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1.
Br J Anaesth ; 124(1): 73-83, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31860444

RESUMO

BACKGROUND: Socioeconomic circumstances can influence access to healthcare, the standard of care provided, and a variety of outcomes. This study aimed to determine the association between crude and risk-adjusted 30-day mortality and socioeconomic group after emergency laparotomy, measure differences in meeting relevant perioperative standards of care, and investigate whether variation in hospital structure or process could explain any difference in mortality between socioeconomic groups. METHODS: This was an observational study of 58 790 patients, with data prospectively collected for the National Emergency Laparotomy Audit in 178 National Health Service hospitals in England between December 1, 2013 and November 31, 2016, linked with national administrative databases. The socioeconomic group was determined according to the Index of Multiple Deprivation quintile of each patient's usual place of residence. RESULTS: Overall, the crude 30-day mortality was 10.3%, with differences between the most-deprived (11.2%) and least-deprived (9.8%) quintiles (P<0.001). The more-deprived patients were more likely to have multiple comorbidities, were more acutely unwell at the time of surgery, and required a more-urgent surgery. After risk adjustment, the patients in the most-deprived quintile were at significantly higher risk of death compared with all other quintiles (adjusted odds ratio [95% confidence interval]: Q1 [most deprived]: reference; Q2: 0.83 [0.76-0.92]; Q3: 0.84 [0.76-0.92]; Q4: 0.87 [0.79-0.96]; Q5 [least deprived]: 0.77 [0.70-0.86]). We found no evidence that differences in hospital-level structure or patient-level performance in standards of care explained this association. CONCLUSIONS: More-deprived patients have higher crude and risk-adjusted 30-day mortality after emergency laparotomy, but this is not explained by differences in the standards of care recorded within the National Emergency Laparotomy Audit.


Assuntos
Serviços Médicos de Emergência , Laparotomia/mortalidade , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/mortalidade , Fatores Socioeconômicos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Inglaterra/epidemiologia , Feminino , Hospitais/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Assistência Perioperatória/economia , Assistência Perioperatória/normas , Pobreza , Risco Ajustado , Medicina Estatal , Adulto Jovem
2.
Spine (Phila Pa 1976) ; 44(13): 959-966, 2019 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-31205177

RESUMO

STUDY DESIGN: The enhanced perioperative care (EPOC) program is an institutional quality improvement initiative. We used a historically controlled study design to evaluate patients who underwent major spine surgery before and after the implementation of the EPOC program. OBJECTIVE: To determine whether multidisciplinary EPOC program was associated with an improvement in clinical and financial outcomes for elective adult major spine surgery patients. SUMMARY OF BACKGROUND DATA: The enhanced recovery after surgery (ERAS) programs successfully implemented in hip and knee replacement surgeries, and improved clinical outcomes and patient satisfaction. METHODS: We compared 183 subjects in traditional care (TRDC) group to 267 intervention period (EPOC) in a single academic quaternary spine surgery referral center. One hundred eight subjects in no pathway (NOPW) care group was also examined to exclude if the observed changes between the EPOC and TRDC groups might be due to concurrent changes in practice or population over the same time period. Our primary outcome variables were hospital and intensive care unit lengths of stay and the secondary outcomes were postoperative complications, 30-day hospital readmission and cost. RESULTS: In this highly complex patient population, we observed a reduction in mean hospital length of stay (HLOS) between TRDC versus EPOC groups (8.2 vs. 6.1 d, standard deviation [SD] = 6.3 vs. 3.6, P < 0.001) and intensive care unit length of stay (ILOS) (3.1 vs. 1.9 d, SD = 4.7 vs. 1.4, P = 0.01). The number (rate) of postoperative intensive care unit (ICU) admissions was higher for the TRDC n = 109 (60%) than the EPOC n = 129 (48%) (P = 0.02). There was no difference in postoperative complications and 30-day hospital readmissions. The EPOC spine program was associated with significant average cost reduction-$62,429 to $53,355 (P < 0.00). CONCLUSION: The EPOC program has made a clinically relevant contribution to institutional efforts to improve patient outcomes and value. We observed a reduction in HLOS, ILOS, costs, and variability. LEVEL OF EVIDENCE: 3.


Assuntos
Procedimentos Neurocirúrgicos/normas , Assistência Perioperatória/normas , Complicações Pós-Operatórias/epidemiologia , Adulto , Idoso , Procedimentos Cirúrgicos Eletivos/economia , Procedimentos Cirúrgicos Eletivos/métodos , Procedimentos Cirúrgicos Eletivos/normas , Feminino , Humanos , Tempo de Internação/economia , Tempo de Internação/tendências , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos/economia , Procedimentos Neurocirúrgicos/métodos , Readmissão do Paciente/economia , Readmissão do Paciente/tendências , Satisfação do Paciente , Assistência Perioperatória/economia , Assistência Perioperatória/métodos , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/economia , Melhoria de Qualidade/normas , Resultado do Tratamento
3.
Gynecol Oncol ; 154(2): 388-393, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31202505

