± 2.93 and 3.73 ± 1.32, respectively, for 40 patients without complications, and 20.15 ± 13.93 and 8.58 ± 6.92, respectively, for 40 patients with complications. The total treatment cost reached €606,358, but the total reimbursement was €262,931; thus, the CRS and HIPEC profit margin was €-343,427. Multivariate analysis showed that blood loss ≥1.000 ml (p = 0.03) and grade I-V Clavien-Dindo complications (p < 0.001) were independently associated with increased costs. CONCLUSION: The Czech public health insurance system does not fully compensate for the costs of CRS and HIPEC. Hospital losses remain the main limiting factor for further improving these procedures. Furthermore, treatment costs increase with increasing severity of postoperative complications.

Baseline Resilience and Posttraumatic Symptoms in Dyads of Neurocritical Patients and Their Informal Caregivers: A Prospective Dyadic Analysis.

BACKGROUND: Admission to a neuroscience intensive care unit (Neuro-ICU) is sudden and often traumatic for both patients and their informal caregivers. No prior studies have assessed prospectively risk and resiliency factors for chronic posttraumatic symptoms, as well as the potential interdependence between patients' and caregivers' symptoms over time. OBJECTIVE: To analyze the impact of baseline resiliency factors on symptoms of posttraumatic stress (PTS) longitudinally in dyads of patients admitted to the Neuro-ICU and their primary family caregivers. METHODS: We recruited dyads (M = 108) of patients admitted to the Neuro-ICU (total N = 102) and their family caregivers (total N = 103). Dyads completed self-report assessments of PTS and resiliency factors (mindfulness and coping) at baseline in the Neuro-ICU. PTS was measured again at 3- and 6-month follow-up. RESULTS: Clinically significant PTS symptoms were high at baseline in both patients (20%) and caregivers (16%) and remained high through 6 months (25% in patients; 14% in caregivers). Actor-partner interdependence modeling demonstrated that severity of PTS symptoms was predictive of PTS symptoms at subsequent time points (P < 0.001). High baseline mindfulness and coping predicted less severe PTS symptoms in patients and caregivers (P < 0.001) at all time points. Own degree of PTS symptoms at 3 months predicted worse PTS symptoms in one's partner at 6 months, for both patients and caregivers (P = 0.02). CONCLUSIONS: Findings highlight the need to prioritize assessment and treatment of PTS in Neuro-ICU patients and their informal caregivers through a dyadic approach.

Survival rates following medical intensive care unit admission from 2003 to 2013: An observational study based on a representative population-based sample cohort of Korean patients.

The decision as to whether patients should be admitted to a medical intensive care unit (ICU), in the absence of information concerning survival rates or prognostic factors in survival, is often challenging. We analyzed survival trends in relation to hospital discharge and examined patient and hospital characteristics associated with survival following ICU care, using a sample of nationwide claims data in Korea from 2002 through 2013. The Korean government implements a compulsory social insurance program that covers the country's entire population, and the Korean National Health Insurance Service-National Sample Cohort (NHIS-NSC) data from 2002 based on this program were used for this study. The NHIS-NSC is a stratified random sample of 1,025,340 subjects selected from around 46 million Koreans. We evaluated annual survival trends using the Kaplan-Meier test. Analyses of the relationship between survival and patient and hospital characteristics were performed using Cox regression analyses. Employing a multivariate model, variables were selected using the forward selection method to consider the multicollinearity of variables. A total of 32,553 patients admitted to an ICU between 2002 and 2013 were identified among the eligible beneficiaries. The number of patients who had histories of ICU admission steadily increased throughout the study period, and patients older than 80 years constituted a progressively increasing proportion of ICU admissions, from 7.3% in 2002 to 16.9% in 2007 to 23.1% in 2013. The mean number of mechanical equipment items applied consistently increased, while no difference was observed in the trend for overall 1-year survival in patients following ICU treatment across the study period: the 1-year survival rate ranged from 66.7% (year 2003) to 64.2% (year 2010). Advanced age, cancer, renal failure, pneumonia, and influenza were all associated with heightened risk of mortality within 1 year. Our results should prove useful to older patients and their clinicians in their decisions regarding whether to seek ICU care, with the goals of improving the end-of life care and optimizing resource utilization.

Analysis to determine cost-effectiveness of procalcitonin-guided antibiotic use in adult patients with suspected bacterial infection and sepsis.

