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1.
Medicine (Baltimore) ; 99(22): e20476, 2020 May 29.
Artigo em Inglês | MEDLINE | ID: mdl-32481457

RESUMO

To investigate the healthcare expenditures and length of stay (LOS) of sepsis-related hospitalizations in Taiwan.This is a retrospective claim database study. Data were obtained from the two-million-sample longitudinal health and welfare database (LHWD). Adult patients hospitalized with sepsis between 2010 and 2014 were identified by International Classification of Diseases 9th Edition Clinical Modification (ICD-9-CM) codes, and these patients were divided into three levels of sepsis severity. The amount and distribution of their total medical expenditures were investigated.In total, 62,517 patients with 97,790 sepsis-related hospitalizations were included in the present study. It was found that ward fees and medicines comprised the largest component of expenses for sepsis-related hospitalizations. In addition, our study results indicated that the median sepsis-related hospitalization cost was 66.4 thousand New Taiwan Dollar (NT dollars) in 2014, and a significant temporal change was found between 2010 and 2014. The median LOS in a hospital and in an intensive care unit were 11 and 7 days, respectively. Both expenditures and LOS were found to increase with sepsis severity.This study provides an updated and better understanding of the costs and LOS of sepsis-related hospitalizations in Taiwan. It was found that ward fees and medicine fees were the major components of hospital costs.


Assuntos
Hospitalização/economia , Sepse/economia , Cuidados Críticos/economia , Gastos em Saúde/estatística & dados numéricos , Custos Hospitalares/estatística & dados numéricos , Humanos , Tempo de Internação/economia , Estudos Longitudinais , Estudos Retrospectivos , Índice de Gravidade de Doença , Taiwan
2.
Bull Cancer ; 107(3): 308-321, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32035648

RESUMO

INTRODUCTION: Health care utilization of people with lung cancer (LC) the last year of life, their causes of death and place of death and the associated expenditure have been poorly described together. Then we conducted an observational study. METHODS: People with LC covered by the French health Insurance general scheme (77% of the population) who died in 2015 were identified in the national health data system, together with their health care utilization and, in 95% of cases, their causes of death. RESULTS: A total of 22,899 individuals were included (mean age: 68 years, SD±11.4), 72% of whom died in short-stay hospitals (SSH), 4% in hospital-at-home, 8% in Rehab hospital, 2% in skilled nursing homes and 14% at home. One-half of these people had also a chronic respiratory tract disease and 18% another cancer. Hospital palliative care (HPC) was identified for 65% of people, but for only 9% prior to their end-of-life stay. During the last month of life, 49% of people had two or more SSH stays, 15% were admitted to an intensive care unit, 23% received a chemotherapy session (13% during the last 14 days). The main cause of death was cancer for 92% of individuals (LC for 82%) The mean expenditure during the last year of life was €43,329 per individual. DISCUSSION: This study indicates high rates of intensive care unit admissions and chemotherapy during the last month of life and a SSH hospital-centered management with intensive use of HPC mainly during the end-of-life stay.


Assuntos
Gastos em Saúde , Necessidades e Demandas de Serviços de Saúde/estatística & dados numéricos , Neoplasias Pulmonares/economia , Neoplasias Pulmonares/terapia , Idoso , Idoso de 80 Anos ou mais , Causas de Morte , Comorbidade , Cuidados Críticos/economia , Cuidados Críticos/estatística & dados numéricos , Tratamento Farmacológico/economia , Tratamento Farmacológico/estatística & dados numéricos , Feminino , França/epidemiologia , Mortalidade Hospitalar , Humanos , Cobertura do Seguro/estatística & dados numéricos , Unidades de Terapia Intensiva/estatística & dados numéricos , Neoplasias Pulmonares/epidemiologia , Neoplasias Pulmonares/mortalidade , Masculino , Pessoa de Meia-Idade , Cuidados Paliativos/estatística & dados numéricos , Características de Residência , Assistência Terminal/estatística & dados numéricos , Fatores de Tempo
3.
J Intensive Care Med ; 35(1): 14-23, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30309279