RESUMO

OBJECTIVES: Enhanced recovery after surgery (ERAS) programs has shown clinical benefits in gynecologic surgery. The aim of the present study was to compare costs before and after implementation of an ERAS program for gynecologic surgery. METHODS: Retrospective study comparing perioperative costs between consecutive patient groups undergoing gynecologic surgery (benign, staging or debulking) (I, 2012-13) prior, (II) immediately after, and (III, 2014-16) the three years after ERAS implementation. Preoperative, intraoperative, and postoperative real costs were collected for each patient via hospital administration. A bootstrap independent t-test was used for comparison. RESULTS: Demographics and preoperative characteristics were similar between group I (n = 42), II (n = 51), and III (ERAS I; n = 122, II; n = 134, III; n = 90). Average ERAS-specific costs were $687 per patient. Total mean individual costs per patient were $13'329 (95% confidence interval (CI): 11'301-15'213) and $17'710 (95% CI: 14'452-21'605) in the ERAS and pre-ERAS groups respectively, resulting in net savings of $4'381 (95% CI: 549-8'752, p = 0.043) in favour of ERAS group. Cost savings were explained by lower pre- and postoperative costs (difference: $5'011 95% CI: 1'587-8'998, p = 0.019). Total costs continued to decrease by $2'520 (mean: $15'190, 95% CI: 13'791-16'631) in year 1, by $3'077 (mean: $14'633, 95% CI: 13'378-16'250) and $5'070 (mean: $12'640, 95% CI: 11'460-14'015) (p = 0.03) respectively, in year 2 and 3 after implementation. CONCLUSION: Based on real costs and including specific costs due to ERAS implementation, ERAS program in gynecologic surgery induced significant decrease of overall costs by $4'381 per patient. Total costs continued to decrease in the three years after implementation.


Assuntos
Análise Custo-Benefício , Procedimentos Cirúrgicos em Ginecologia/economia , Assistência Perioperatória/economia , Adulto , Idoso , Redução de Custos/estatística & dados numéricos , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Pessoa de Meia-Idade , Assistência Perioperatória/métodos , Avaliação de Programas e Projetos de Saúde , Estudos Retrospectivos
4.
J Neurooncol ; 143(3): 465-473, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31055681

RESUMO

INTRODUCTION: Identification of groups of patients or interventions with higher associated treatment costs may be beneficial in efforts to decrease the overall financial burden of glioblastoma (GBM) treatment. The authors' objective was to evaluate perioperative surgical treatment cost differences between elderly and nonelderly patients with GBM using the Value Driven Outcome (VDO) database. METHODS: The authors obtained data from a retrospective cohort of GBM patients treated surgically (resection or biopsy) at their institution from August 2011 to February 2018. Data were compiled using medical records and the VDO database. RESULTS: A total of 181 patients with GBM were included. Patients were grouped into age < 70 years at time of surgery (nonelderly; n = 121) and ≥ 70 years (elderly; n = 60). Costs were approximately 38% higher in the elderly group on average (each patient was mean 0.68% of total cohort cost vs. 0.49%, p = 0.044). Higher age significantly, but weakly, correlated with higher treatment cost on linear regression analysis (p = 0.007; R2 = 0.04). Length of stay was significantly associated with increased cost on linear regression (p < 0.001, R2 = 0.84) and was significantly longer in the elderly group (8.7 ± 11.3 vs. 5.2 ± 4.3 days, p = 0.025). The cost breakdown by facility, pharmacy, supply/implants, imaging, and laboratory costs was not significantly different between age groups. Elderly patients with any postoperative complication had 2.1 times greater total costs than those without complication (p = 0.094), 2.9 times greater total costs than nonelderly patients with complication (p = 0.013), and 2.3 times greater total costs than nonelderly patients without complication (p = 0.022). CONCLUSIONS: GBM surgical treatment costs are higher in older patients, particularly those who experience postoperative complications.


Assuntos
Neoplasias Encefálicas/economia , Bases de Dados Factuais , Glioblastoma/economia , Custos de Cuidados de Saúde/estatística & dados numéricos , Procedimentos Neurocirúrgicos/economia , Assistência Perioperatória/economia , Complicações Pós-Operatórias , Fatores Etários , Idoso , Neoplasias Encefálicas/patologia , Neoplasias Encefálicas/cirurgia , Feminino , Seguimentos , Glioblastoma/patologia , Glioblastoma/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Taxa de Sobrevida , Resultado do Tratamento
5.
Medicine (Baltimore) ; 98(17): e15376, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-31027127

RESUMO

The purpose of this study was to investigate the effects of preoperative oral management (POM) by dentists on the incidence of postoperative pulmonary complications (PPCs), length of hospital stay, medical costs, and days of antibiotics administration following both open and thoracoscopic esophagectomy.Dental plaque is an established risk factor for postoperative pneumonia, which could be reduced by POM. However, few clinical guidelines for cancer treatment, including those for esophageal cancer, recommend POM as routine perioperative care.We extracted data of esophagectomy cases from the Japanese Diagnosis Procedure Combination database. We subsequently conducted propensity score (PS) analyses for multilevel data, including matching, inverse probability of treatment weighting (IPTW), and standardized mortality ratio weighting (SMRW), to estimate the effect of POM by dentists on the outcomes of esophagectomy.We analyzed 3412 esophagectomy cases of which 812 were open, and 2600 were thoracoscopic surgery. In IPTW analysis to estimate the average treatment effect, the risk difference of postoperative aspiration pneumonia ranged from -2.49% to -2.02% between the POM and control groups of both open and thoracoscopic esophagectomy cases. IPTW analyses indicated that the total medical costs of thoracoscopic esophagectomy were reduced by 221,200 to 253,100 Japanese Yen (equivalent to about $2000-$2200). In PS matching and SMRW analyses to estimate average treatment effect on treated, there was no difference in outcomes between the POM and control groups.Our results suggested that in patients undergoing open or thoracoscopic esophagectomy, POM by dentists prevented the occurrence of postoperative aspiration pneumonia. It could also reduce the total medical costs of thoracoscopic esophagectomy. Thus, POM by dentists can be considered as a routine perioperative care for all patients undergoing esophagectomy, regardless of the expected risk for PPC.


