A cost analysis of colonoscopy using microcosting and time-and-motion techniques.

BACKGROUND: The cost of an individual colonoscopy is an important determinant of the overall cost and cost-effectiveness of colorectal cancer screening. Published cost estimates vary widely and typically report institutional costs derived from gross-costing methods. OBJECTIVE: Perform a cost analysis of colonoscopy using micro-costing and time-and-motion techniques to determine the total societal cost of colonoscopy, which includes direct health care costs as well as direct non-health care costs and costs related to patients' time. The design is prospective cohort. The participants were 276 contacted, eligible patients who underwent colonoscopy between July 2001 and June 2002, at either a Veterans' Affairs Medical Center or a University Hospital in the Southeastern United States. MAJOR RESULTS: The median direct health care cost for colonoscopy was $379 (25%, 75%; $343, $433). The median direct non-health care and patient time costs were $226 (25%, 75%; $187, $323) and $274 (25%, 75%; $186, $368), respectively. The median total societal cost of colonoscopy was $923 (25%, 75%; $805, $1047). The median direct health care, direct non-health care, patient time costs, and total costs at the VA were $391, $288, $274, and $958, respectively; analogous costs at the University Hospital were $376, $189, $368, and $905, respectively. CONCLUSION: Microcosting techniques and time-and-motion studies can produce accurate, detailed cost estimates for complex medical interventions. Cost estimates that inform health policy decisions or cost-effectiveness analyses should use total costs from the societal perspective. Societal cost estimates, which include patient and caregiver time costs, may affect colonoscopy screening rates.

Effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial.

CONTEXT: Lorazepam is currently recommended for sustained sedation of mechanically ventilated intensive care unit (ICU) patients, but this and other benzodiazepine drugs may contribute to acute brain dysfunction, ie, delirium and coma, associated with prolonged hospital stays, costs, and increased mortality. Dexmedetomidine induces sedation via different central nervous system receptors than the benzodiazepine drugs and may lower the risk of acute brain dysfunction. OBJECTIVE: To determine whether dexmedetomidine reduces the duration of delirium and coma in mechanically ventilated ICU patients while providing adequate sedation as compared with lorazepam. DESIGN, SETTING, PATIENTS, AND INTERVENTION: Double-blind, randomized controlled trial of 106 adult mechanically ventilated medical and surgical ICU patients at 2 tertiary care centers between August 2004 and April 2006. Patients were sedated with dexmedetomidine or lorazepam for as many as 120 hours. Study drugs were titrated to achieve the desired level of sedation, measured using the Richmond Agitation-Sedation Scale (RASS). Patients were monitored twice daily for delirium using the Confusion Assessment Method for the ICU (CAM-ICU). MAIN OUTCOME MEASURES: Days alive without delirium or coma and percentage of days spent within 1 RASS point of the sedation goal. RESULTS: Sedation with dexmedetomidine resulted in more days alive without delirium or coma (median days, 7.0 vs 3.0; P = .01) and a lower prevalence of coma (63% vs 92%; P < .001) than sedation with lorazepam. Patients sedated with dexmedetomidine spent more time within 1 RASS point of their sedation goal compared with patients sedated with lorazepam (median percentage of days, 80% vs 67%; P = .04). The 28-day mortality in the dexmedetomidine group was 17% vs 27% in the lorazepam group (P = .18) and cost of care was similar between groups. More patients in the dexmedetomidine group (42% vs 31%; P = .61) were able to complete post-ICU neuropsychological testing, with similar scores in the tests evaluating global cognitive, motor speed, and attention functions. The 12-month time to death was 363 days in the dexmedetomidine group vs 188 days in the lorazepam group (P = .48). CONCLUSION: In mechanically ventilated ICU patients managed with individualized targeted sedation, use of a dexmedetomidine infusion resulted in more days alive without delirium or coma and more time at the targeted level of sedation than with a lorazepam infusion. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00095251.

Improved compliance with quality measures at hospital discharge with a computerized physician order entry system.

