Impact of children with complex chronic conditions on costs in a tertiary referral hospital

ABSTRACT OBJECTIVES To investigate the impact of complex chronic conditions on the use of healthcare resources and hospitalization costs in a pediatric ward of a public tertiary referral university hospital in Brazil. METHODS This is a longitudinal study with retrospective data collection. Overall, three one-year periods, separated by five-year intervals (2006, 2011, and 2016), were evaluated. Hospital costs were calculated in three systematic samples of 100 patients each, consisting of patients with and without complex chronic conditions in proportion to their participation in the studied year. RESULTS Over the studied period, the hospital received 2,372 admissions from 2,172 patients. The proportion of hospitalized patients with complex chronic conditions increased from 13.3% in 2006 to 16.9% in 2016 as a result of a greater proportion of neurologically impaired children, which rose from 6.6% to 11.6% of the total number of patients in the same period. Patients' complexity also progressively increased, which greatly impacted the use of healthcare resources and costs, increasing by 11.6% from 2006 (R$1,300,879.20) to 2011 (R$1,452,359.71) and 9.4% from 2011 to 2016 (R$1,589,457.95). CONCLUSIONS Hospitalizations of pediatric patients with complex chronic conditions increased from 2006 to 2016 in a Brazilian tertiary referral university hospital, associated with an important impact on hospital costs. Policies to reduce these costs in Brazil are greatly needed.

Effect of COVID-19 pandemic decisions on tertiary-level surgical services in Pietermaritzburg, KwaZulu-Natal Province, South Africa.

BACKGROUND: The COVID-19 pandemic has led to the implementation of restrictive policies on theatre procedures, with profound impacts on service delivery and theatre output. OBJECTIVES: To quantify these effects at a tertiary hospital in KwaZulu-Natal Province, South Africa. METHODS: A retrospective review of morbidity and mortality data was conducted. The effects on emergency and elective caseload, intensive care unit (ICU) admissions from theatre, theatre cancellations and regional techniques were noted. RESULTS: Theatre caseload decreased by 30% from January to April 2020 (p=0.02), ICU admissions remained constant, and theatre cancellations were proportionally reduced, as were the absolute number of regional techniques. CONCLUSIONS: The resulting theatre case deficit was 1 260 cases. It will take 315 days to clear this deficit if four additional surgeries are performed per day.

Identification and referral of patients with refractory epilepsy from the primary to the tertiary care interface in New South Wales, Australia.

OBJECTIVES: This mixed-method feasibility study conducted in New South Wales (NSW), Australia, aimed to explore clinical practices around the identification of patients with refractory epilepsy and referral from primary care to Tertiary Epilepsy Centers. The perceptions of general practitioners, neurologists, and adults living with refractory epilepsy were considered. METHODS: Fifty-two data collection events were achieved through 22 semi-structured interviews with six neurologists and 12 adults who currently have, or have had refractory epilepsy, and four family members, 10 clinical observations of patient consultations and 20 surveys with general practitioners. A thematic analysis was conducted on the qualitative data alongside assessment of observational fieldnotes and survey data. FINDINGS: Two main themes emerged: 1) Patient healthcare pathways and care experiences highlighted the complex and deeply contextualized experiences of both patients and healthcare professionals, from first identification of people's seizures, in primary and community care settings, to referral to Tertiary Epilepsy Centers, shedding light on a fragmented, nonstandardized referral process, influenced by both individual and shared-care practices. 2) Factors impacting referrals and patient pathways indicated that onward referral to a Tertiary Epilepsy Center is affected by the knowledge, or the lack thereof, of healthcare professionals regarding treatment options. Barriers include limited person-centered care, shared decision-making, and refractory epilepsy education for healthcare professionals, which can delay patients' disease identification and can hinder speedy referral pathways and processes, in Australia for up to 17 years. In addition, person-centered communication around care pathways is affected by relationships between clinicians, patients, and family members. CONCLUSION: This study has identified a noticeable lack of standardized care across epilepsy-related healthcare sectors, which recognizes a need for developing and implementing clearer epilepsy-related guidelines and Continuing Professional Development in the primary and community care settings. This, however, requires greater collaboration and commitment in the primary, community, and tertiary care sectors to address the ongoing misconceptions around professional roles and responsibilities to optimize shared-care practices. Ultimately, prioritizing person-centered care on both patients' and professionals' agendas, in order to improve satisfaction with care experiences of people living with complex epilepsy.

