The Impact of an Acute Care Surgery Model on General Surgery Service Productivity.

BACKGROUND: The Acute Care Surgery (ACS) model has been widely adopted by hospitals across the United States, with ACS services managing emergency general surgery (EGS) patients previously treated by general surgery (GS) services. We evaluated the operational and financial impact of an ACS service model on general surgeons at an academic medical center. METHODS: Using WiseOR® (Palo Alto, CA), we compared surgical case volumes for the GS service two years before (October, 2013 - September, 2015) and two years after (October, 2015 - September, 2017) implementation of an ACS service at the University of Vermont Medical Center. From financial reports, we obtained monthly wRVUs, clinical FTEs, net patient revenue, and payer mix for the GS service and compared the two years before and after ACS model implementation. RESULTS: There was a significant reduction in the average number of cases performed by the GS service following ACS service implementation (monthly mean ± SD, 139.1 ± 16.0 vs. 116.7 ± 14.0, p < 0.001). The normal-hours caseload remained stable, while a significant decrease in after-hours cases accounted for the reduction in overall volume. Despite the reduction in operative volume, the decrease in mean monthly wRVU/FTE for the GS service when comparing the pre- and post- ACS periods did not reach statistical significance (614.9 ± 82.9 vs. 576.3 ± 62.1, p = 0.08).There was a significant increase in average monthly clinic-derived wRVU/FTE for the GS service (106.3 ± 13.5 vs. 120.5 ± 16.4, p = 0.007). CONCLUSIONS: Shifting EGS patient management from the GS to ACS service did not negatively impact the productivity of the GS service.

The Burden of Cost in Bronchiolitis Obliterans Syndrome: Predictions for the Next Decade.

In health economics, costs can be divided into both direct and indirect categories. Direct costs tend to consist of medical costs, which are those directly attributed to health care interventions (e.g., hospitalizations, pharmaceuticals, devices), and non-medical direct costs such as monitoring and professional caregiving. Indirect costs tend to comprise those related to lost productivity due to illness (or treatment), burden on systems outside of the healthcare domain, and other costs that can sometimes outweigh the entire sum of direct healthcare costs. The most common life-threatening complication of lung and hematopoietic stem-cell transplantation (HSCT) is bronchiolitis obliterans syndrome (BOS). BOS is currently diagnosed as a 20% decline in the forced expiratory volume in one second (FEV1) from the best (baseline) post-transplantation value, and is a major cause of morbidity and mortality amongst lung and stem cell transplant patients. BOS affects half of all lung transplant patients within the first 5 years post-transplant, rising to the majority of patients (~80%) within the first decade following transplant. We estimated both direct and indirect costs for the first 10 years following BOS diagnosis, a viewpoint that highlights a tremendous imbalance between healthcare and non-healthcare costs. The lost workforce resulting from BOS-related infirmity will cost society more than $3.7 Billion over the next decade, a figure that is more than double the estimated 10-year cost of treating BOS ($1.4B), including diagnostics, immunosuppressives, and additional complications. As such, BOS is estimated to present a burden of cost that must be evaluated in a new light to include the wider societal perspective.

Estimating the Burden of Cost in Chronic Graft-versus-Host Disease: A Human Capital Approach.

With advances in organ matching and preventing acute graft-versus-host-disease (aGvHD), chronic graft-versus-host disease (cGvHD) following allogeneic hematopoietic stem cell transplantation (HSCT) has become a focus of transplant-related morbidity and mortality. Given that cGvHD often presents years following a transplant, our objective was to estimate its burden of cost resulting from allogeneic HSCT based on published estimates of incidence, morbidity, the value of lost work time and survivorship. Our choice of a ten-year time horizon is novel to the field of rare disease and was determined to be meaningful after consultations with present co-authors, including five physicians, one of whom is a transplant surgeon. A total of 44 450 cGvHD patients in the United States were estimated to require treatment over the next decade (from 2015 to 2025). This estimate is based on the last 5 years of trends reported in the transplant registries. What is not reported in any registry is that these patients will accrue a total of 605 631 years of lost wages, a collective lost productivity that will cost society over $27 Billion in the decade ahead: more than five times ($27B vs. $5.2B) the estimated ten-year cost of treating the condition.

