RESUMEN
Introduction and objectives: Acute abdominal pain (AAP) is one of the most common complaints in the emergency department (ED). Rapid diagnosis is essential and is often achieved through imaging. Computed tomography (CT) is widely considered an exemplary test in the diagnosis of AAP in adult patients. As previous studies show disparities in healthcare treatment based on insurance status, our objective was to assess the association between insurance status and frequency of CT ordered for adult patients presenting to the ED with AAP from 2005 to 2014. Methods: This study used the National Hospital and Ambulatory Medical Care Survey: Emergency Department Record (NHAMCS) database, which collects data over a randomly assigned 4 week period in the 50 states and DC, to perform an observational retrospective analysis of patients presenting to the ED with AAP. Patients with Medicaid, Medicare or no insurance were compared to patients with private insurance. The association between insurance status and frequency of CT ordered was measured by obtaining odds ratios along with 95% CIs adjusted for age, gender and race/ethnicity. Results: Individuals receiving Medicaid are 20% less likely to receive CT than those with private insurance (OR 0.8, CI 0.6-0.99, p = .046). Those on Medicare or who are uninsured have no difference in odds of obtaining a CT scan compared to patients with private insurance. Additional findings are that black patients are 42% less likely to receive a CT scan than white patients. Conclusions and implications: Patients on Medicaid are significantly less likely to receive a CT when presenting to the ED with AAP. Differences in diagnostic care may correlate to inferior health outcomes in patients without private insurance.
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Abdomen Agudo , Dolor Abdominal , Cobertura del Seguro/estadística & datos numéricos , Abdomen Agudo/diagnóstico por imagen , Abdomen Agudo/economía , Abdomen Agudo/epidemiología , Dolor Abdominal/diagnóstico por imagen , Dolor Abdominal/economía , Dolor Abdominal/epidemiología , Servicio de Urgencia en Hospital , Humanos , Estudios Retrospectivos , Tomografía Computarizada por Rayos X , Estados Unidos/epidemiologíaRESUMEN
OBJECTIVE: The use of computed tomography (CT) and ultrasound (US) in patients with acute abdominal pain has substantial variation across pediatric emergency departments (EDs). This study compares the cost of diagnosing and treating suspected appendicitis across a multicenter network of children's hospitals. METHODS: This study is a secondary analysis using deidentified data of a prospective, observational study of patients with suspected appendicitis at nine pediatric EDs. The study included patients 3 to 18 years old who presented to the ED with acute abdominal pain of <96 hours' duration. RESULTS: Our data set contained 2,300 cases across nine sites. There was an appendicitis rate of 31.8% and perforation rate of 25.7%. Sites correctly diagnosed appendicitis in over 95% of cases. The negative appendicitis rate ranged from 2.5% to 4.7% while the missed appendicitis rate ranged from 0.3% to 1.1% with no significant differences in these rates across site. Across sites, we found a strong positive correlation (0.95) between CT rate and total cost per case and a strong negative correlation (-0.71) between US rate and cost. The cost per case at US sites was 5.2% ($367) less than at CT sites (p < 0.001). Similarly, costs per case at mixed sites were 3.4% ($244) less than at CT sites (p < 0.001). Comparing costs among CT sites or among US sites, the cost per case generally increased as the images per case increased among both CT sites and US sites, but the costs were universally higher at CT sites. CONCLUSIONS: Our results provide support for US as the primary imaging modality for appendicitis. Sites that preferentially utilized US had lower costs per case than sites that primarily used CT. Imaging rates across sites varied due to practice patterns and resulted in a significant cost consequence without higher rates for negative appendectomies or missed appendicitis cases.