BACKGROUND: Most measures used to assess the quality of care of hospitalized patients with congestive heart failure (CHF) and acute myocardial infarction (AMI) involve discharge medications and instructions. Implementation of disease-specific computerized physician order entry (CPOE) discharge tools may improve compliance with these measures. METHODS: We studied 286 versus 290 AMI and 595 versus 656 CHF discharges in the pre-CPOE (July 2001 to June 2002) and CPOE (October 2002 to September 2003) periods, respectively. Compliance with chosen quality measures (aspirin and beta-blocker use for AMI, ejection fraction determination and discharge instructions for CHF, and angiotensin-converting enzyme inhibitor use, and smoking cessation counseling for both) was assessed. RESULTS: Compliance with recommended discharge medications was high at baseline and did not change significantly. Smoking cessation counseling (43% vs 1% for CHF and 62% vs 21% for AMI) and discharge instructions for CHF (56% vs 3%) improved significantly in the CPOE period. Overall, 63% of patients with CHF and AMI in the CPOE period were discharged using the tools. Compliance with prescription of recommended medications was 100% among eligible patients when CPOE was used; however, this improvement was due entirely to better documentation of contraindications in the CPOE period. The actual proportion of patients who received discharge prescriptions between the pre-CPOE and CPOE periods did not change: beta-blockers (85% vs 84%), angiotensin-converting enzyme inhibitor for AMI (77% vs 76%), and for CHF (56% vs 61%). However, nonmedication measures significantly improved when CPOE was used. CONCLUSIONS: Implementation of a CPOE discharge tool improved compliance with selected quality measures in patients with AMI and CHF. Effective methods of rapid implementation and acceptance of these tools by providers require further study.

Assessment of adverse drug events among patients in a tertiary care medical center.

PURPOSE: Specific patient and clinical characteristics associated with an increased risk of sustaining an adverse event (AE) were identified. METHODS: AE reports for patients in a 658-bed tertiary care medical center between January 1, 2000, and June 30, 2002, were analyzed. The data collected from each report included medical record number, patient sex, patient age, clinical service, date of occurrence, diagnoses, type of error, suspected medication, and severity of the AE. A three-stage logistic regression model with high-risk indicators was used to evaluate key indicators of the most vulnerable patient populations. RESULTS: The number of control patients and those with AEs totaled 60,206. This population was then randomly split into two equal groups of patients: the training data set (n = 30,103) and the validation data set (n = 30,103). AEs occurred in a higher percentage of patients who were age <1 year, 1-15, 47-59, and > or =60 years than in other groups. A higher percentage of AEs were reported in men than women, but the groups were not significantly different when comparing those with an AE and those without an AE. Asian Indian patients demonstrated a high rate of AEs, but this may be a statistical artifact, reflecting their very small percentage in the study. Evaluation of admission sources revealed that doctors' offices, clinic referrals, and local hospital transfers accounted for higher rates of AEs than other sources. CONCLUSION: Certain age groups, diagnoses, admission sources, types of insurance, and the use of specific medications or medication classes were associated with increased AE rates at a tertiary care medical center.

Crew resource management training--clinicians' reactions and attitudes.

Many health care organizations are adopting crew resource management (CRM) training from the aviation industry as a patient safety practice. Although CRM has high face validity, its effects have not been thoroughly evaluated in aviation or health care. Its potential to improve team communication, coordination, and patient safety, however, makes efforts to study CRM necessary and worthwhile. This article evaluates clinicians' attitudes about and reactions to CRM after they participated in an eight-hour, commercially developed training program.

The impact of aviation-based teamwork training on the attitudes of health-care professionals.

BACKGROUND: Both the Institute of Medicine and the Agency for Healthcare Research and Quality suggest patient safety can be enhanced by implementing aviation Crew Resource Management (CRM) in health care. CRM emphasizes six key areas: managing fatigue, creating and managing teams, recognizing adverse situations (red flags), cross-checking and communication, decision making, and performance feedback. This study evaluates participant reactions and attitudes to CRM training. STUDY DESIGN: From April 22, 2003, to December 11, 2003, clinical teams from the trauma unit, emergency department, operative services, cardiac catheterization laboratory, and administration underwent an 8-hour training course. Participants completed an 11-question End-of-Course Critique (ECC), designed to assess the perceived need for training and usefulness of CRM skill sets. The Human Factors Attitude Survey contains 23 items and is administered on the same day both pre- and posttraining. It measures attitudinal shifts toward the six training modules and CRM. RESULTS: Of the 489 participants undergoing CRM training during the study period, 463 (95%) completed the ECC and 338 (69%) completed the Human Factors Attitude Survey. The demographics of the group included 288 (59%) nurses and technicians, 104 (21%) physicians, and 97 (20%) administrative personnel. Responses to the ECC were very positive for all questions, and 95% of respondents agreed or strongly agreed CRM training would reduce errors in their practice. Responses to the Human Factors Attitude Survey indicated that the training had a positive impact on 20 of the 23 items (p < 0.01). CONCLUSIONS: CRM training improves attitudes toward fatigue management, team building, communication, recognizing adverse events, team decision making, and performance feedback. Participants agreed that CRM training will reduce errors and improve patient safety.

Behind-the-scenes of patient-centered care: content analysis of electronic messaging among primary care clinic providers and staff.