Evaluation of serum alkaline phosphatase as a marker of metastasis in early breast cancer / Evaluación de la fosfatasa alcalina sérica como marcador de metástasis en cáncer de mama precoz

INTRODUCTION: Breast cancer is a common worldwide healthcare problem. Identifying metastatic lesions is crucial for adequate staging. However, there is no standardized metastatic work-up in early-stage breast cancer patients. MATERIALS AND METHODS: We retrospectively analyzed data from patients treated in a tertiary hospital for clinical early-stage breast cancer, to assess the value of alkaline phosphatase (ALP) as a predictor of metastasis and as a prognostic factor. RESULTS: We detected a significant correlation between ALP and metastasis at diagnosis, and found that ALP is both a sensitive and specific marker in screening for metastasis in early-stage breast cancer. CONCLUSION: ALP is a useful marker of metastasis at diagnosis. Further prospective studies are needed to delineate the incidence and impact of missed metastatic patients if metastatic work-up is omitted

INTRODUCCIÓN: El cáncer de mama es un problema de salud común en todo el mundo. La identificación de lesiones metastásicas es crucial para una estadificación adecuada. Sin embargo, no hay un estudio metastásico estandarizado en pacientes de cáncer de mama precoz. MATERIALES Y MÉTODOS: Se analizaron retrospectivamente datos de pacientes tratados en un hospital terciario por cáncer de mama en estadio clínico temprano, para evaluar el valor de la fosfatasa alcalina (ALP) como predictor de metástasis y como factor pronóstico. RESULTADOS: Los autores detectaron correlación significativa entre ALP y metástasis en el momento del diagnóstico, y demostraron que ALP es un marcador sensible y específico en la detección de metástasis en cáncer de mama precoz. CONCLUSIÓN: La ALP es útil en el diagnóstico de metástasis en el momento de la valoración. Se necesitan más estudios prospectivos para delinear la incidencia y el impacto de los pacientes metastásicos perdidos, si se omite el análisis metastásico

Long-term mortality of patients discharged from the hospital after successful critical care in the ICU in Korea: a retrospective observational study in a single tertiary care teaching hospital.

BACKGROUND: The long-term outcomes of patients discharged from the hospital after successful care in intensive care unit (ICU) are not briskly evaluated in Korea. The aim of this study was to assess long-term mortality of patients treated in the ICU and discharged alive from the hospital and to identify predictive factors of mortality. METHODS: In 3,679 adult patients discharged alive from the hospital after ICU care between 2006 and 2011, the 1-year mortality rate (primary outcome measure) was investigated. Various factors were entered into multivariate analysis to identify independent factors of 1-year mortality, including sex, age, severity of illness (APACHE II score), mechanical ventilation, malignancy, readmission, type of admission (emergency, elective surgery, and medical), and diagnostic category (trauma and non-trauma). RESULTS: The 1-year mortality rate was 13.4%. Risk factors that were associated with 1-year mortality included age (hazard ratio: 1.03 [95% CI, 1.02-1.04], P < 0.001), APACHE II score (1.03 [1.01-1.04], P < 0.001), mechanical ventilation (1.96 [1.60-2.41], P < 0.001), malignancy (2.31 [1.82-2.94], P < 0.001), readmission (1.65 [1.31-2.07], P < 0.001), emergency surgery (1.66 [1.18-2.34], P = 0.003), ICU admission due to medical causes (4.66 [3.68-5.91], P < 0.001), and non-traumatic diagnostic category (6.04 [1.50-24.38], P = 0.012). CONCLUSIONS: The 1-year mortality rate was 13.4%. Old age, high APACHE II score, mechanical ventilation, malignancy, readmission, emergency surgery, ICU admission due to medical causes, and non-traumatic diagnostic category except metabolic/endocrinologic category were associated with 1-year mortality.

