Complications of Serious Pediatric Conditions in the Emergency Department: Definitions, Prevalence, and Resource Utilization.

OBJECTIVES: To define and measure complications across a broad set of acute pediatric conditions in emergency departments using administrative data, and to assess the validity of these definitions by comparing resource utilization between children with and without complications. STUDY DESIGN: Using local consensus, we predefined complications for 16 acute conditions including appendicitis, diabetic ketoacidosis, ovarian torsion, stroke, testicular torsion, and 11 others. We studied patients under age 18 years using 3 data years from the Healthcare Cost and Utilization Project Statewide Databases of Maryland and New York. We measured complications by condition. Resource utilization was compared between patients with and without complications, including hospital length of stay, and charges. RESULTS: We analyzed 27 087 emergency department visits for a serious condition. The most common was appendicitis (n = 16 794), with 24.3% of cases complicated by 1 or more of perforation (24.1%), abscess drainage (2.8%), bowel resection (0.3%), or sepsis (0.9%). Sepsis had the highest mortality (5.0%). Children with complications had higher resource utilization: condition-specific length of stay was longer when complications were present, except ovarian and testicular torsion. Hospital charges were higher among children with complications (P < .05) for 15 of 16 conditions, with a difference in medians from $3108 (testicular torsion) to $13 7694 (stroke). CONCLUSIONS: Clinically meaningful complications were measurable and were associated with increased resource utilization. Complication rates determined using administrative data may be used to compare outcomes and improve healthcare delivery for children.

[Seguridad y eficacia del modelo de atención fast-track vs. atención convencional en apendicitis no complicada del paciente pediátrico]. / Safety and effectiveness of the fast-track attention model vs. conventional care in uncomplicated appendicitis of the pediatric patient.

OBJETIVO: Comparar la seguridad y la eficacia de la atención fast-track vs. atención convencional en apendicitis no complicada en un hospital pediátrico. MÉTODO: Ensayo clínico controlado, aleatorizado, con dos grupos de 30 pacientes cada uno: A) fast-track, apendicitis no complicada que cumplieron el programa; y B) atención convencional, apendicitis no complicada con atención habitual. Variables de seguridad y eficacia: proporción de complicaciones y tiempo de estancia hospitalaria. RESULTADOS: Se incluyeron 60 pacientes, sin diferencia entre grupos: sexo masculino (53 vs. 60%), edad (8 ± 3 vs. 8 ± 2 años), tiempo de evolución (23 ± 21 vs. 24 ± 20 horas), tiempo desde ingreso a urgencias hasta inicio de cirugía (6 ± 4 vs. 8 ± 6 horas), y tipo de apendicitis edematosa (27 vs. 24%) o supurada (73 vs. 76%). La estancia hospitalaria promedio del grupo fast-track fue de 13 ± 5 vs. 72 ± 40 horas del grupo de atención convencional (p = 0.001). Hubo complicaciones en el 3 y el 6%, respectivamente (p = 1.0). La estancia hospitalaria disminuyó 2.45 días por paciente con el protocolo fast-track, lo que representa un ahorro de $ 6,731 pesos/día/paciente/hospitalización (US$ 373), sin un aumento de las complicaciones. CONCLUSIÓN: El protocolo fast-track en los niños con apendicitis no complicada es seguro y efectivo en un hospital universitario. El programa fast-track aportó beneficios clínicos y económicos, ahorrando en total $ 403,860 en los 30 pacientes. OBJECTIVE: To compare safety and efficacy of fast-track program vs. conventional attention in non-complicated appendicitis attending a pediatric university hospital. METHOD: Randomized clinical trial, comparing two groups with 30 patients each: (A) fast-track group, appendicitis agreeing the treatment protocol; and (B) conventional attention group, appendicitis following habitual surgical care. The efficacy and safety measures were length of hospital stay and proportion of complications. RESULTS: We included 60 patients, there were no significant difference between groups with regard: male gender (53 vs. 60%), age (8 ± 3 vs. 8 ± 2 years-old), time of evolution (23 ± 21 vs. 24 ± 20 h), time since admittance to emergency and beginning of surgery (6 ± 4 vs. 8 ± 6 h), and type of appendicitis edematous (27 vs. 24%) or suppurate (73 vs. 76%). Mean length of hospital stay in fast-track group was 13 ± 5 vs. 72 ± 40 h in conventional attention (p = 0.001). The complications were 3 and 6%, respectively (p = 1.0). Fast-track program diminished length of hospital stay in 2.45 days per patient, representing a mean cost saving of 6,731 Mexican pesos per day, per patient hospitalized (US$ 373), without increased complications. CONCLUSION: Fast-track program in children with non-complicated appendicitis is safe and effective in pediatric university hospital; there was cost-minimization without carelessness of safety. This program support clinical and economic benefits, a total saving of 403,860 Mexican pesos for the 30 patients in the fast-track group.