BACKGROUND: Transitions to patient-centered health care, the increasing complexity of care, and growth in self-management have all increased the frequency and intensity of clinical services provided outside office settings and between visits. Understanding how electronic messaging, which is often used to coordinate care, affects care is crucial. A taxonomy for codifying clinical text messages into standardized categories could facilitate content analysis of work performed or enhanced via electronic messaging. OBJECTIVE: To codify electronic messages exchanged among the primary care providers and the staff managing diabetes patients at an academic medical center. RESEARCH DESIGN: Retrospective analysis of 27,061 electronic messages exchanged among 578 providers and staff caring for a cohort of 639 adult primary care patients with diabetes between April 1, 2003 and October 31, 2003. SUBJECTS: Providers and staff using locally developed electronic messaging in an academic medical center's adult primary care clinic. MEASURES: Raw data included clinical text message content, message ID, thread ID, and user ID. Derived measures included user job classification, 35 flags codifying message content, and a taxonomy grouping the flags. RESULTS: Messages contained diverse content: communications with patients, families, and other providers (47.2%), diagnoses (25.4%), documentation (33%), logistics and support functions (29.6%), medications (32.9%), and treatments (28.9%). All messages could be classified; 59.5% of messages addressed 2 or more content areas. CONCLUSIONS: Systematic content analysis of provider and staff electronic messages yields specific insight regarding clinical and administrative work carried out via electronic messaging.

A randomized controlled trial to prevent glycemic relapse in longitudinal diabetes care: study protocol (NCT00362193).

BACKGROUND: Diabetes is a common disease with self-management a key aspect of care. Large prospective trials have shown that maintaining glycated hemoglobin less than 7% greatly reduces complications but translating this level of control into everyday clinical practice can be difficult. Intensive improvement programs are successful in attaining control in patients with type 2 diabetes, however, many patients experience glycemic relapse once returned to routine care. This early relapse is, in part, due to decreased adherence in self-management behaviors. OBJECTIVE: This paper describes the design of the Glycemic Relapse Prevention study. The purpose of this study is to determine the optimal frequency of maintenance intervention needed to prevent glycemic relapse. The primary endpoint is glycemic relapse, which is defined as glycated hemoglobin greater than 8% and an increase of 1% from baseline. METHODS: The intervention consists of telephonic contact by a nurse practitioner with a referral to a dietitian if indicated. This intervention was designed to provide early identification of self-care problems, understanding the rationale behind the self-care lapse and problem solve to find a negotiated solution. A total of 164 patients were randomized to routine care (least intensive), routine care with phone contact every three months (moderate intensity) or routine care with phone contact every month (most intensive). CONCLUSION: The baseline patient characteristics are similar across the treatment arms. Intervention fidelity analysis showed excellent reproducibility. This study will provide insight into the important but poorly understood area of glycemic relapse prevention.

Volatility: a new vital sign identified using a novel bedside monitoring strategy.

BACKGROUND: SIMON (Signal Interpretation and Monitoring) monitors and archives continuous physiologic data in the ICU (HR, BP, CPP, ICP, CI, EDVI, SVO2, SPO2, SVRI, PAP, and CVP). We hypothesized: heart rate (HR) volatility predicts outcome better than measures of central tendency (mean and median). METHODS: More than 600 million physiologic data points were archived from 923 patients over 2 years in a level one trauma center. Data were collected every 1 to 4 seconds, stored in a MS-SQL 7.0 relational database, linked to TRACS, and de-identified. Age, gender, race, Injury Severity Score (ISS), and HR statistics were analyzed with respect to outcome (death and ventilator days) using logistic and Poisson regression. RESULTS: We analyzed 85 million HR data points, which represent more than 71,000 hours of continuous data capture. Mean HR varied by age, gender and ISS, but did not correlate with death or ventilator days. Measures of volatility (SD, % HR >120) correlated with death and prolonged ventilation. CONCLUSIONS: 1) Volatility predicts death better than measures of central tendency. 2) Volatility is a new vital sign that we will apply to other physiologic parameters, and that can only be fully explored using techniques of dense data capture like SIMON. 3) Densely sampled aggregated physiologic data may identify sub-groups of patients requiring new treatment strategies.

For the record.

The author relates her personal journey toward understanding her role as an academic and as a practitioner. She ponders what, exactly, is the nature of her role and her conclusion is: "For me, the answer is that I am first and foremost an advocate, and the roots of my advocacy run deep."

Impact of transaction costs on healthcare outcomes.

This article reviews transaction cost economics to frame a discussion of how inefficiencies in healthcare delivery processes affect clinical outcomes and differentiate between inefficiencies that are tractable from those that are transitional or intractable. Recognizing and quantifying these effects improves the ability of organizations to calculate returns on investment in quality improvement, research and development and related value enhancing, but it is subject to high-risk undertakings.

Suboptimal statin adherence and discontinuation in primary and secondary prevention populations.