Modelo de evaluación del plan de respuesta frente a la pandemia de COVID-19 en un hospital de tercer nivel / Assessment model for evaluating the preparedness plan for COVID-19 in a tertiary care hospital

ANTECEDENTES Y OBJETIVO: Durante la primera onda epidémica del SARS-CoV-2, los hospitales han soportado una importante presión asistencial. Este escenario de incertidumbre, baja evidencia científica y medios insuficientes ha generado una importante variabilidad de la práctica entre diferentes centros sanitarios. En este contexto, planteamos desarrollar un modelo basado en estándares para la evaluación del sistema de preparación y respuesta frente a la COVID-19 en un hospital terciario. MATERIALES Y MÉTODOS: El estudio se llevó a cabo en el Hospital Universitario Vall d'Hebron de Barcelona en dos fases: 1) desarrollo de modelo de estándares mediante revisión narrativa de la literatura, análisis de planes y protocolos del hospital, método Delphi por profesionales expertos y plan de actualización y 2) validación de aplicabilidad y utilidad del modelo mediante autoevaluación y auditoría. RESULTADOS: El modelo consta de 208 estándares distribuidos en nueve criterios: liderazgo y estrategia; prevención y control de la infección; gestión de profesionales y competencias; áreas públicas comunes; áreas asistenciales; áreas de apoyo asistencial; logística, tecnología y obras; comunicación y atención al paciente; sistemas de información e investigación. La evaluación alcanza un 85,2% de cumplimiento, y se identifican 42 áreas de mejora y 96 buenas prácticas. CONCLUSIONES: La implementación de un modelo basado en estándares es útil para identificar áreas de mejora y buenas prácticas en los planes de preparación y respuesta frente a la COVID-19 en un hospital. En el actual contexto, proponemos la conveniencia de adaptar esta metodología a otros ámbitos de atención sanitaria no hospitalaria o de salud pública

BACKGROUND AND PURPOSE: During the first wave of the epidemic caused by SARS-CoV-2, hospitals have come under significant pressure. This scenario of uncertainty, low scientific evidence, and insufficient resources, has generated significant variability in practice between different health organisations. In this context, it is proposed to develop a standards-based model for the evaluation of the preparedness and response system against COVID-19 in a tertiary hospital. MATERIALS AND METHODS: The study, carried out at the University Hospital of Vall d'Hebron in Barcelona (Spain), was designed in two phases: 1) development of the standards-based model, by means of a narrative review of the literature, analysis of plans and protocols implemented in the hospital, a review process by expert professionals from the centre, and plan of action, and 2) validation of usability and usefulness of the model through self-assessment and hospital audit. RESULTS: The model contains 208 standards distributed into nine criteria: leadership and strategy; prevention and infection control; management of professionals and skills; public areas; healthcare areas; areas of support for diagnosis and treatment; logistics, technology and works; communication and patient care; and information and research systems. The evaluation achieved 85.2% compliance, with 42 areas for improvement and 96 good practices identified. CONCLUSIONS: Implementing a standards-based model is a useful tool to identify areas for improvement and good practices in COVID-19 preparedness and response plans in a hospital. In the current context, it is recommended to repeat this methodology in other non-hospital and public health settings

Ultrasonographic length of morphologically-normal kidneys in children presented to a premier tertiary healthcare setting of Sri Lanka.

BACKGROUND: Accurate prediction of reference ranges of renal lengths facilitates clinical decision making. Currently a single renal-length-reference chart is used for both kidneys, which is solely based on the age of the child without adjusting for anthropometrics. Objective of the study is to assess the length of morphologically-normal kidneys ultrasonically and to build models to predict the renal lengths of children presenting at the Radiology Department of Lady Ridgeway Hospital for Children. METHODS: A descriptive cross sectional study was done among 424 children with 233 males and 191 females at the study setting. Study population included children undergoing abdominal ultrasound scans for indications not related to renal disease. Children with a family history of renal diseases or with morphologically-abnormal kidneys were excluded. Bipolar-lengths of kidneys, gender and anthropometrics were documented. Having tested for assumptions, Wilcoxon-signed rank test, Mann-Whitney U test and multiple linear regression were used. RESULTS: The mean (SD) bipor-length of right and left kidneys were 6.83 (1.43) and 7.05 (1.36) respectively (p < 0.001). Age, height and weight were significantly correlated with the renal lengths (p < 0.05). Until 16 months, there was a significant difference between the renal lengths between males and females (P < 0.05). Yet the association with gender was not significant from 17 months and in overall. Until 16 months, the best linear-regression equation (p < 0.001) for the left kidney was; 3.827 +  0.019(length in centimeters) +  0.141(weight in kilograms) - 0.023(age in months) - 0.347(for male sex). For the right kidney, it was; 3.888 + 0.020(length or height) + 0.121(weight) - 0.037(age) - 0.372 (for male sex). The respective R squares were 59.2 and 53.5% with VIF (Variance-Inflation-Factor) ranging from 1.06 to 2.08. From 17 months, best equation for left kidney (p < 0.001) was; 5.651+ 0.022(age) + 0.01(BMI). For right kidney it was; 5.336 + 0.022(age) + 0.012(BMI). The R squares were 62.5 and 66.1% with VIF being 1. CONCLUSIONS: The established models explain more variability for children above 17 months. Both renal lengths are affected significant by the body's' anthropometric parameters. For each kidney, separate normograms of renal lengths which are local-context-specific must be prepared. Further research must be promoted.