Assuntos
Odontólogos , Neoplasias Esofágicas/cirurgia , Esofagectomia , Assistência Perioperatória , Pneumonia Aspirativa/prevenção & controle , Complicações Pós-Operatórias/prevenção & controle , Adulto , Idoso , Idoso de 80 Anos ou mais , Placa Dentária/economia , Placa Dentária/epidemiologia , Placa Dentária/terapia , Neoplasias Esofágicas/economia , Neoplasias Esofágicas/epidemiologia , Esofagectomia/economia , Feminino , Custos de Cuidados de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Assistência Perioperatória/economia , Pneumonia Aspirativa/economia , Pneumonia Aspirativa/epidemiologia , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/epidemiologia , Toracoscopia/economia , Resultado do Tratamento
6.
Ulus Travma Acil Cerrahi Derg ; 25(1): 66-70, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30742289

RESUMO

BACKGROUND: The aim of our study was to determine the efficacy and cost-effectiveness of intraoperative autotransfusion that uses the cell saver system (CSS) in patients undergoing posterior instrumentation and fusion of thoracic and lumbar vertebral fractures. METHODS: We divided 121 patients who were to undergo posterior instrumentation and fusion due to thoracic and lumbar vertebral fractures into two groups: 59 patients (23 males and 36 females) were in the cell saver group, and 62 patients (22 males and 40 females) were in the control group. Hemoglobin, hematocrit, and red blood cell (RBC) values were recorded for all patients preoperatively, on the postoperative first, second, and third days, and on the hospital discharge day. Transfusion rates and numbers of allogeneic erythrocyte transfusions, as well as the costs of transfused total auto- and allogeneic transfusions were compared. RESULTS: The numbers of erythrocyte suspensions transfused perioperatively were 0.2±0.6 units in the cell saver group and 0.7±1.4 units in the control group (p=0.01). Statistically significant differences were noted between the two groups on the postoperative first, second, and third days in terms of hemoglobin, hematocrit, and RBC values. These differences had disappeared by the hospital discharge day. The average cost of perioperative blood transfusions was $431±27.4 in the cell saver group and $34.5±66.25 in the control group (p<0.001). CONCLUSION: The use of the CSS was not cost-effective, but it was particularly successful at reducing the rate and the number of units of postoperative allogenic blood transfusions.


Assuntos
Transfusão de Sangue Autóloga , Assistência Perioperatória , Fusão Vertebral , Transfusão de Sangue Autóloga/economia , Transfusão de Sangue Autóloga/estatística & dados numéricos , Análise Custo-Benefício , Feminino , Humanos , Masculino , Assistência Perioperatória/economia , Assistência Perioperatória/estatística & dados numéricos , Fusão Vertebral/efeitos adversos , Fusão Vertebral/economia , Fusão Vertebral/estatística & dados numéricos
7.
J Med Econ ; 22(3): 238-244, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30523724

RESUMO

AIMS: The objective of this (trial based) economic evaluation was to assess, from a societal perspective, the cost-effectiveness of perioperative enteral nutrition compared with standard care in patients undergoing colorectal surgery. MATERIALS AND METHODS: Alongside the SANICS II randomized controlled trial, global quality-of-life, utilities (measured by EQ-5D-5L), healthcare costs, production losses, and patient and family costs were assessed at baseline, 3 months, and 6 months. Incremental cost-effectiveness ratios (ICERs) (i.e. cost per increased global quality-of-life score or quality-adjusted life year [QALY] gained) and cost effectiveness acceptability curves were visualized. RESULTS: In total, 265 patients were included in the original trial (n = 132 in the perioperative enteral nutrition group and n = 133 in the standard care group). At 6 months, global quality-of-life (83 vs 83, p = .357) did not differ significantly between the groups. The mean total societal costs for the intervention and standard care groups were €14,673 and €11,974, respectively, but did not reach statistical significance (p = .109). The intervention resulted in an ICER of -€6,276 per point increase in the global quality of life score. The gain in QALY was marginal (0.003), with an additional cost of €2,941, and the ICUR (Incremental cost utility ratio) was estimated at €980,333. LIMITATIONS: The cost elements for all the participating centers reflect the reference prices from the Netherlands. Patient-reported questionnaires may have resulted in recall bias. Sample size was limited by exclusion of patients who did not complete questionnaires for at least at two time points. A power analysis based on costs and health-related quality-of-life (HRQoL) was not performed. The economic impact could not be analyzed at 1 month post-operatively where the effects could potentially be higher. CONCLUSIONS: This study suggests that perioperative nutrition is not beneficial for the patients in terms of quality-of-life and is not cost-effective.


Assuntos
Cirurgia Colorretal/economia , Cirurgia Colorretal/métodos , Nutrição Enteral/economia , Nutrição Enteral/métodos , Assistência Perioperatória/economia , Assistência Perioperatória/métodos , Efeitos Psicossociais da Doença , Análise Custo-Benefício , Método Duplo-Cego , Recursos em Saúde/economia , Recursos em Saúde/estatística & dados numéricos , Humanos , Modelos Econométricos , Países Baixos , Qualidade de Vida , Anos de Vida Ajustados por Qualidade de Vida
8.
J Am Acad Orthop Surg ; 27(1): 1-11, 2019 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-30260912

RESUMO

Since passage of the Patient Protection and Affordable Care Act of 2010, the current decade has witnessed an explosion of the value-based total hip and knee arthroplasty literature. Total hip arthroplasty and total knee arthroplasty are the most common inpatient surgeries for Medicare beneficiaries, and thus, it is no surprise that total joint arthroplasty is currently a prime target of efforts toward cost reduction and quality improvement. The purpose of this review was to provide a framework for understanding the rapidly growing quality and cost literature. Research efforts toward quality improvement are likely to be effective when they address the structure, process, and most importantly outcomes of total joint arthroplasty. Similarly, cost savings should be evaluated with an understanding of existing accounting methods, relationships to the entire cycle of osteoarthritis care, and the direct effect on the quality of care provided.