OBJECTIVES: To compare statin nonadherence and discontinuation rates of primary and secondary prevention populations and to identify factors that may affect those suboptimal medication-taking behaviors. DESIGN: Retrospective cohort utilizing pharmacy claims and administrative databases. SETTING: A midwestern U.S. university-affiliated hospital and managed care organization (MCO). PATIENTS: Non-Medicaid MCO enrollees, 18 years old and older, who filled 2 or more statin prescriptions from January 1998 to November 2001; 2258 secondary and 2544 primary prevention patients were identified. MEASUREMENTS: Nonadherence was assessed by the percent of days without medication (gap) over days of active statin use, a measurement known as cumulative multiple refill-interval gap (CMG). Discontinuation was identified by cessation of statin refills prior to the end of available pharmacy claims data. RESULTS: On average, the primary and secondary groups went without medication 20.4% and 21.5% of the time, respectively (P=.149). Primary prevention patients were more likely to discontinue statin therapy relative to the secondary prevention cohort (relative risk [RR], 1.24; 95% confidence interval [CI], 1.08 to 1.43). Several factors influenced nonadherence and discontinuation. Fifty percent of patients whose average monthly statin copayment was < US dollars 10 discontinued by the end of follow-up (3.9 years), whereas 50% of those who paid >US dollars 10 but US dollars 20 discontinued by 2.2 and 1.0 years, respectively (RR, 1.39 and 4.30 relative to

Reduced heart rate volatility: an early predictor of death in trauma patients.

OBJECTIVE: To determine if using dense data capture to measure heart rate volatility (standard deviation) measured in 5-minute intervals predicts death. BACKGROUND: Fundamental approaches to assessing vital signs in the critically ill have changed little since the early 1900s. Our prior work in this area has demonstrated the utility of densely sampled data and, in particular, heart rate volatility over the entire patient stay, for predicting death and prolonged ventilation. METHODS: Approximately 120 million heart rate data points were prospectively collected and archived from 1316 trauma ICU patients over 30 months. Data were sampled every 1 to 4 seconds, stored in a relational database, linked to outcome data, and de-identified. HR standard deviation was continuously computed over 5-minute intervals (CVRD, cardiac volatility-related dysfunction). Logistic regression models incorporating age and injury severity score were developed on a test set of patients (N = 923), and prospectively analyzed in a distinct validation set (N = 393) for the first 24 hours of ICU data. RESULTS: Distribution of CVRD varied by survival in the test set. Prospective evaluation of the model in the validation set gave an area in the receiver operating curve of 0.81 with a sensitivity and specificity of 70.1 and 80.0, respectively. CVRD predict death as early as 24 hours in the validation set. CONCLUSIONS: CVRD identifies a subgroup of patients with a high probability of dying. Death is predicted within first 24 hours of stay. We hypothesize CVRD is a surrogate for autonomic nervous system dysfunction.

Costs associated with delirium in mechanically ventilated patients.

OBJECTIVE: To determine the costs associated with delirium in mechanically ventilated medical intensive care unit patients. DESIGN: Prospective cohort study. SETTING: A tertiary care academic hospital. PATIENTS: Patients were 275 consecutive mechanically ventilated medical intensive care unit patients. INTERVENTIONS: We prospectively examined patients for delirium using the Confusion Assessment Method for the Intensive Care Unit. MEASUREMENTS AND MAIN RESULTS: Delirium was categorized as "ever vs. never" and by a cumulative delirium severity index. Costs were determined from individual ledger-level patient charges using cost-center-specific cost-to-charge ratios and were reported in year 2001 U.S. dollars. Fifty-one of 275 patients (18.5%) had persistent coma and died in the hospital and were excluded from further analysis. Of the remaining 224 patients, delirium developed in 183 (81.7%) and lasted a median of 2.1 (interquartile range, 1-3) days. Baseline demographics were similar between those with and without delirium. Intensive care unit costs (median, interquartile range) were significantly higher for those with at least one episode of delirium ($22,346, $15,083-$35,521) vs. those with no delirium ($13,332, $8,837-$21,471, p <.001). Total hospital costs were also higher in those who developed delirium ($41,836, $22,782-$68,134 vs. $27,106, $13,875-$37,419, p =.002). Higher severity and duration of delirium were associated with incrementally greater costs (all p <.001). After adjustment for age, comorbidity, severity of illness, degree of organ dysfunction, nosocomial infection, hospital mortality, and other potential confounders, delirium was associated with 39% higher intensive care unit (95% confidence interval, 12-72%) and 31% higher hospital (95% confidence interval, 1-70%) costs. CONCLUSIONS: Delirium is a common clinical event in mechanically ventilated medical intensive care unit patients and is associated with significantly higher intensive care unit and hospital costs. Future efforts to prevent or treat intensive care unit delirium have the potential to improve patient outcomes and reduce costs of care.