PURPOSE: Results of a study incorporating real-world results into a predictive model to assess the cost-effectiveness of procalcitonin (PCT)-guided antibiotic use in intensive care unit patients with sepsis are reported. METHODS: A single-center, retrospective cross-sectional study was conducted to determine whether reductions in antibiotic therapy duration and other care improvements resulting from PCT testing and use of an associated treatment pathway offset the costs of PCT testing. Selected base-case cost outcomes in adults with sepsis admitted to a medical intensive care unit (MICU) were assessed in preintervention and postintervention cohorts using a decision analytic model. Cost-minimization and cost-utility analyses were performed from the hospital perspective with a 1-year time horizon. Secondary and univariate sensitivity analyses tested a variety of clinically relevant scenarios and the robustness of the model. RESULTS: Base-case modeling predicted that use of a PCT-guided treatment algorithm would results in hospital cost savings of $45 per patient and result in a gain of 0.0001 quality-adjusted life-year. After exclusion of patients in the postintervention cohort for PCT test ordering outside of institutional guidelines, the mean inpatient antibiotic therapy duration was significantly reduced in the postintervention group relative to the preintervention group (6.2 days versus 4.9 days, p = 0.04) after adjustment for patient sex and age, Charlson Comorbidity Index score, study period, vasopressor use, and ventilator use. Total annual hospital cost savings of $4,840 were predicted. CONCLUSION: Real-world implementation of PCT-guided antibiotic use may have improved patients' quality of life while decreasing hospital costs in MICU patients with undifferentiated sepsis.

Effects of a multifaceted intervention QI program to improve ICU performance.

BACKGROUND: To benefit from the increasing clinical evidence, organisational changes have been among the main drivers behind the reduction of ICU mortality during the last decade. Increasing demand, costs and complexity, amplifies the need for optimisation of clinical processes and resource utilisation. Thus, multidisciplinary teamwork and critical care processes needs to be adapted to profit from increased availability of human skill and technical resources in a cost-effective manner. Inadequate clinical performance and outcome data compelled us to design a quality improvement project to address current work processes and competence utilisation. METHODS: During revision period, clinical processes, professional performance and clinical competence were targeted using "scientific production management methodology" approach. As part of the project, an intensivist training program was instituted, and full time intensivist coverage was obtained in the process of creating multi-professional teams, composed of certified intensivists, critical care nurses, assistant nurses, physiotherapists and social counsellors. The use of staff resources and clinical work-processes were optimised in accordance with the outcome of a "value stream mapping". In this process, efforts to enhance the personal dynamics and performance within the teams were paramount. Clinical and economic outcome data were analysed during a seven year follow up period. RESULTS: • Consecutive reduced overall ICU (24%) and long-term (600 days) mortality. The effect on ICU mortality was especially pronounced in the subgroup of patients > 65 years (30%) • Consecutive reduced length of stay (43%, septic patients) and time on ventilator (for septic patients and patients > 65 years of age (23 resp.52%). • Substantial increase in life years gained (13,140 life years) as well as quality-adjusted life-years (9593 QALY: s) over the study period. • High cost-effectiveness as ICU costs were  reduced while patient outcomes were improved. Disregarding the cost reduction in ICU, the intervention is highly cost effective with cost- effectiveness ratios of (75€/QALY) and (55€ / life year) CONCLUSIONS: We have shown favourable results of a QI project aiming to improve the clinical performance and quality through the development of multi-professional interaction, teamwork and systematic revisions of work processes. The economic evaluation shows that the intervention is highly cost-effective and potentially dominating.

Telemedicine/Virtual ICU: Where Are We and Where Are We Going?

Intensive care unit telemedicine (tele-ICU) is technology enabled care delivered from off-site locations that was developed to address the increasing complexity of patients and insufficient supply of intensivists. Although tele-ICU deployment is increasing, it continues to cover only a small proportion of ICU patients. This is primarily due to expense, with first-year costs exceeding $50,000 per bed. Meta-analyses of outcomes indicate survival benefits and quality improvements, albeit with significant heterogeneity. Depending on the context, a wide range of estimated incremental cost-effectiveness ratios reflects variable effects on cost and outcomes, such as mortality or length of stay. Tele-ICUs may fit within a hybrid model of care to complement high-intensity ICU staff coverage. However, more research is required to foster consensus and determine best practices. This review summarizes data on tele-ICU structure, operations, outcomes, and costs. Evidence was extracted from meta-analyses, with secondary data from Cleveland Clinic's tele-ICU experience.

Is 24/7 In-House Intensivist Staffing Necessary in the Intensive Care Unit?