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Apendicitis/diagnóstico , Tomografía Computarizada por Rayos X/economía , Ultrasonografía/economía , Abdomen Agudo/economía , Abdomen Agudo/epidemiología , Abdomen Agudo/etiología , Adolescente , Apendicitis/economía , Apendicitis/epidemiología , Niño , Preescolar , Costos y Análisis de Costo , Servicio de Urgencia en Hospital/economía , Servicio de Urgencia en Hospital/estadística & datos numéricos , Femenino , Humanos , Masculino , Estudios Prospectivos , Tomografía Computarizada por Rayos X/estadística & datos numéricos , Ultrasonografía/estadística & datos numéricosRESUMEN
OBJECTIVES: To evaluate the impact of patient age on hospital resource use and treatment costs of acute abdominal pain (AAP). MATERIALS AND METHODS: A total of 300 adult patients with AAP were randomised to either computed tomography (CT, n=150) or selective imaging practice (SIP, n=150) groups. Final analysis included 254 patients, 143 (42 patients ≥65years) in the CT and 111 (32 patients ≥65years) in the SIP group. All CT group patients underwent abdominal CT whereas in the SIP group, imaging was based on the clinical assessment. For each patient, the hospital length of stay (LOS), the numbers and costs of diagnostic and treatment procedures arising from AAP were calculated and registered. The incremental cost-effectiveness ratio (ICER) and bootstrapped cost-effectiveness acceptability curve (CEAC) were estimated for routine CT. RESULTS: Treatment costs, imaging costs and LOS increased in conjunction with aging in both study groups, and were generally higher in the CT group compared to the SIP group. In the SIP group, CT was undertaken in 34% (27/79) of the <65year olds but in 59% (19/32) of the older patients (≥65years) (p=0.02). The proportion of patients with non-specific abdominal pain was significantly lower in patients ≥65years than in their younger counterparts (p=0.04). In the routine CT group, the ICER of obtaining a specific diagnosis was 1682 for patients <65years and 1055 for patients ≥65years. According to CEAC estimation, routine CT for every patient with AAP has a 95% probability of being cost-effective if society is willing to pay 14087 for an additional specific diagnosis for patients <65 years but only 4204 in those ≥65years. CONCLUSION: Treatment costs of AAP increase in parallel with aging, and the costs are generally higher with routine CT compared to selective imaging. The probability of obtaining a specific diagnosis of AAP increases with aging. If obtaining a specific diagnosis is deemed crucial, then routine CT is more cost-effective in patients over 65 years compared to younger patients. Considering the diagnostic challenges of AAP in the elderly, liberal CT use can be advocated in this patient group.
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Abdomen Agudo/diagnóstico por imagen , Abdomen Agudo/economía , Costos de la Atención en Salud/estadística & datos numéricos , Recursos en Salud/estadística & datos numéricos , Tomografía Computarizada por Rayos X/economía , Tomografía Computarizada por Rayos X/métodos , Abdomen/diagnóstico por imagen , Adolescente , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Análisis Costo-Beneficio/economía , Análisis Costo-Beneficio/estadística & datos numéricos , Diagnóstico por Imagen/economía , Diagnóstico por Imagen/métodos , Femenino , Humanos , Tiempo de Internación/economía , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Adulto JovenRESUMEN
OBJECTIVES: To evaluate the costs of treatment and use of hospital resources when comparing routine abdominal CT and selective imaging practice based on clinical assessment in patients with acute abdomen. METHODS: Altogether 300 patients with acute abdominal pain were randomised to computed tomography (CT, n = 150) or selective imaging practice (SIP, n = 150) groups. Final analysis included 254 patients, 143 in the CT and 111 in the SIP group. All CT group patients underwent contrast-enhanced abdominal CT within 24 h of admission. In the SIP group, imaging was individually tailored based on clinical assessment. The numbers of various examinations and procedures as well as costs of treatment arising from acute abdomen were calculated for each patient. Length of hospital stay was registered. RESULTS: Total treatment cost per patient was 1,202 euros (
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Abdomen Agudo/diagnóstico por imagen , Abdomen Agudo/economía , Medios de Contraste/química , Diagnóstico por Imagen/economía , Tomografía Computarizada por Rayos X/economía , Adulto , Anciano , Análisis Costo-Beneficio , Medicina de Emergencia/economía , Femenino , Finlandia , Costos de la Atención en Salud , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Modelos Económicos , Alta del Paciente , Estudios ProspectivosRESUMEN