Workplace violence and risk for psychiatric morbidity among health workers in a tertiary health care setting in Nigeria: Prevalence and correlates.

The objectives were to evaluate the workplace violence and risk for psychiatric morbidity, as well as their correlates, among health workers in a tertiary healthcare setting in Nigeria. A stratified random sampling technique was used to recruit the health workers. Each participant was administered a socio-demographic questionnaire, the ILO/ICN/WHO/PSI Workplace Violence Questionnaire and the 12- item General Health Questionnaire. A total of 380 health workers were recruited, with a mean age of 36.4 (±7.64) years. The prevalence rates of workplace violence and risk of psychiatric morbidity were 39.9% and 38.5%. Factors with independent associations with workplace violence included young age, female sex and worry about workplace violence while a widowed, separated or divorced marital status and being victim of workplace violence independently increased risk for developing psychiatric morbidity. This study therefore showed that workplace violence is common in the health care setting, and significant proportion of workers are at risk for developing psychiatric morbidity. These observations suggest need for the regular mental health screening of health workers, as well as the need for programmes aimed at preventing workplace violence in this setting.

Complicaciones de la analgesia continua invasiva para el control del dolor agudo postoperatorio en un hospital de tercer nivel. Incidencia de complicaciones técnicas y uso de métodos de analgesia alternativos / Complications of continuous catheter analgesia for postoperative pain management in a tertiary care hospital. Incidence of technical complications and alternative analgesia methods used

Antecedentes: La analgesia continua invasiva es el método de referencia para el manejo del dolor postoperatorio en cirugía mayor pero no está exenta de posibles complicaciones. Existe poca información sobre las complicaciones de las técnicas analgésicas continuas con catéter (TACC) y su impacto en el control del dolor. Material y métodos: Diseñamos un estudio prospectivo longitudinal incluyendo a pacientes tratados mediante cirugía que recibieron una TACC postoperatoria. Se registraron el tipo de analgesia, la intensidad del dolor mediante escala NRS, las características de las TACC, sus complicaciones técnicas y la satisfacción de los pacientes. Se aplicó estadística descriptiva y análisis comparativo mediante t de Student. Resultados: Se registraron datos de 106 pacientes. La duración de las TACC fue 47,52 ± 21,23 h; 52 pacientes (49,1%) fueron controlados en hospitalización convencional y 54 (50,9%) en unidades de críticos o alta dependencia. La tasa global de complicaciones técnicas fue del 9,43%. Las complicaciones más frecuentes fueron desplazamiento del catéter (2,38%), inflamación en el punto de inserción del catéter IV (2,38%) y dosificación excesiva de analgésicos (2,38%). El valor medio de NRS fue ≤ 3 durante la permanencia de la TACC. La intensidad máxima de dolor fue mayor en los pacientes con complicaciones técnicas (media ± desviación estándar [x̅ ± DE]: 4,4 ± 2,8 vs. 2,9 ± 1,9; p < 0,05). La satisfacción con la comodidad de la técnica y la satisfacción global con el tratamiento del dolor se redujeron significativamente en presencia de complicaciones. Conclusiones: La incidencia de complicaciones técnicas de las TACC fue del 9,43% y tuvieron un impacto negativo en el control del dolor postoperatorio y en la satisfacción de los pacientes