Assuntos
Artroplastia de Quadril/economia , Artroplastia de Quadril/normas , Artroplastia do Joelho/economia , Artroplastia do Joelho/normas , Redução de Custos , Humanos , Medicare/economia , Osteoartrite do Quadril/economia , Osteoartrite do Quadril/cirurgia , Osteoartrite do Joelho/economia , Osteoartrite do Joelho/cirurgia , Patient Protection and Affordable Care Act , Assistência Perioperatória/economia , Estados Unidos , Seguro de Saúde Baseado em Valor
9.
Am J Surg ; 217(6): 1089-1093, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30471811

RESUMO

BACKGROUND: Surgical site infections (SSI) are a source of patient morbidity and increased cost. In 2007, our organization discovered an SSI rate of 18% after colorectal surgery (CRS), corresponding to an ACS NSQIP benchmarked high outlier. METHODS: From 2007 to 2016, surgeons championed a stepwise, multidisciplinary improvement pathway for SSI reduction. NSQIP was used to track SSI rates and estimate cost savings. RESULTS: From 2007 to 2016, 1508 patients underwent CRS at our facility. In 2007, our SSI rate was 18%. In 2016, the SSI rate was 7%, corresponding to a NSQIP benchmarked exemplary performance. 54 patients avoided the morbidity of a SSI. The expense of SSI reduction implementation was $180,000. Cost savings was estimated at $1.3 million. CONCLUSIONS: Our approach reduced SSI rates by 58% over ten years. We observed a significant morbidity reduction and cost savings. Our strategy could be adopted within other medical centers focused on CRS SSI improvement.


Assuntos
Centros Médicos Acadêmicos/normas , Redução de Custos/estatística & dados numéricos , Custos Hospitalares/tendências , Assistência Perioperatória/normas , Melhoria de Qualidade/tendências , Infecção da Ferida Cirúrgica/epidemiologia , Infecção da Ferida Cirúrgica/prevenção & controle , Centros Médicos Acadêmicos/tendências , Adulto , Idoso , Benchmarking , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Assistência Perioperatória/economia , Assistência Perioperatória/métodos , Melhoria de Qualidade/economia , Estudos Retrospectivos , Infecção da Ferida Cirúrgica/economia , Wisconsin
10.
J Invest Surg ; 32(2): 127-136, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-29095073

RESUMO

AIM: Hemophilic pseudotumors result from repeated episodes of bleeding into bone, subperiosteum, and soft tissue. Since clotting factors became available, uncontrolled perioperative bleeding is a less significant problem for surgeons in developed countries. However, they are more difficult to come by in China. Additionally, patients often have to undergo surgery for giant masses and suffer complications. We wanted to present our experience in the surgical management of hemophilic pseudotumors over a 40-year period. METHODS: We retrospectively reviewed 429 hemorrhagic coagulopathy patients between 1983 and 2015. Diagnosis of hemophilic pseudotumor was confirmed following clinical, radiological, and pathological criteria. The data were recorded and analyzed: type and severity of hemophilia, presence of inhibitor, etiological antecedent, localization of pseudotumors, clinical signs, surgical management and outcomes. RESULTS: Eighteen pseudotumor patients underwent surgical treatment. All of them were male, with mean age of 34.3 years. Fifteen patients had hemophilia A and three patients had hemophilia B. There were twelve proximal and two distal pseudotumor patients. The mean follow-up was 51.9 months. For pseudotumors in the extremities, complete surgical resection was achieved. For four patients with pelvic or abdominal pseudotumors, complete surgical resection was only achieved in two patients because of preventing potential vital organs injuries. Delayed healing of the incision, allergic reactions, and ureteral injury were the major complications. CONCLUSION: Surgery is an alternative method with safety and efficacy. Careful and individual treatment is required by the hematologist, orthopedic surgeon and other members of the team who collaborate and participate in hemophilic surgery.


Assuntos
Hematoma/cirurgia , Hemofilia A/complicações , Assistência Perioperatória/métodos , Hemorragia Pós-Operatória/prevenção & controle , Procedimentos Cirúrgicos Operatórios/métodos , Adolescente , Adulto , Perda Sanguínea Cirúrgica/prevenção & controle , China , Países em Desenvolvimento , Seguimentos , Hematoma/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Equipe de Assistência ao Paciente , Assistência Perioperatória/economia , Hemorragia Pós-Operatória/etiologia , Estudos Retrospectivos , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Resultado do Tratamento , Adulto Jovem
11.
J Knee Surg ; 32(10): 995-1000, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30423590