Acute abdominal pain represents the cardinal symptom behind a vast number of possible under-lying causes including several ones that re-quire surgical treatment. It is the most common sur-gical emergency, the most common cause for a surgical consultation in the emergency department and the most common cause for non-trauma related hospital admissions. The golden mis-sion statement is to rapidly identify whether the underlying cause requires an urgent or even immediate surgical intervention. However, behind the same cardinal symptom one may encounter harmless or non-urgent problems. By employing diagnostic means cost effectively and with the aim to avoid unnecessary exposure of the patient to X-rays in mind, the challenge remains to identify patients with an indication for emergency surgery from those who suffer from a less serious condition and thus can be treated conservatively and without any pressure of time. Dealing with such a highly complex decision-making process calls for a clinical algorithm. Many publications are available that have scrutinised the different aspects of the initial assessment and the emergency management of acute abdominal pain. How-ever, the large body of evidence seems to miss articles that describe a formally correct priority- and problem-based approach. Clinical algorithms apply to complex disease states such as acute abdominal pain and translate them into one clearly laid out, logically coordinated and systematic overall process. Our intention is to devel-op such an algorithm to approach acute abdominal pain from the surgeon's point of view. Based on daily practice and with reference to available literature, it is the aim of this study to define a work flow that simply summarises all steps in-volved and defines the required decision process in order to form the intellectual basis for an evidence-based clinical algorithm. The result is illustrated as a first draft of such an evidence-based algorithm to allow emergency evaluation of adult patients with acute abdominal pain.
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Abdomen Agudo/etiología , Algoritmos , Servicio de Urgencia en Hospital , Abdomen Agudo/economía , Abdomen Agudo/cirugía , Adulto , Anciano , Analgésicos/uso terapéutico , Analgésicos Opioides/uso terapéutico , Análisis Costo-Beneficio , Técnicas de Apoyo para la Decisión , Diagnóstico Diferencial , Errores Diagnósticos , Documentación/economía , Diagnóstico Precoz , Servicio de Urgencia en Hospital/economía , Medicina Basada en la Evidencia/economía , Alemania , Humanos , Persona de Mediana Edad , Programas Nacionales de Salud/economía , Dimensión del Dolor/efectos de los fármacos , Examen Físico/economía , Tomografía Computarizada por Rayos X/economía , Procedimientos Innecesarios/economía , Flujo de TrabajoRESUMEN
AIM: To determine the financial consequences of a policy of admission first, followed by definitive investigation for patients with an admission diagnosis of suspected acute abdomen. RESULTS: Over a 1-month period, 122 patients were admitted with a suspected surgical diagnosis of acute abdomen (55 men, 67 women); age range 16-95 years (median: 56.5). Based on surgical operation required (n = 36), death after admission (n = 6, three postoperative deaths) and/or severe surgical illness (n = 17), 56 required surgical inpatient admission, while 66 did not. The patients who did not require admission spent significantly shorter time in hospital than those who required admission (median: 5 days vs. 8.5 days; p = 0.0000). Total hospital hotel and investigation cost (not including ITU or theatre costs) for all 122 patients was 330,468 pounds. Overall, 205,468 pounds was consumed by these 56 patients who required admission, while 125,000 pounds was spent on 66 patients whose clinical course did not justify admission; 92% of which was spent on hospital hotel costs and 8% on the cost of imaging and/or endoscopy. DISCUSSION AND CONCLUSION: On a national basis, emergency General Surgery admissions account for 1000 Finished Consultant Episodes per 100,000 population. The findings of this study suggest that this equates to a national NHS spend of 650 million pounds each year, for the hotel costs of patients that could arguably avoid surgical admission altogether. Continuing to admit patients with a suspected acute abdomen first and then requesting definitive investigation makes neither clinical nor economic sense.