Background: Continuous invasive analgesia remains the gold-standard method for managing acute post-operative pain after major surgery. However, this procedure is not exempt from complications that may have detrimental effects on the patient and affect the post-operative recovery process. Data of the complications of continuous catheter analgesic techniques (CCATs) and their impact on pain relief are scarce in the literature. Material and methods: We conducted a prospective longitudinal study and patients who underwent a surgical procedure and received continuous invasive analgesia after surgery were included. Post-operative analgesic strategy, pain scores (NRS), CCAT's characteristics and technical complications were recorded. Patient satisfaction was determined. Descriptive statistics and Student's t-tests were applied for the comparative analyses. Results: We collected data from 106 patients. Mean duration of the CCAT was 47.52±21.23hours and 52 patients (49.1%) were controlled in conventional hospitalisation units whereas 54 patients (50.9%) were controlled on intensive or high-dependency care units. The overall incidence of technical complications was 9.43%. The most common complications were catheter displacement (2.38%), inflammation at the IV catheter insertion point (2.38%) and excessive dosing of analgesic drugs (2.38%). Mean NRS scores were ≤3 during the permanence of CCATs. Maximum pain intensity was significantly higher in patients who suffered technical complications (mean±standard deviation [x̅ ± SD]: 4.4 ± 2.8 vs. 2.9 ± 1.9; P<0.05). Satisfaction levels with the technique and overall satisfaction with the pain management strategy were negatively impacted by the occurrence of complications. Conclusions: The incidence of technical complications of CCATs was 9.43% and had a negative impact in pain control and patient's satisfaction

Illness perception in patients with migraine: An exploratory study in a tertiary care headache centre.

BACKGROUND: Illness perception is significantly related to several outcome measures in different medical conditions. However, little is known about headache-related causal attributions and cognitive and emotional representations in patients with migraine. OBJECTIVE: To examine perceived causes of headache and demographic, clinical, and psychological correlates and predictors of illness perception in patients with migraine attending a tertiary care headache centre. METHODS: A sample of 143 patients with migraine (85.3% women, mean age 44.0 ±â€¯12.1 years) completed the Brief Illness Perception Questionnaire (Brief IPQ), the Symptom Questionnaire (SQ), and the Migraine Disability Assessment (MIDAS) Questionnaire. A set of demographic and clinical characteristics was also collected. RESULTS: Stress, heredity, and nervousness were the most frequent perceived causes of headache. Female gender was significantly related to higher Brief IPQ "consequences" and "emotional response" scores. Increased psychological distress and a poorer clinical course were significantly associated with more negative illness representations. In multiple regression analysis, a longer illness duration, increased depressive symptoms, and higher levels of headache-related disability and painfulness of headache attacks independently predicted a worse illness perception. CONCLUSIONS: In patients with migraine, depressive symptoms and a worse disease status, characterized by a longer history of suffering, higher disability and more painful headache attacks, may negatively affect illness perception. It could also be that dysfunctional illness representations lead to depressive symptoms and decrease patients' motivation to adhere to treatments, resulting in a worse outcome. Future studies should examine whether the improvement of illness perception through specific psychological interventions may promote a better adaptation to migraine.

Impact of specific training in anaphylaxis for triage nursing staff in the Pediatric Emergency Department of a Tertiary Hospital

Background: After a diagnosis of anaphylaxis, patients receive action management plans to prevent and treat new episodes, including attending the emergency department for follow-up or further treatment. In a previous study, we observed that more than half of the children with anaphylaxis were incorrectly prioritized in our Pediatric Emergency Unit (PEU), thus delaying their treatment. In conjunction with our PEU staff, we designed a basic educational intervention (BEI) to try to solve this problem. We analyzed the effect of the intervention on triage of children subsequently diagnosed with anaphylaxis. Methods: Our BEI consisted of a training lecture given to the PEU triage nurses and the design of a reference card highlighting symptoms and risk factors of anaphylaxis. We included 138 children with a medical diagnosis of anaphylaxis and assessed modifications in their triage priority level and waiting times (WT) before seeing a physician after our intervention. According to the BEI implementation date, 69 children were diagnosed before the intervention (G1) and 69 after (G2). Clinical data were compared to assess the severity of the episodes. Results: There were no differences between the groups. WT decreased (from 8 to 1 minute; P=.03), and the number of correctly identified patients increased after the BEI (36.2% [G1] and 72.2% [G2]; P=.0001). Conclusions: Our BEI was effective, improving the identification and prioritization of children with anaphylaxis and reducing their WT. We need to pay attention to the functioning of our patients' reference emergency department and establish interdisciplinary measures that enable optimal management of anaphylaxis