RESUMO

Perioperative blood management is essential to minimize allogeneic blood transfusion in total knee replacement. The effect of preoperative administration of erythropoietin, intraoperative cell saver, tranexamic acid, and restrictive transfusion strategies on allogeneic transfusion is studied in total knee replacement. A retrospective comparative study of 106 patients who underwent total knee replacement in different time periods was performed. Group A (n 1 = 45) underwent restrictive strategies of transfusion between 2009 and 2010. Group B (n 2 = 24) includes patients where erythropoietin of either 10.000 IU or 20.000 IU was given preoperatively. Patients of Group C (n 3 = 21) underwent autologous washed erythrocytes transfusion through a cell saver. Lastly, in Group D (n 4 = 15) tranexamic acid dose of 1 gr IV was given intraoperatively. The preoperative and discharge hemoglobin together with total units of blood transfusion and creatinine levels was studied. Tranexamic acid noted the least units of blood transfusion (mean = 0.82 units/patient, p < 0.001, CI 95%) in contrast to the two regimens of erythropoietin (1.16 units/patient) OrthoPAT (1.43 units/patient) and restrictive strategies (1.92 units/patient). The mean preoperative hemoglobin was 13.37 g/dL with no statistical difference among the groups of patients. The postoperative mean hemoglobin was 10.59 with no statistical difference among the groups of patients too. Additionally, the mean creatinine level was 0.93 mg/dL; however, no statistical difference among the groups of patients was noted. Finally, tranexamic acid seemed to be the most cost-effective regime. In our study, tranexamic acid proved its superiority concerning the postoperative blood transfusion on patients undergoing total knee replacement, in comparison with the other existing methods of perioperative blood management. This is a Level III, retrospective comparative study.


Assuntos
Artroplastia do Joelho/métodos , Perda Sanguínea Cirúrgica/prevenção & controle , Eritropoetina/administração & dosagem , Fármacos Hematológicos/administração & dosagem , Recuperação de Sangue Operatório/métodos , Ácido Tranexâmico/administração & dosagem , Idoso , Antifibrinolíticos/administração & dosagem , Antifibrinolíticos/economia , Artroplastia do Joelho/economia , Transfusão de Sangue , Transfusão de Sangue Autóloga/economia , Transfusão de Sangue Autóloga/instrumentação , Transfusão de Sangue Autóloga/métodos , Análise Custo-Benefício , Eritropoetina/economia , Feminino , Hematínicos/administração & dosagem , Hematínicos/economia , Fármacos Hematológicos/economia , Hemoglobinas/análise , Humanos , Masculino , Pessoa de Meia-Idade , Recuperação de Sangue Operatório/economia , Assistência Perioperatória/economia , Assistência Perioperatória/métodos , Estudos Retrospectivos , Ácido Tranexâmico/economia
12.
BMC Health Serv Res ; 18(1): 1008, 2018 Dec 29.
Artigo em Inglês | MEDLINE | ID: mdl-30594252

RESUMO

BACKGROUND: Enhanced Recovery After Surgery (ERAS) is a perioperative management based on multimodality and multidisciplinary work. ERAS has been shown to have important clinical and economic benefits, but its spread remains slow worldwide. DISCUSSION: This manuscript reviews the overall program benefits and focuses on important aspects for implementation well beyond surgery. Implementation of ERAS pathways improves clinical outcomes and induces substantial economic gains. ERAS is the current surgical revolution.


Assuntos
Deambulação Precoce/economia , Assistência Perioperatória/economia , Complicações Pós-Operatórias/prevenção & controle , Protocolos Clínicos , Redução de Custos , Humanos , Assistência Perioperatória/métodos , Complicações Pós-Operatórias/economia , Desenvolvimento de Programas , Avaliação de Programas e Projetos de Saúde
13.
BMJ Open ; 8(10): e021647, 2018 10 21.
Artigo em Inglês | MEDLINE | ID: mdl-30344168

RESUMO

INTRODUCTION: Perioperative complications have a lasting effect on health-related quality of life and long-term survival. The Royal College of Anaesthetists has proposed the development of perioperative medicine (POM) services as an intervention aimed at improving postoperative outcome, by providing better coordinated care for high-risk patients. The Perioperative Medicine Service for High-risk Patients Implementation Pilot was developed to determine if a specialist POM service is able to reduce postoperative morbidity, failure to rescue, mortality and cost associated with hospital admission. The service involves individualised objective risk assessment, admission to a postoperative critical care unit and follow-up on the surgical ward by the POM team. This paper introduces the service and how it will be evaluated. METHODS AND ANALYSIS OF THE EVALUATION: A mixed-methods evaluation is exploring the impact of the service. Clinical effectiveness of the service is being analysed using a 'before and after' comparison of the primary outcome (the PostOperative Morbidity Score). Secondary outcomes will include length of stay, validated surveys to explore quality of life (EQ-5D) and quality of recovery (Quality of Recovery-15 Score). The impact on costs is being analysed using 'before and after' data from the Patient-Level Information and Costing System and the National Schedule of Reference Costs. The perceptions and experiences of staff and patients with the service, and how it is being implemented, are being explored by a qualitative process evaluation. ETHICS AND DISSEMINATION: The study was classified as a service evaluation. Participant information sheets and consent forms have been developed for the interviews and approvals required for the use of the validated surveys were obtained. The findings of the evaluation are being used formatively, to make changes in the service throughout implementation. The findings will also be used to inform the potential roll-out of the service to other sites.