Over the past few decades, an increasing number of studies have shown that intensivist-staffed intensive care units (ICUs) lead to overall economic benefits and improved patient outcomes, including shorter length of stay and lower rates of complications and mortality. This body of evidence has convinced advocacy groups to adopt this staffing model as a standard of care in the ICU so that more hospitals are offering around-the-clock intensivist coverage. Even so, opponents have pointed to high ICU staffing costs and a shortage of physicians trained in critical care as barriers to implementing this model. While these arguments may hold true in low-acuity, low-volume ICUs, evidence has shown that in high-acuity, high-volume centers such as teaching hospitals and tertiary care centers, the benefits outweigh the costs. This article explores the history of intensivists and critical care, the arguments for 24/7 ICU staffing, and outcomes in various ICU settings but is not intended to be a comprehensive review of all controversies surrounding continuous ICU staffing.

Cost analysis of Omega-3 supplementation in critically ill patients with sepsis.

INTRODUCTION: Nutritional supplement of omega-3 fatty acids have been proposed to improve clinical outcomes in critically ill patients. While previous work have demonstrated that omega-3 supplementation in patients with sepsis is associated with reduced ICU and hospital length of stay, the financial impact of this intervention is unknown. OBJECTIVE: Perform a cost analysis to evaluate the impact of omega-3 supplementation on ICU and hospital costs. METHODS: We extracted data related to ICU and hospital length of stay from the individual studies reported in a recent systematic review. The Cochrane Collaboration tool was used to assess the risk of bias in these studies. Average daily ICU and hospital costs per patient were obtained from a cost study by Kahn et al. We estimated the ICU and hospital costs by multiplying the mean length of stay by the average daily cost per patient in ICU or Hospital. Adjustments for inflation were made according to the USD annual consumer price index. We calculated the difference between the direct variable cost of patients with omega-3 supplementation and patients without omega-3 supplementation. 95% confidence intervals were estimated using bootstrap re-sampling procedures with 1000 iterations. RESULTS: A total of 12 RCT involving 925 patients were included in this cost analysis. Septic patients supplemented with omega-3 had both lower mean ICU costs ($15,274 vs. $18,172) resulting in $2897 in ICU savings per patient and overall hospital costs ($17,088 vs. $19,778), resulting in $2690 in hospital savings per patient. Sensitivity analyses were conducted to investigate the impact of different study methods on the LOS. The results were still consistent with the overall findings. CONCLUSION: Patients with sepsis who received omega-3 supplementation had significantly shorter LOS in the ICU and hospital, and were associated with lower direct variable costs than control patients. The 12 RCTs used in this analysis had a high risk of bias. Large-scaled, high-quality, multi-centered RCTs on the effectiveness of this intervention is recommended to improve the quality of the existing evidence.

Is treatment of geriatric hip fracture patients cost-covering? Results of a prospective study conducted at a German University Hospital.

INTRODUCTION: Hip fractures have increased medical and socio-economic importance due to demographic transition. Information concerning direct treatment costs and their reimbursement in Germany is lacking. MATERIALS AND METHODS: Four hundred two hip fracture patients older than 60 years of age were observed prospectively at a German University Hospital. Treatment costs were determined with up to 196 cost factors and compared to the reimbursement. Finally, statistical analysis was performed to identify clinical parameters influencing the cost-reimbursement relation. RESULTS: Treatment costs were 8853 € (95% CI 8297-9410 €), while reimbursement was 8196 € (95% CI 7707-8772 €), resulting in a deficit of 657 € (95% CI 143-1117 €). Bivariate analysis showed that the cost-reimbursement relation was negatively influenced mainly by higher age, higher ASA score, readmission to the intensive care unit (ICU) and red blood cell transfusion. Adjusted for other parameters, readmission to the ICU was a significant negative predictor (- 2669 €; 95% CI - 4070 to - 1268 €; p < 0.001), while age of 60-75 years was a positive predictor for the cost-reimbursement relation (1373 €; 95% CI 265-2480 €; p = 0.015). CONCLUSIONS: Treatment of geriatric hip fracture patients in a university hospital in Germany does not seem to be cost-covering. Adjustment of the reimbursement for treatment of complex hip fracture patients should be considered.

Antimicrobial consumption, costs and resistance patterns: a two year prospective study in a Romanian intensive care unit.