[Costs of appendicitis treatment by diagnosis-related groups in a third-level pediatric hospital]. / Costos de tratamiento de la apendicitis mediante grupos relacionados con el diagnóstico en un tercer nivel de atención pediátrica.

BACKGROUND: Diagnosis-related groups (DRGs) are widely used in Europe. They allow performing comparisons in hospitals and incurrent hospital payment systems, defining the payment categories. We undertook this study to classify children who underwent appendectomy according to DRGs. METHODS: Cross-sectional study. Comorbidities, length of hospitalization, histopathologic classification, and DRG classifications were analyzed. RESULTS: We included 313 patients, 62% males, with an average age of 8 ± 3 years; 91% were referred by another hospital and 67% were treated at night. Average length of hospitalization was 4 ± 3 days. There were comorbidities in 8% and surgical complications in 11%. According to histopathology, appendicitis was edematous (11%), suppurative (36%), gangrenous (22%), perforated (29%), and abscessed (2%). At discharge, 97% of the patients were healthy. Total cost for DRG 343 was $10,470,173.00 (Mexican pesos), DRG 342 was $1,227,592.00 and DRG 340 was $511,521.00. The global amount was $12,209,286.00 (Mexican pesos). CONCLUSION: The unitary cost for treatment of appendectomy for DRG 343 was $37,935.00, for DRG 342 was $49,103.00 and for DRG 340 was $42,626.00 (Mexican pesos). Because 88% of the cases of appendicitis were uncomplicated, this amount of money could be spent to treat these patients in a second-level hospital, using reimbursement 343 without generating additional expenses.

Antecedentes: los grupos relacionados con el diagnóstico se utilizan ampliamente en Europa; permiten comparar el desempeño de los hospitales y facilitan el sistema de pago hospitalario. Objetivo: clasificar mediante grupos relacionados con el diagnóstico a los niños operados por apendicitis en un hospital de tercer nivel de atención. Material y métodos: estudio transversal. Se analizaron: comorbilidad, tiempo de hospitalización, histología de la apendicitis y clasificación mediante grupos relacionados con el diagnóstico. Resultados: se incluyeron 313 pacientes, 62% hombres, con edad promedio de 8 ± 3 años, 91% llegaron referidos de otra unidad. Recibieron atención en el turno nocturno 67%, y permanecieron hospitalizados durante 4 ± 3 días. Hubo comorbilidad en 8% y complicaciones quirúrgicas en 11%. La apendicitis fue: edematosa en 11%, supurada en 36%, gangrenada en 22%, perforada en 29% y abscedada en 2%. La condición de egreso fue: con mejoría en 97%. El gasto total del grupo relacionado con el diagnóstico 343 fue 10,470,173 pesos, del grupo relacionado con el diagnóstico 342 de 1,227,592 pesos, y del grupo relacionado con el diagnóstico 340 de 511,521 pesos, lo que sumó 12,209,286 pesos mexicanos. Conclusión: el costo unitario del tratamiento de la apendicitis correspondiente al grupo relacionado con el diagnóstico 343 fue de 37,935 pesos, del grupo relacionado con el diagnóstico 342 de 49,103 pesos y del grupo relacionado con el diagnóstico 340 de 42,626 pesos. Puesto que 88% de los casos de apendicitis ocurrieron sin diagnóstico principal complicado, esos pacientes se podrían haber intervenido en un segundo nivel de atención, utilizando el reembolso obtenido del monto 343, sin necesidad de generar gastos adicionales.

Hospitalization costs of open vs. laparoscopic appendectomy: 5-year experience.