Assuntos
Implementação de Plano de Saúde/métodos , Assistência Centrada no Paciente/normas , Assistência Perioperatória/economia , Procedimentos Cirúrgicos Operatórios/mortalidade , Comorbidade , Análise Custo-Benefício , Humanos , Tempo de Internação , Modelos Logísticos , Qualidade de Vida , Projetos de Pesquisa , Medição de Risco
14.
Reprod Health ; 15(1): 168, 2018 Oct 05.
Artigo em Inglês | MEDLINE | ID: mdl-30290812

RESUMO

BACKGROUND: Uganda is far from meeting the sustainable development goals on maternal and neonatal mortality with a maternal mortality ratio of 383/100,000 live births, and 33% of the women gave birth by 18 years. The neonatal mortality ratio was 29/1000 live births and 96 stillbirths occur every day due to placental abruption, and/or eclampsia - preeclampsia and other unkown causes. These deaths could be reduced with access to timely safe surgery and safe anaesthesia if the Comprehensive Emergency Obstetric and Newborn Care services (CEmONC), and appropriate intensive care post operatively were implemented. A 2013 multi-national survey by Epiu et al. showed that, the Safe Surgical Checklist was not available for use at main referral hospitals in East Africa. We, therefore, set out to further assess 64 government and private hospitals in Uganda for the availability and usage of the WHO Checklists, and investigate the post-operative care of paturients; to advocate for CEmONC implementation in similarly burdened low income countries. METHODS: The cross-sectional survey was conducted at 64 government and private hospitals in Uganda using preset questionnaires. RESULTS: We surveyed 41% of all hospitals in Uganda: 100% of the government regional referral hospitals, 16% of government district hospitals and 33% of all private hospitals. Only 22/64 (34.38%: 95% CI = 23.56-47.09) used the WHO Safe Surgical Checklist. Additionally, only 6% of the government hospitals and 14% not-for profit hospitals had access to Intensive Care Unit (ICU) services for postoperative care compared to 57% of the private hospitals. CONCLUSIONS: There is urgent need to make WHO checklists available and operationalized. Strengthening peri-operative care in obstetrics would decrease maternal and neonatal morbidity and move closer to the goal of safe motherhood working towards Universal Health Care.


Assuntos
Acesso aos Serviços de Saúde/normas , Mortalidade Materna , Serviços de Saúde Materno-Infantil/normas , Mortalidade Perinatal , Assistência Perioperatória/economia , Assistência Perioperatória/métodos , Indicadores de Qualidade em Assistência à Saúde/normas , Estudos Transversais , Feminino , Humanos , Recém-Nascido , Gravidez , Melhoria de Qualidade
15.
Gynecol Oncol ; 151(1): 117-123, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-30100053

RESUMO

OBJECTIVE: Enhanced recovery pathways have been shown to reduce length of stay without increasing readmission or complications in numerous areas of surgery. Uptake of gynecologic oncology ERAS guidelines has been limited. We describe the effect of ERAS guideline implementation in gynecologic oncology on length of stay, patient outcomes, and economic impact for a province-wide single-payer system. METHODS: We compared pre- and post-guideline implementation outcomes in consecutive staging and debulking patients at two centers that provide the majority of surgical gynecologic oncology care in Alberta, Canada between March 2016 and April 2017. Clinical outcomes and compliance were obtained using the ERAS Interactive Audit System. Patients were followed until 30 days after discharge. Negative binomial regression was employed to adjust for patient characteristics. RESULTS: We assessed 152 pre-ERAS and 367 post-ERAS implementation patients. Mean compliance with ERAS care elements increased from 56% to 77.0% after implementation (p < 0.0001). Median length of stay for all surgeries decreased from 4.0 days to 3.0 days post-ERAS (p < 0.0001), which translated to an adjusted LOS decrease of 31.4% (95% CI = [21.7% - 39.9%], p < 0.0001). In medium/high complexity surgery median LOS was reduced by 2.0 days (p = 0.0005). Complications prior to discharge decreased from 53.3% to 36.2% post-ERAS (p = 0.0003). There was no significant difference in readmission (p = 0.6159), complications up to 30 days (p = 0.6274), or mortality (p = 0.3618) between the cohorts. The net cost savings per patient was $956 (95%CI: $162 to $1636). CONCLUSIONS: Systematic implementation of ERAS gynecologic oncology guidelines across a healthcare system improves patient outcomes and saves resources.


Assuntos
Neoplasias dos Genitais Femininos/cirurgia , Fidelidade a Diretrizes/estatística & dados numéricos , Procedimentos Cirúrgicos em Ginecologia/efeitos adversos , Assistência Perioperatória/normas , Complicações Pós-Operatórias/epidemiologia , Idoso , Redução de Custos , Procedimentos Cirúrgicos de Citorredução/efeitos adversos , Procedimentos Cirúrgicos de Citorredução/economia , Procedimentos Cirúrgicos de Citorredução/métodos , Feminino , Neoplasias dos Genitais Femininos/economia , Procedimentos Cirúrgicos em Ginecologia/economia , Procedimentos Cirúrgicos em Ginecologia/métodos , Humanos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Auditoria Médica , Pessoa de Meia-Idade , Alta do Paciente/estatística & dados numéricos , Readmissão do Paciente/economia , Readmissão do Paciente/estatística & dados numéricos , Assistência Perioperatória/economia , Assistência Perioperatória/métodos , Guias de Prática Clínica como Assunto , Avaliação de Programas e Projetos de Saúde
16.
J Arthroplasty ; 33(10): 3138-3142, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-30077468

RESUMO

BACKGROUND: Institutional pathways in total joint arthroplasty (TJA) have been shown to reduce costs and improve patient care, but questions remain regarding their efficacy in certain populations. We sought to evaluate the comprehensive effect of a rapid recovery perioperative TJA protocol in the Veterans Health Administration (VA) setting. METHODS: In a VA hospital, a rapid recovery protocol was implemented for all patients undergoing primary total hip or knee arthroplasty. A retrospective chart review was performed comparing pre-protocol (n = 174) and protocol (n = 78) cohorts. Measured outcomes included length of stay (LOS), discharge destination, unplanned readmissions, overall complications, and total cost of healthcare during admission and at 30 and 90 days postoperatively. RESULTS: After implementation of the protocol, the average LOS decreased from 3.2 to 1.7 days (P < .0001). In the protocol group, there was a 12.3% increase in patients discharging directly home (85.1% vs 97.4%, P = .005). There were lower unplanned readmissions (6.3% vs 3.8%, P = .56) and overall complications (7.5% vs 3.8%, P = .40), but these were not statistically significant. The summative cost of all perioperative healthcare was lower after implementation of the protocol during the inpatient stay ($19,015 vs $21,719, P = .002) and out to 30 days postoperatively ($21,083 vs $23,420, P = .03) and 90 days postoperatively ($24,189 vs $26,514, P = .07). CONCLUSION: In the VA setting, implementation of a rapid recovery TJA protocol led to decreased LOS, decreased cost of perioperative healthcare, and an increase in patients discharging directly home without increased readmission or complication rates. Such protocols are essential as we transition into an era of value-based arthroplasty.