Introducción: Tras un diagnóstico de anafilaxia los pacientes reciben planes de tratamiento para prevenir y tratar nuevos episodios, que incluyen acudir a Urgencias para control o tratamiento subsiguientes. Previamente, nuestro grupo había observado que más de la mitad de los niños con anafilaxia eran priorizados incorrectamente en nuestra Unidad de Urgencias de Pediatría (UP). Elaboramos, en colaboración con el personal de UP, una intervención educativa básica (IEB) para resolver el problema. Analizamos el efecto de dicha intervención en el triaje de los niños atendidos posteriormente por anafilaxia. Métodos: Nuestra IEB consistió en una sesión clínica para el personal de enfermería responsable del triaje y diseñamos una Reference Card destacando síntomas y factores de riesgo de anafilaxia.Incluimos 138 niños con diagnóstico de anafilaxia, analizando los cambios en el nivel de prioridad, tiempos de espera para valoración médica (TEM) tras nuestra IEB. Según la fecha de implementación, 69 niños fueron atendidos antes (G1) y el resto después (69). Se compararon además los datos clínicos de los episodios. Resultados: No hubo diferencias en los datos clínicos entre grupos. Los TEM disminuyeron (de 8 a 1 minutos [p: 0,03]), incrementándose las cifras de pacientes priorizados correctamente (36,2% [G1] y 72,2% [G2][p=0,0001]) tras nuestra intervención. Conclusiones: Nuestra EIB ha sido eficaz, mejorando la identificación, priorización de los niños con anafilaxia y reduciendo los TEM. Debemos conocer el funcionamiento de los Servicios de Urgencias de referencia para nuestros pacientes y establecer medidas multidisciplinarias que optimicen el manejo de la anafilaxia

Costes y procesos hospitalarios en un servicio de urología de un hospital terciario. Análisis de los grupos relacionados por el diagnóstico / Costs and hospital procedures in an urology department of a tertiary hospital. Analysis of groups related by their diagnosis

Introducción: El sistema sanitario tiene disponibles herramientas de gestión en los hospitales que facilitan la valoración de la eficiencia mediante el estudio de los costes y el control de gestión con la finalidad de sacar un mayor provecho de los recursos. Objetivo: El objetivo del estudio ha sido el cálculo y análisis del coste total de un servicio de urología de un hospital terciario, tanto de la actividad ambulatoria como de hospitalización y quirúrgica, así como la realización de una cuenta de resultados donde se compararon los costes del servicio con los ingresos obtenidos a partir de la Ley de Tasas durante el año 2014. Material y métodos: A partir de la información registrada por el Sistema de Información Económica de la Consellería de Sanidad, se aplicó el método ABC y top-down para el cálculo de costes por proceso de la actividad asistencial de 2014. Los resultados de costes obtenidos se compararon con las tarifas establecidas para la producción ambulatoria y hospitalaria en la Ley de Tasas de la Generalitat Valenciana. La producción se estructuró en ambulatoria (consultas externas y técnicas) y hospitalaria (estancias e intervenciones quirúrgicas). Resultados: Se realizaron 32.510 consultas externas, 7.527 técnicas, 2.860 intervenciones y 4.855 estancias hospitalarias. El coste total fue de 7.579.327 € consultas externas 1.748.14 5 €, consultas técnicas 1.229.836 €, cirugía 2.621.036 € e ingresos hospitalarios 1.980.310 €. Considerándose como ingresos económicos las tarifas aplicadas vigentes el año 2014 (un total de 15.035.843 €), la diferencia entre ingresos y gastos fue de 7.456.516 €. Conclusiones: La cuenta de resultados fue positiva, con un ahorro producido sobre las tasas cercano al 50% y mejor que el índice de estancias medias ajustadas por casuística, que fue de 0,67 (un 33% mejor que el estándar). El incremento de la cirugía mayor ambulatoria CMA repercute favorablemente en el control de costes