Vaporous Marketing: Uncovering Pervasive Electronic Cigarette Advertisements on Twitter.

BACKGROUND: Twitter has become the "wild-west" of marketing and promotional strategies for advertisement agencies. Electronic cigarettes have been heavily marketed across Twitter feeds, offering discounts, "kid-friendly" flavors, algorithmically generated false testimonials, and free samples. METHODS: All electronic cigarette keyword related tweets from a 10% sample of Twitter spanning January 2012 through December 2014 (approximately 850,000 total tweets) were identified and categorized as Automated or Organic by combining a keyword classification and a machine trained Human Detection algorithm. A sentiment analysis using Hedonometrics was performed on Organic tweets to quantify the change in consumer sentiments over time. Commercialized tweets were topically categorized with key phrasal pattern matching. RESULTS: The overwhelming majority (80%) of tweets were classified as automated or promotional in nature. The majority of these tweets were coded as commercialized (83.65% in 2013), up to 33% of which offered discounts or free samples and appeared on over a billion twitter feeds as impressions. The positivity of Organic (human) classified tweets has decreased over time (5.84 in 2013 to 5.77 in 2014) due to a relative increase in the negative words 'ban', 'tobacco', 'doesn't', 'drug', 'against', 'poison', 'tax' and a relative decrease in the positive words like 'haha', 'good', 'cool'. Automated tweets are more positive than organic (6.17 versus 5.84) due to a relative increase in the marketing words like 'best', 'win', 'buy', 'sale', 'health', 'discount' and a relative decrease in negative words like 'bad', 'hate', 'stupid', 'don't'. CONCLUSIONS: Due to the youth presence on Twitter and the clinical uncertainty of the long term health complications of electronic cigarette consumption, the protection of public health warrants scrutiny and potential regulation of social media marketing.

10-year follow-up of patients with and without mediastinitis.

Mediastinitis is a dreaded complication of CABG surgery. Short-term outcomes have been described, but there have been only a few long-term studies. We examined the survival of patients undergoing isolated CABG surgery between 1992 and 2001. Mediastinitis was identified during the index admission. Proportional hazards regression was used to calculate adjusted hazard ratios (HR) and 95% confidence intervals (CI 95%). Among 36,078 consecutive patients, there were 5749 deaths during 148,319 person years of follow-up. There were 418 cases of mediastinitis (1.16%). The incidence of death was 11.15 per 100 person/years with mediastinitis and 3.81 deaths/100 person years without. (P < 0.001). We also examined the mortality rates of patients who survived at least 6 months after their CABG surgery. Patients with mediastinitis had an incidence rate of 5.70 deaths per 100 person/years while those without had a rate of 2.66 deaths per 100 person/years (P < 0.001). After adjustment for baseline differences in patient and disease characteristics, the hazard ratio was 2.12 (CI95% = 1.86,2.58; P < 0.001). The adjusted hazard ratios for patients who survived 6 months postsurgery was 1.70 (CI95% = 1.36,2.13; P < 0.001). Mediastinitis is associated with a marked increase in both acute and long-term mortality rates.

Granulomatous chest disease following intravesical bacillus Calmette-Guerin immunotherapy.

Bacillus Calmette-Guerin (BCG) is well accepted as an intravesicular method of treatment of bladder cancer. Although well tolerated in the majority of patients, adverse local and systemic adverse effects of this therapy have been described. In particular, lung disease complicating intravesicular use of BCG has been reported, producing 5 recognized forms of chest disease: 1) allergic interstitial lung disease, 2) miliary infection, 3) empyema, 4) diffuse alveolar damage, and 5) localized consolidative or cavitary lung disease. We report an asymptomatic form of pulmonary disease complicating intravesical BCG therapy, that of pulmonary granulomas with mediastinal and hilar lymph node enlargement.