Assuntos
Artroplastia de Quadril/normas , Artroplastia do Joelho/normas , Protocolos Clínicos/normas , Hospitais de Veteranos/estatística & dados numéricos , Assistência Perioperatória/normas , Idoso , Artroplastia de Quadril/efeitos adversos , Artroplastia de Quadril/economia , Artroplastia de Quadril/estatística & dados numéricos , Artroplastia do Joelho/efeitos adversos , Artroplastia do Joelho/economia , Artroplastia do Joelho/estatística & dados numéricos , Análise Custo-Benefício , Feminino , Custos de Cuidados de Saúde/estatística & dados numéricos , Hospitais de Veteranos/economia , Hospitais de Veteranos/normas , Humanos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Alta do Paciente , Readmissão do Paciente/economia , Readmissão do Paciente/estatística & dados numéricos , Assistência Perioperatória/economia , Assistência Perioperatória/estatística & dados numéricos , Estudos Retrospectivos , Estados Unidos/epidemiologia
17.
Acta Orthop ; 89(5): 515-521, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30078348

RESUMO

Background and purpose - Length of stay (LOS) following total hip and knee arthroplasty (THA and TKA) has been reduced over the years due to fast-track. Short stays of 2 days in fast-track departments in Denmark have resulted in low total costs of around US$2,550. Outpatient THA and TKA is gaining popularity, albeit in a limited and selected group of patients; however, the financial benefit of outpatient arthroplasty remains unknown. We present baseline detailed economic calculations of outpatient THA and TKA in 2 different settings: one from the hospital and another from the ambulatory surgery department. Patients and methods - Data from 6 patients (1 TKA, 1 uncemented THA, 1 cemented THA in each department) were collected prospectively using the Time Driven Activity Based Costing method (TDABC). Time consumed by different staff members involved in patient treatment in the perioperative period of outpatient THA and TKA was calculated in 2 different settings: one in the orthopedic department and one in the ambulatory surgery department. Results - LOS was around 11 h in the orthopedic department and around 7 h in the ambulatory surgery department, respectively. TDABC revealed minor differences in the operative settings between departments and similar expenses occurred during the short stay of US$777 and US$746, respectively. Adding the preoperative preparation and postoperative follow-up resulted in total cost of US$951 and US$942 for the ward and the ambulatory surgery department, respectively. Interpretation - Outpatient THA and TKA in hospital and ambulatory surgery departments results in similar cost using the TDABC method. Compared with the cost associated with 2-day stays, outpatient procedures are around two-thirds cheaper provided no increase occurs in complications or readmissions.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/economia , Artroplastia de Quadril/economia , Artroplastia do Joelho/economia , Custos de Cuidados de Saúde/estatística & dados numéricos , Procedimentos Cirúrgicos Ambulatórios/métodos , Artroplastia de Quadril/métodos , Artroplastia do Joelho/métodos , Dinamarca , Humanos , Tempo de Internação/estatística & dados numéricos , Assistência Perioperatória/economia , Estudos Prospectivos
18.
J Arthroplasty ; 33(10): 3125-3129, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-30029928

RESUMO

BACKGROUND: With the recent implementation of a bundled payment model for total joint arthroplasty, healthcare providers are financially responsible for management of complications throughout the 90-day perioperative period. Our aim was to assess the effectiveness of a surveillance system that was implemented to enhance communication during this period. METHODS: A retrospective study was conducted using a prospectively collected database of patients who underwent primary total joint arthroplasty from January 2015 to April 2016. Surveillance was performed using electronic messages and telephone calls. The use of this system in response to several clinical scenarios was measured by the total number of messages and calls exchanged. RESULTS: Communication was greater among patients who experienced a complication (median 8), went to the emergency department (ED; median 9), and were readmitted to the hospital (median 8), relative to patients who had an uncomplicated course (median 5). Additionally, communication was greater among patients who presented to outside facilities for ED visits (median 11) and readmissions (median 9) relative to those who returned to the index hospital for ED visits (median 7) and readmissions (median 6). More distant patients had decreased follow-up attendance but did not have a compensatory increase in use of the surveillance system. CONCLUSION: Patients used the surveillance system to relay information about clinically significant events when such events arose. Additionally, patients who returned to outside facilities used the surveillance system to remain engaged with their original provider. However, more distant patients did not appear to use the surveillance system to compensate for decreased follow-up attendance.