Introduction: The health care system has management tools available in hospitals that facilitate the assessment of efficiency through the study of costs and management control in order to make a better use of the resources. Objective: The aim of the study was the calculation and analysis of the total cost of a urology department, including ambulatory, hospitalization and surgery activity and the drafting of an income statement where service costs are compared with income earned from the Government fees during 2014. Material and methods: From the information recorded by the Economic Information System of the Department of Health, ABC and top-down method of cost calculation was applied by process care activity. The cost results obtained were compared with the rates established for ambulatory and hospital production in the Tax Law of the Generalitat Valenciana. The production was structured into outpatient (external and technical consultations) and hospital stays and surgeries (inpatient). Results: A total of 32,510 outpatient consultations, 7,527 techniques, 2,860 interventions and 4,855 hospital stays were made during 2014. The total cost was 7,579,327 €; the cost for outpatient consultations was 1,748,145 €, 1,229,836 € for technical consultations, 2,621,036 € for surgery procedures and 1,980,310 € for hospital admissions. Considered as income the current rates applied in 2014 (a total of 15,035,843 Euros), the difference between income and expenditure was 7,456,516 Euros. Conclusions: The economic balance was positive with savings over 50% and a mean adjusted hospitalization stay rate (IEMAC) rate of 0.67 (33% better than the standard). CMA had a favorable impact on cost control

Comentario a «Costes y procesos hospitalarios en un servicio de urología de un hospital terciario. Análisis de los grupos relacionados por el diagnóstico» / Comment to «Costs and hospital procedures in an urology department of a tertiary hospital. Analysis of groups related by their diagnosis»

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Diabetes Nurse Case Management in a Canadian Tertiary Care Setting: Results of a Randomized Controlled Trial.

OBJECTIVES: To examine the effects of a 6-month nurse case manager (NCM) intervention compared to standard care (SC) on glycemic control and diabetes distress in a Canadian tertiary-care setting. METHODS: We recruited 140 adults with type 2 diabetes and glycated hemoglobin (A1C) levels >8% (64 mmol/mol) from 2 tertiary care facilities and randomized them to: 1) a 6-month NCM intervention in addition to SC or 2) SC by the primary endocrinologists. Assessments were conducted at baseline and at 6 months. Primary outcomes included A1C levels and diabetes distress scores (DDS). Secondary outcomes included body mass index, blood pressure, diabetes-related behaviour measures, depressive symptoms, self-motivation and perception of support. RESULTS: At the 6-month follow up, the NCM group experienced larger reductions in A1C levels of -0.73% compared to the SC group (p=0.027; n=134). The NCM group also showed an additional reduction of -0.40 (26% reduction) in DDS compared to those in the SC group (p=0.001; n=134). The NCM group had lower blood pressure, ate more fruit and vegetables, exercised more, checked their feet more frequently, were more motivated, were less depressed and perceived more support. There were no changes and no group differences in terms of body mass index, medication compliance or frequency of testing. CONCLUSIONS: Compared to SC, NCM intervention was more effective in improving glycemic control and reducing diabetes distress. It is, therefore, a viable adjunct to standard diabetes care in the tertiary care setting, particularly for patients at high risk and with poor control.

Direct and indirect cost of myasthenia gravis: A prospective study from a tertiary care teaching hospital in India.

Myasthenia gravis (MG) requires lifelong treatment. The cost of management MG is very high in developed countries but there is no information on the cost of management of MG in the developing countries. This study reports the direct and indirect cost and predictors of cost of MG in a tertiary care teaching hospital in India. In a prospective hospital based study, from a tertiary hospital in India 66 consecutive patient during 2014-2015 were included. The age of the patients ranged between 6 and 75years. The severity of MG was assessed by myasthenia gravis foundation association (MGFA) class (MGFA) I-V. The patient data was collected s and their direct cost was calculated from the computerized Hospital information system. The indirect cost was calculated from patient's memory, checking the bills of transportation and wages loss by the patient or the care giver. Total annual cost of MG ranged between INR (4560-532227) with median INR 61390.5 (US$911.64). The median cost of outpatient department (OPD) consultation of 16 patients was INR 20439.9 (US$303.53), of 50 admitted patients was INR 44311.8 (US$658.03) and 21 intensive care unit (ICU) patients was INR 59574.3 (US$ 884.6) and the direct cost of thymectomy was INR 45000 (US$ 668.25). Direct cost was related to indirect cost (r=0.55; p=0.0001). Predictors of patient outcome were severity of MG, ICU admission, and thymectomy. The total median cost for management of myasthenia gravis was INR 61390.5 (4560-532227, US$911.64) per year, and the cost was mainly determined by the severity of MG.