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Abdomen Agudo/economía , Hospitalización/economía , Abdomen Agudo/etiología , Abdomen Agudo/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Costos de Hospital , Humanos , Masculino , Persona de Mediana Edad , Derivación y Consulta , Medicina Estatal/economía , Reino Unido , Adulto JovenRESUMEN
BACKGROUND/PURPOSE: Appendicitis is the most common surgical emergency presenting in the pediatric population. Approximately one third of these patients present with equivocal signs and symptoms frequently resulting in inpatient observation or additional diagnostic investigation. Although sonographic examination of patients with suspected appendicitis has been shown to be a highly accurate diagnostic modality, the cost effectiveness of this technology in the pediatric population has not been addressed. The economic value of this examination can be evaluated using a structured decision analysis. METHODS: The authors constructed a decision analysis model of treatment strategies for 2 groups of patients with a suspected diagnosis of acute appendicitis. Patients were categorized as either presenting with a "definitive acute abdomen" or "equivocal examination." Data drawn from published literature reports of the sensitivity and specificity of ultrasound, institution-specific cost data, and expert judgment were used to construct 2 decision trees. These data were used to determine the least costly diagnostic strategy for each group of patients, and sensitivity analysis performed to assess the robustness of the conclusions. RESULTS: The use of ultrasonography in patients with "an acute abdomen" is not cost efficient and results in average additional cost of $234 per patient. In patients with equivocal diagnoses who are discharged from the emergency room after a negative ultrasound examination finding results in an average cost savings of $260 when compared with admission and observation. Patients who are discharged without examination incur an average additional cost of $373 as a result of the high cost of a missed diagnosis resulting in a perforated appendix. CONCLUSION: The use of ultrasonography can be recommended for children with suspected appendicitis and equivocal examinations who are discharged from the emergency room after a negative examination result.
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Apendicitis/diagnóstico por imagen , Apendicitis/economía , Técnicas de Apoyo para la Decisión , Abdomen Agudo/diagnóstico por imagen , Abdomen Agudo/economía , Estudios de Casos y Controles , Niño , Análisis Costo-Beneficio , Costos y Análisis de Costo , Humanos , Sensibilidad y Especificidad , Ultrasonografía/economíaRESUMEN
OBJECTIVES: To describe the costs of medical imaging practices in the diagnosis management of acute abdominal pain (AAP). METHODS: Medical imaging techniques until decision for treatment were prospectively recorded in patients presenting with AAP. Direct costs used hospital analytic accountability. Time of human resources involved was also surveyed prospectively. RESULTS: In 122 adult patients (2.3 examinations on average) before treatment decision making, the more frequent practices were: initial plain abdomen x-ray followed by tomodensitometry (36.8%), by echography or endoscopy (17.2%), plain abdomen solely (19.6%) or initial abdominal tomodensitometry (12.3%). Direct costs ranged from 977 to 1073 FF for practices with initial plain abdomen x-ray, and from 996 to 1150 FF with initial tomodensitometry. It ranged from 808 to 880 FF when the treatment decision was surgery, and 300 FF higher when it was medical. CONCLUSION: Differences in costs assessed for practices were very narrow. Such information should be taken into account to determine cost-effective strategies, and to built up reference guidelines.
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Abdomen Agudo/diagnóstico , Abdomen Agudo/economía , Endoscopía del Sistema Digestivo/economía , Radiografía Abdominal/economía , Tomografía Computarizada por Rayos X/economía , Ultrasonografía/economía , Abdomen Agudo/diagnóstico por imagen , Abdomen Agudo/etiología , Adulto , Distribución de Chi-Cuadrado , Análisis Costo-Beneficio , Costos y Análisis de Costo , Femenino , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
The correct and early diagnosis and treatment are essential for the outcome of the patient with an acute abdomen. In 520 patients with the initial diagnosis of acute abdomen early laparoscopy revealed certain advantages. 183 (35.2%) patients with 11 different diseases could be treated laparoscopically, 129 (24.8%) underwent a laparotomy. In 96.7% of our patients the initial diagnosis was correct, so that these patients received a suitable therapy. The method is economically justified because we have equal costs both with CT/szintiscanning and laparoscopy, whereas the costs of MRI are nearly 400 DM higher.