BACKGROUND: Due to the vulnerable nature of its patients, the wide use of invasive devices and broad-spectrum antimicrobials used, the intensive care unit (ICU) is often called the epicentre of infections. In the present study, we quantified the burden of hospital acquired pathology in a Romanian university hospital ICU, represented by antimicrobial agents consumption, costs and local resistance patterns, in order to identify multimodal interventional strategies. METHODS: Between 1st January 2012 and 31st December 2013, a prospective study was conducted in the largest ICU of Western Romania. The study group was divided into four sub-samples: patients who only received prophylactic antibiotherapy, those with community-acquired infections, patients who developed hospital acquired infections and patients with community acquired infections complicated by hospital-acquired infections. The statistical analysis was performed using the EpiInfo version 3.5.4 and SPSS version 20. RESULTS: A total of 1596 subjects were enrolled in the study and the recorded consumption of antimicrobial agents was 1172.40 DDD/ 1000 patient-days. The presence of hospital acquired infections doubled the length of stay (6.70 days for patients with community-acquired infections versus 16.06/14.08 days for those with hospital-acquired infections), the number of antimicrobial treatment days (5.47 in sub-sample II versus 11.18/12.13 in sub-samples III/IV) and they increased by 4 times compared to uninfected patients. The perioperative prophylactic antibiotic treatment had an average length duration of 2.78 while the empirical antimicrobial therapy was 3.96 days in sample II and 4.75/4.85 days for the patients with hospital-acquired infections. The incidence density of resistant strains was 8.27/1000 patient-days for methicilin resistant Staphylococcus aureus, 7.88 for extended spectrum ß-lactamase producing Klebsiella pneumoniae and 4.68/1000 patient-days for multidrug resistant Acinetobacter baumannii. CONCLUSIONS: Some of the most important circumstances collectively contributing to increasing the consumption of antimicrobials and high incidence densities of multidrug-resistant bacteria in the studied ICU, are represented by prolonged chemoprophylaxis and empirical treatment and also by not applying the definitive antimicrobial therapy, especially in patients with favourable evolution under empirical antibiotic treatment. The present data should represent convincing evidence for policy changes in the antibiotic therapy.

Making the Case for Palliative Care at the System Level: Outcomes Data.

BACKGROUND: A recent trend in health care is to integrate palliative care (PC) programs across multiple hospitals to reduce variation, improve quality, and reduce cost. OBJECTIVE: The study objective was to demonstrate the benefits of PC for a system. METHODS: The study was a descriptive study using retrospective medical records in seven federated hospitals where PC developed differently before system integration. Measured were length of stay (LOS), mortality, readmissions, saved intensive care unit (ICU) days, cost avoidance, and hospice referrals. RESULTS: PC services within the first 48 hours of admission demonstrate a shorter LOS (5.08 days), reduced costs 40% ($2,362 per day), and decreased mortality (1.01 versus 1.10) for one hospital. Readmissions at 30, 60, and 90 days after a PC consult decreased (61.5%, 47.0%, and 42.1%, respectively). Annual pre- and postprogram referrals to hospice increased (65 to 107). Using modified matched pairs, LOS of PC patients seen within 48 hours of admission average 1.67 days less compared to non-PC patients. LOS for ICU patients with PC services in the ICU within the first 48 hours decreased by 1.12 days. Overall cost avoidance was 1.5 times total cost for PC programs systemwide. One pilot project using a full-time physician in the ICU reduced cost more than $600,000, with 315 saved ICU days, annualized. Systemwide, 69.3% of all referrals to hospice were made by the PC service. CONCLUSION: Early involvement of PC services emerged as advantageous to the net benefit. Given that health care's changing landscape will increasingly include bundled payment and risk holding strategies to improve quality and reduce cost in health care systems, systemwide PC will play a vital role.

Updated cost-effectiveness analysis of supplemental glutamine for parenteral nutrition of intensive-care patients.

BACKGROUND/OBJECTIVES: Intravenous (i.v.) glutamine supplementation of parenteral nutrition (PN) can improve clinical outcomes, reduce mortality and infection rates and shorten the length of hospital and/or intensive care unit (ICU) stays compared with standard PN. This study is a pharmacoeconomic analysis to determine whether i.v. glutamine supplementation of PN remains both a highly favourable and cost-effective option for Italian ICU patients. SUBJECTS/METHODS: A previously published discrete event simulation model was updated by incorporating the most up-to-date and clinically relevant efficacy data (a clinically realistic subgroup analysis from a published meta-analysis), recent cost data from the Italian health-care system and the latest epidemiology data from a large Italian ICU database (covering 230 Italian ICUs and more than 77,000 patients). Sensitivity analyses were performed to test the robustness of the results. RESULTS: Parenteral glutamine supplementation can significantly improve ICU efficiency in Italy, as the additional cost of supplemented treatment is more than completely offset by cost savings in hospital care. Supplementation was more cost-effective (cost-effectiveness ratio (CER)=[euro ]35,165 per patient discharged alive) than standard, non-supplemented PN (CER=[euro ]40,156 per patient discharged alive), and it resulted in mean cost savings of [euro ]4991 per patient discharged alive or [euro ]1047 per patient admitted to the hospital. Sensitivity analyses confirmed the robustness of these results. CONCLUSIONS: Alanyl-glutamine supplementation of PN is a clinically and economically attractive strategy for ICU patients in Italy and may be applicable to selected ICU patient populations in other countries.