Analysis of emergency vascular surgery consults within a tertiary health care system.

OBJECTIVE: Patients with vascular disease often have multisystem atherosclerosis and multiple comorbidities requiring comprehensive interdisciplinary specialty care. Consultation is a critical component of a tertiary vascular surgery practice, but analysis of this service is under-reported in the literature. After-hours inpatient consultations and interhospital transfers are associated with urgent patient care. METHODS: A retrospective analysis of vascular surgery consultations was carried out from January 1, 2013, to December 31, 2013. Consultations included inpatient services, the emergency department, surgical and medical intensive care unit, and interhospital transfers. Data analysis included number of consults, time of consultation (during hours, 0700-1859; after hours, 1900-0659), referring service, nature, and outcome of consultation. Consultations were then classified as urgent if vascular surgical intervention was required as an intraoperative consultation, within 24 hours, or during the same hospitalization. Patients without a same-hospital vascular surgical intervention were classified as nonurgent. RESULTS: During a 1-year period, 823 independent consult requests of 749 patients were analyzed. It was found that 57.8% of after-hours consults resulted in urgent patient care (P = .003); 29.7% of medicine, 33.3% of medical intensive care unit, 41.9% of trauma surgery, and 60% of emergency department after-hours consultations were urgent; 73% of surgery and 79.2% of interhospital after-hours consults required urgent vascular surgical intervention. Extremity ischemia, aortic disease, and iatrogenic consults accounted for 44.8%, 20.4%, and 11.1% of after-hours consults, with 57.9%, 56.4%, and 70% requiring urgent vascular surgical intervention, respectively. CONCLUSIONS: After-hours consultations are not always associated with an urgent vascular surgical intervention. Nonurgent after-hours consultations are requested more frequently from some services and may present an opportunity for education that could improve workflow of the vascular workforce.

Pattern of emergency department visits by elderly patients: study from a tertiary care hospital, Karachi.

BACKGROUND: Worldwide the proportion of elderly people in the population is increasing. Currently in Pakistan 7.3 million people (5.6% of total population) are more than 60 years old. This age shift has emerged as an important health issue and is associated with an increased utilization of emergency services by the elderly. We carried out this study to assess the pattern of elderly patients (>60 years) who visit emergency departments in comparison to young adults (18-60 years). METHODS: Data was collected retrospectively of patients aged 18 years or more who visited the Emergency Department (ED) of Aga Khan University Hospital, Karachi (AKUH) during September, 2009 to September, 2011. The data collection sheet included patient's demographic information, triage category, reason for visit, clinical presentation, ED length of stay, day and time of presentation and their disposition. Data was entered and analyzed using SPSS version 19.0. Descriptive statistics were used to describe patient's demographics. Chi-square (χ²) test was used as a test of significance to compare differences between groups for categorical data and t-test for continuous data. Multiple logistic regression analysis was done to find out the association between the patient characteristics and outcomes (admission and expiry). RESULTS: Almost 24% (n = 13014) of all adults (n = 54588) presenting to the ED were over the age of 60 years. More than 57% of elderly patients belonged to the high priority triage category compared to 35% in younger patients. Most of the elderly patients ( 27%) presented with nonspecific complaints followed by shortness of breath (13%) and fever (9%). The median length of stay (LOS) in the ED for elderly was 379 minutes (252 min in under-60 yrs patients) and they were more likely to get admitted to in-patient departments compared to younger patients (OR 1.7 95% CI 1.6-1.8). A high proportion of those admitted (20%) required intensive or special care. Mortality in elderly patients was 2.3% as compared to 0.7% in young adults. This was accompanied by a higher mortality risk in the elderly with an odds ratio of 2.3 (CI 2-2.5). CONCLUSION: Elderly ED users differ significantly from younger adults in terms of criticality on presentation, ED LOS and final disposition.