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Abdomen Agudo/etiología , Laparoscopía , Abdomen Agudo/economía , Abdomen Agudo/cirugía , Análisis Costo-Beneficio , Diagnóstico Diferencial , Femenino , Humanos , Laparoscopía/economía , MasculinoAsunto(s)
Abdomen Agudo/diagnóstico , Abdomen Agudo/economía , Abdomen Agudo/diagnóstico por imagen , Diagnóstico por Computador/economía , Diagnóstico Diferencial , Costos de la Atención en Salud , Humanos , Laparoscopía/economía , Países Bajos , Tomografía Computarizada por Rayos X/economía , Ultrasonografía/economíaAsunto(s)
Abdomen Agudo/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Abdomen , Abdomen Agudo/economía , Abdomen Agudo/etiología , Apendicitis/diagnóstico por imagen , Divertículo/diagnóstico por imagen , Humanos , Obstrucción Intestinal/diagnóstico por imagen , Pancreatitis/diagnóstico por imagen , Neumoperitoneo/diagnóstico por imagen , Sensibilidad y Especificidad , Tomografía Computarizada por Rayos X/economía , Cálculos Ureterales/diagnóstico por imagenAsunto(s)
Apendicitis/diagnóstico por imagen , Evaluación de la Tecnología Biomédica/economía , Ultrasonografía/economía , Abdomen Agudo/diagnóstico por imagen , Abdomen Agudo/economía , Abdomen Agudo/cirugía , Adolescente , Apendicitis/economía , Apendicitis/cirugía , Niño , Preescolar , Análisis Costo-Beneficio , Femenino , Costos de Hospital , Humanos , Masculino , Valor Predictivo de las Pruebas , Estudios Prospectivos , SueciaRESUMEN
1. Managed care gate-keeper financial responsibility must be balanced with specialist diagnostic and therapeutic responsibility to maximize cost effectiveness and quality of medical service. 2. Cost in health care is closely tied to length of stay and operating room time; extremes of patient age are associated with increased costs. 3. Through years of training and subsequent experience, surgeons are best qualified to direct work-up of patients with an acute abdomen, especially when the work-up requires costly imaging (e.g., CT scan, ultrasonography, angiography). 4. Cost is increased when the surgeon is not involved early in cases of acute abdomen. 5. Surgeons must be willing to enter the evaluation phase of the patient with an acute abdomen patient early and follow during the observation period to best reduce unnecessary laboratory work or tests. 6. Health care teams willing to implement pathways and then document the effect such pathways exert will be most successful in assessing new technologies' cost effectiveness.
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Abdomen Agudo/diagnóstico , Abdomen Agudo/economía , Apendicectomía/economía , Abdomen Agudo/etiología , Abdomen Agudo/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Arizona , California , Niño , Preescolar , Análisis Costo-Beneficio , Investigación sobre Servicios de Salud , Precios de Hospital , Humanos , Lactante , Recién Nacido , Tiempo de Internación/economía , Programas Controlados de Atención en Salud/economía , Persona de Mediana EdadRESUMEN
Survey of 304 cases of surgical, abdominal emergencies (peritonitis and bowel occlusions). We deplored 42 post-operative deaths (14%). When patients are operated within 12 hours after the beginning of the pain, out of a group of 56 patients, two died (4%). After the 48th hour, of 114 patients operated, 26 died (23%) despite a stay in an intensive care unit. 174 patients, under 60 years old, we operated; 4 died (2.3%). This is mainly due to a stay in an intensive care unit (50 were operated after the 48th hour). Out of a group of 60 eighty years old patients, 18 were operated before the 24th hour; one death, that of a 94 years old patient, was deplored. Out of the 42 patients operated after the 24th hour, 19 died (45%). On the 304 patients, 56 (18%) were operated before the 12th hour, and 18 only, before the 6th hour (6%). the delay in operating, does not increases mortality only, but increase the duration of hospitalisation; this in itself increase expenses and sufferings. The causes of these delays are analyzed. A wiser use of clinical examination would decrease them.