[Concept for a department of intensive care]. / Konzept einer Klinik für Intensivmedizin.

BACKGROUND: Demographic change and increasing complexity are among the reasons for high-tech critical care playing a major and increasing role in today's hospitals. At the same time, intensive care is one of the most cost-intensive departments in the hospital. PREREQUISITES: To guarantee high-quality care, close cooperation of specialised intensive care staff with specialists of all other medical areas is essential. A network of the intensive care units within the hospital may lead to synergistic effects concerning quality of care, simultaneously optimizing the use of human and technical resources. GOAL: Notwithstanding any organisational concepts, development and maintenance of the highest possible quality of care should be of overriding importance.

Economic burden of routine hematologic tests and intensive care unit observation for elective anterior cervical discectomy and fusion.

BACKGROUND: Anterior cervical discectomy and fusion is one of the most common surgical interventions performed by spine surgeons. As efforts are made to control healthcare spending because of the limited or capped resources offered by the National Health Insurance, surgeons are faced with the challenge of offering high-level patient care while minimizing associated healthcare expenditures. Routine ordering of postoperative hematologic tests and observational intensive care unit (ICU) stay might be areas of potential cost containment. This study was designed to determine the necessity of routine postoperative hematologic tests and ICU stay for patients undergoing elective anterior cervical discectomy and fusion and to investigate whether the elimination of unnecessary postoperative laboratory blood studies and ICU stay inhibits patient care. METHODS: The necessity for postoperative blood tests was determined if there were needs for a postoperative blood transfusion and hospital readmission within 1 month after surgery. The necessity for postoperative ICU observation was decided if immediate surgical intervention was required when any kind of complications occurred during the ICU stay. RESULTS: There were 168 patients collected in the study. Among them, all had routine preoperative and postoperative blood tests and were transferred to ICU for observation. No need for blood transfusion was observed, and no patient required immediate surgical intervention when the complications occurred during the ICU stay. CONCLUSION: Cost savings per admission amounted to approximately 10% of the hospitalization cost by the elimination of unnecessary postoperative routine laboratory blood studies and observational ICU stay without waiving patient care in the current volatile, cost-conscious healthcare environment in Taiwan.

[Cross sectional study of structural quality of German intensive care units. A reevaluation of the DIVI register]. / Querschnittstudie der Strukturqualität deutscher Intensivstationen. Eine Reevaluation der Strukturdaten des DIVI-Registers.

BACKGROUND: Effectiveness of intensive care treatment is essential to cope with increasing costs. The German national register of intensive care established by the German Interdisciplinary Association for Intensive Care Medicine (DIVI) contains basic data on the structure of intensive care units in Germany. A repeat analysis of data of the DIVI register within 8 years provides information for the development of intensive care units under different economic circumstances. METHODS: The recent data on the structure of intensive care units were obtained in 2008 and compared with the primary multicenter study from 2000. The hospitals selected were a representative sample for the whole of Germany. Data on the status of the hospital, staff and technical facilities, foundation of the hospital and the statistics of mechanically ventilated patients were analyzed. RESULTS: The technical facilities and the number of staff have improved from 2000 to 2008. A smaller availability of diagnostic procedures and staff remain in hospitals for basic treatment outside normal working hours. The average utilization of intensive care unit beds was not altered. The existence of intermediate care units did not significantly change the proportion of patients with artificial ventilation or ventilation times. The number of beds in intensive care units was unchanged as was the average number of beds in units and the number of patients treated. A relevant number of beds of intensive care units shifted towards hospitals with private foundation without changes in the overall numbers. The structure of the hospitals was comparable at both time points. CONCLUSIONS: The introduction of intermediate care units did not alter ventilation parameters of patients in 2008 compared with 2000. There is no obvious medical reason for the shift of intensive care beds towards private hospitals. The number of staff and patients varied considerably between the intensive care units. The average number of patients treated per bed was not different between the periods or between hospitals with different structures. Overall availability of medical staff and diagnostic procedures increased during the study period. An increase of availability of fully trained medical staff in intensive care medicine is desirable to increase the quality of treatment.