BACKGROUND: There is an ongoing debate over certain aspects of laparoscopic appendectomy (LA) over open appendectomy (OA) in regard to hospitalization costs and associated complications. METHODS: A database was used to obtain the charts for either LA or OA performed during a 5-year period. Variables analyzed were age, gender, hospitalization cost, length of stay and complications. RESULTS: Of 1792 appendectomies performed, 633 (35.3%) were OA and 1159 (64.6%) were LA. Both groups were statistically similar with regard to gender (p = 0.075) but differed with respect to age, demonstrating an older patient population in the LA group (p <0.0001). Length of stay was significantly higher in the OA group (3.33 vs. 2.52) days, p <0.0001). The overall hospitalization cost of LA was 25% higher than the OA cost (p = 0.0005). The cost of an uncomplicated LA case was 1.7 times higher than in the OA group (p ≤ 0.0001). We found no statistically significant differences between the hospitalization cost of an OA and LA group when both procedures were associated with a complication (p = 0.5319). A higher complication rate was observed in the OA group, 60 cases (9.47%) as compared to the LA group, 46 cases (3.96%), p <0.0001. The increased rate of complications observed was related to cardiovascular, wound and infectious problems. CONCLUSIONS: Noncomplicated LA was associated with a higher hospitalization cost. There was no difference with regard to complicated cases. The incidence of complications increased in the OA group.

Cost-effectiveness of computed tomography and ultrasound in the diagnosis of appendicitis.

INTRODUCTION: Diagnosis of acute appendicitis is difficult in nearly 30% of patients with pain in low right quadrant. Diagnostic imaging may provide a means of a more accurate diagnosis. OBJECTIVE: The cost-effectiveness of diagnostic image tests was calculated for comparison with routine physical examination in patients with abdominal pain suspected to be appendicitis. MATERIALS AND METHODS: A cost-effectiveness protocol was designed, using a decision analysis model. The standard case was a patient with abdominal pain in right lower quadrant and suspicion of appendicitis. Three independent diagnostic alternatives were selected--ultrasonography, abdominal tomography and physical exam in hospital with the subject under observation less than six hours. Operative characteristics, study design and costs of interventions and outcomes were assessed. The main outcome consisted of a confirmed diagnosis of appendicitis. The point of view taken was that of health maintenance organizations. Direct and indirect medical costs were measured. Time horizon used was three months. A one way sensitivity analysis was made. RESULTS: For a prepaid system, the most cost-effective strategy was abdominal tomography, with a cost-effectiveness ratio of US$965/diagnosed patient. For public system, the most cost-effective strategy was abdominal tomography, with a cost-effectiveness ratio of US$492/diagnosed patient. CONCLUSIONS: Imaging diagnostic methods, in cases of abdominal pain suspected to be appendicitis, are more cost-effective than physical exam to make accurate diagnostic decisions. Tomography offers the best cost-effectiveness in prepaid system and in public health system.

Costo-efectividad en la atención hospitalaria de algunas patológías / Cost-effectiveness in hospital care of some pathologies

Se presentan los resultados del estudio de costo-efectividad realizado en enfermos internados en hospitales públicos del sector norte de Santiago. Corresponden a 181 pacientes con colelitiasis, apendicitis aguda, hernias abdominales, úlceras duodenales, adenoma prostático, embarazo ectópico, IRA e ictericias del recién nacido. Para estimar el costo de la atención médica se emplearon los valores FONASA de Pago Asociado a Diagnóstico (PAD) para estas patologías. La efectividad fue medida por el porcentaje de recuperación completa observada en el seguimiento domiciliario realizado 30 días y 6 meses después del alta. En conjunto, los pacientes tuvieron un 70,2 por ciento de recuperación a 30 días y 84 por ciento a 6 meses plazo. Como el costo promedio de hospitalización alcanzó a $ 414.000, la relación costo-efectividad a 30 días fue de $ 5.900 y a 6 meses de $ 4.960, montos que indican el gasto necesario para mejorar en un punto poncentual el porcentaje de recuperación completa de los pacientes. El costo-efectividad resultó más alto para patologías de manejo quirúrgico, para el género femenino, para adultos de edad media y para beneficiarios de FONASA. Mientras en la atención primaria una buena ecuación de costo-efectividad depende más de la proporción de recuperación de los pacientes que de bajos costos de atención médica, en el caso de la atención hospitalaria el costo-efectividad está fundamentalmente ligado a los costos de operación