Assuntos
Artroplastia de Substituição/efeitos adversos , Readmissão do Paciente/estatística & dados numéricos , Assistência Perioperatória/estatística & dados numéricos , Vigilância da População , Idoso , Artroplastia de Substituição/economia , Comunicação , Bases de Dados Factuais , Serviço Hospitalar de Emergência/economia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Masculino , Pacotes de Assistência ao Paciente/economia , Pacotes de Assistência ao Paciente/estatística & dados numéricos , Assistência Perioperatória/economia , Relações Médico-Paciente , Estudos Retrospectivos
19.
Anesth Analg ; 127(4): 855-863, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-29933267

RESUMO

BACKGROUND: Complication rates after hepatic resection can be affected by management decisions of the hospital care team and/or disparities in care. This is true in many other surgical populations, but little study has been done regarding patients undergoing hepatectomy. METHODS: Data from the claims-based national Premier Perspective database were used for 2006 to 2014. The analytical sample consisted of adults undergoing partial hepatectomy and total hepatic lobectomy with anesthesia care consisting of general anesthesia (GA) only or neuraxial and GA (n = 9442). The key independent variable was type of anesthesia that was categorized as GA versus GA + neuraxial. The outcomes examined were clinical complications and health care resource utilization. Unadjusted bivariate and adjusted multivariate analyses were conducted to examine the effects of the different types of anesthesia on clinical complications and health care resource utilization after controlling for patient- and hospital-level characteristics. RESULTS: Approximately 9% of patients were provided with GA + neuraxial anesthesia during hepatic resection. In multivariate analyses, no association was observed between types of anesthesia and clinical complications and/or health care utilization (eg, admission to intensive care unit). However, patients who received blood transfusions were significantly more likely to have complications and intensive care unit stays. In addition, certain disparities of care, including having surgery in a rural hospital, were associated with poorer outcomes. CONCLUSIONS: Neuraxial anesthesia utilization was not associated with improvement in clinical outcome or cost among patients undergoing hepatic resections when compared to patients receiving GA alone. Future research may focus on prospective data sources with more clinical information on such patients and examine the effects of GA + neuraxial anesthesia on various complications and health care resource utilization.


Assuntos
Anestesia por Condução/tendências , Anestesia Geral/tendências , Disparidades em Assistência à Saúde/tendências , Hepatectomia/tendências , Assistência Perioperatória/tendências , Complicações Pós-Operatórias/terapia , Padrões de Prática Médica/tendências , Demandas Administrativas em Assistência à Saúde , Adulto , Idoso , Anestesia por Condução/efeitos adversos , Anestesia por Condução/economia , Anestesia Geral/efeitos adversos , Anestesia Geral/economia , Pesquisa Comparativa da Efetividade , Bases de Dados Factuais , Feminino , Disparidades em Assistência à Saúde/economia , Hepatectomia/efeitos adversos , Hepatectomia/economia , Custos Hospitalares/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Assistência Perioperatória/efeitos adversos , Assistência Perioperatória/economia , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/economia , Padrões de Prática Médica/economia , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento
20.
J Surg Res ; 229: 145-149, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-29936981

RESUMO

BACKGROUND: Appendicitis has been cited to be the most common abdominal disorder that requires acute care surgery in the pediatric population. Enhanced Recovery After Surgery protocols are multimodal perioperative care pathways designed to achieve early recovery after surgical procedures by maintaining preoperative organ function and reducing the profound stress response following surgery. Such pathways have been found to enhance quality of care for surgical patients as well as improve recovery and shorten hospital stays. The purpose of this study was to determine the key factors that facilitate same-day discharge (SDD) and early return to normal activities after laparoscopic appendectomies in children. METHODS: This is a single-center retrospective chart review of pediatric patients (<18 y old) who underwent appendectomies for acute appendicitis from January 2015 to April 2017. The patient population was divided into two groups: those with SDD and those who were discharged one or more days after surgery. SDD was defined as discharge less than 24 h of surgical admission. Patient factors, including prehospital, preoperative, perioperative, and postoperative factors, were compared and analyzed between the two groups and statistically evaluated using Fisher's exact test for categorical data and student t-test for continuous variables. RESULTS: Two hundred forty eight patients were found under International Classification of Diseases-9 and International Classification of Diseases-10 codes for acute appendicitis. Of these, 63 were excluded due to perforated appendicitis, nonoperative management, interval appendectomies, or misdiagnosis. The remaining 185 had laparoscopic appendectomies; 59.5% (n = 110) were SDDs and 40.5% (n = 75) stayed more than one day. No significant difference was found for time between emergency room arrival and surgical admission (5.27 versus 5.4 h; P = 08.) but SDD patients had a significantly shorter time between surgical admission and operation (5.8 versus 11.4 h; P <0.001). SDD patients and non-SDD patients had no significant difference in rate of complications (0% versus 1.3%; P = 0.4). There was no significant difference in readmission rates between the two groups (2.7% versus 2.7%; P = 1). Total hospital charges, which indirectly reflect costs, were significantly less for SDD ($29,195 versus $33,703; P <0.001). CONCLUSIONS: Surgical leadership can be effective in facilitating SDD without increasing readmission rates or complications and helps reduce hospital costs, decreases chances of nosocomial infection, and increases patient and family satisfaction.


Assuntos
Apendicectomia/efeitos adversos , Apendicite/cirurgia , Laparoscopia/efeitos adversos , Alta do Paciente/estatística & dados numéricos , Assistência Perioperatória/métodos , Adolescente , Fatores Etários , Apendicectomia/economia , Apendicectomia/métodos , Apendicite/economia , Criança , Pré-Escolar , Feminino , Custos Hospitalares/estatística & dados numéricos , Humanos , Laparoscopia/economia , Laparoscopia/métodos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Masculino , Readmissão do Paciente/estatística & dados numéricos , Satisfação do Paciente , Assistência Perioperatória/economia , Assistência Perioperatória/estatística & dados numéricos , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Fatores de Tempo , Gerenciamento do Tempo/métodos , Tempo para o Tratamento/estatística & dados numéricos
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