Effectiveness and cost-effectiveness of supplemental glutamine dipeptide in total parenteral nutrition therapy for critically ill patients: a discrete event simulation model based on Italian data.

INTRODUCTION: The supplementation of alanyl-glutamine dipeptide in critically ill patients necessitating total parenteral nutrition (TPN) improves clinical outcomes, reducing mortality, infection rate, and shortening intensive care unit (ICU) hospital lengths of stay (LOSs), as compared to standard TPN regimens. METHODS: A Discrete Event Simulation model that incorporates outcomes rates from 200 Italian ICUs for over 60,000 patients, alanyl-glutamine dipeptide efficacy data synthesized by means of a Bayesian random effects meta-analysis, and national cost data has been developed to evaluate the alternatives from the cost perspective of the hospital. Simulated clinical outcomes are death and infection rates in ICU, death rate in general ward, and hospital LOSs. Sensitivity analyses are performed by varying all uncertain parameter values in a plausible range. RESULTS: The internal validation process confirmed the accuracy of the model in replicating observed clinical data. Alanyl-glutamine dipeptide on average results more effective and less costly than standard TPN: reduced mortality rate (24.6% ± 1.6% vs. 34.5% ± 2.1%), infection rate (13.8% ± 2.9% vs. 18.8% ± 3.9%), and hospital LOS (24.9 ± 0.3 vs. 26.0 ± 0.3 days) come at a lower total cost per patient (23,409 ± 3,345 vs. 24,161 ± 3,523 Euro).Treatment cost is completely offset by savings on ICU and antibiotic costs. Sensitivity analyses confirmed the robustness of these results. CONCLUSIONS: Alanyl-glutamine dipeptide is expected to improve clinical outcomes and to do so with a concurrent saving for the Italian hospital.

[Non-invasive mechanical ventilation in COPD]. / Nichtinvasive Beatmung bei COPD.

Non-invasive mechanical ventilation is the preferred method for the treatment of acute respiratory failure in patients with chronic obstructive pulmonary disease (COPD). Primary contraindications and stopping criteria must be regarded to avoid delaying endotracheal intubation. The primary interface is usually a nasal-oral mask. Cautious sedation can facilitate non-invasive ventilation in some patients. Under certain circumstances non-invasive ventilation may enable successful extubation in COPD patients with prolonged weaning. COPD patients can also benefit from preventive non-invasive ventilation in order to avoid re-intubation after a planned extubation. Domiciliary nocturnal non-invasive ventilation is an option for some patients with COPD in chronic hypercapnic respiratory failure. This treatment should be established in a specialised unit.

[Cost analysis of contrast-enhanced cranial MRI at a German university hospital]. / Kostenanalyse einer kontrastgestützten MRT des Schädels an einem Universitätsklinikum.

PURPOSE: Detailed evaluation and cost analysis of a cranial contrast-enhanced MRI (c-ceMRI) in outpatients, inpatients, patients in an intensive care unit and children under anesthesia. MATERIALS AND METHODS: Based on a detailed process-oriented model, we calculated the cost of a cranial MRI for the four situations mentioned above. A comprehensive evaluation of the overhead and personnel costs was performed. RESULTS: We performed 5108 MRI examinations on 2 scanners in the year 2008. 2150 examinations (42 %) were identified as c-ceMRI. For inpatients we calculated a total cost of € 242.46 per examination with a personnel cost of € 81.71 for the radiological department. In outpatients we calculated total costs of € 181.97 with radiological personnel costs of € 68.67. Patients coming from an intensive care unit were treated by an intensive care team, which resulted in total costs of € 416.58 with € 283 in costs for radiological personnel (32.8 %). MRI examinations of children under anesthesia resulted in costs of € 616.79 for the hospital, of which € 285.78 were radiological personnel costs (34.5 %). CONCLUSION: In this study we evaluated for the first time different radiological scenarios of a c-ceMRI at a university hospital. Considering the present reimbursement situation, all outpatients covered by statutory health insurance resulted in a deficit for the hospital. Particularly high costs for patients in intensive care units as well as for children under anesthesia have to be taken into account and are currently not adequately covered by care providers.