RESUMO

Static indices, such as the central venous pressure, have proven to be inaccurate predictors of fluid responsiveness. An emerging approach uses dynamic assessment of fluid responsiveness (FT-DYN), such as stroke volume variation (SVV) or surrogate dynamic variables, as more accurate measures of volume status. Recent work has demonstrated that goal-directed therapy guided by FT-DYN was associated with reduced intensive care unit (ICU) mortality; however, no study has specifically assessed this in surgical ICU patients. This study aimed to conduct a systematic review and meta-analysis on the impact of employing FT-DYN in the perioperative care of surgical ICU patients on length of stay in the ICU. As secondary objectives, we performed a cost analysis of FT-DYN and assessed the impact of FT-DYN versus standard care on hospital length of stay and mortality. We identified all randomized controlled trials (RCTs) through MEDLINE, EMBASE, and CENTRAL that examined adult patients in the ICU who were randomized to standard care or to FT-DYN from inception to September 2017. Two investigators independently reviewed search results, identified appropriate studies, and extracted data using standardized spreadsheets. A random effect meta-analysis was carried out. Eleven RCTs were included with a total of 1015 patients. The incorporation of FT-DYN through SVV in surgical patients led to shorter ICU length of stay (weighted mean difference [WMD], -1.43d; 95% confidence interval [CI], -2.09 to -0.78), shorter hospital length of stay (WMD, -1.96d; 95% CI, -2.34 to -1.59), and trended toward improved mortality (odds ratio, 0.55; 95% CI, 0.30-1.03). There was a decrease in daily ICU-related costs per patient for those who received FT-DYN in the perioperative period (WMD, US$ -1619; 95% CI, -2173.68 to -1063.26). Incorporation of FT-DYN through SVV in the perioperative care of surgical ICU patients is associated with decreased ICU length of stay, hospital length of stay, and ICU costs.


Assuntos
Cuidados Críticos/métodos , Hidratação/métodos , Tempo de Internação/estatística & dados numéricos , Ressuscitação/métodos , Acidente Vascular Cerebral/terapia , Cuidados Críticos/economia , Hidratação/economia , Custos Hospitalares , Humanos , Ressuscitação/economia , Acidente Vascular Cerebral/economia , Volume Sistólico
4.
Epidemiol Infect ; 147: e314, 2019 12 05.
Artigo em Inglês | MEDLINE | ID: mdl-31802726

RESUMO

The impact of mechanical ventilation on the daily costs of intensive care unit (ICU) care is largely unknown. We thus conducted a systematic search for studies measuring the daily costs of ICU stays for general populations of adults (age ≥18 years) and the added costs of mechanical ventilation. The relative increase in the daily costs was estimated using random effects meta regression. The results of the analyses were applied to a recent study calculating the excess length-of-stay associated with ICU-acquired (ventilator-associated) pneumonia, a major complication of mechanical ventilation. The search identified five eligible studies including a total of 54 766 patients and ~238 037 patient days in the ICU. Overall, mechanical ventilation was associated with a 25.8% (95% CI 4.7%-51.2%) increase in the daily costs of ICU care. A combination of these estimates with standardised unit costs results in approximate daily costs of a single ventilated ICU day of €1654 and €1580 in France and Germany, respectively. Mechanical ventilation is a major driver of ICU costs and should be taken into account when measuring the financial burden of adverse events in ICU settings.


Assuntos
Cuidados Críticos/economia , Custos Hospitalares/estatística & dados numéricos , Unidades de Terapia Intensiva/economia , Respiração Artificial/economia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Cuidados Críticos/métodos , França , Alemanha , Humanos , Pessoa de Meia-Idade , Adulto Jovem
5.
Vasc Health Risk Manag ; 15: 385-393, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31564888

RESUMO

Background: Perioperative health care utilization and costs in patients undergoing elective fast-track vs standard endovascular aneurysm repair (EVAR) remain unclear. Methods: The fast-track EVAR group included patients treated with a 14 Fr stent graft, bilateral percutaneous access, no general anesthesia or intensive care monitoring, and next-day hospital discharge. The standard EVAR group was identified from Medicare administrative claims using a matching algorithm to adjust for imbalances in patient characteristics. Hospital outcomes included operating room time, intensive care monitoring, hospital stay, secondary interventions, and major adverse events (MAEs). Perioperative outcomes occurring from hospital discharge to 30 days postdischarge included MAE, secondary interventions, and unrelated readmissions. Results: Among 1000 matched patients (250 fast-track; 750 standard), hospital outcomes favored the fast-track EVAR group, including shorter operating room time (2.30 vs 2.83 hrs, P<0.001), shorter hospital stay (1.16 vs 1.69 d, P<0.001), less need for intensive care monitoring (4.4% vs 48.0%, P<0.001), and lower secondary intervention rate (0% vs 2.4%, P=0.01). Postdischarge outcomes also favored fast-track EVAR with a lower rate of MAE (0% vs 7.2%, P<0.001) and all-cause readmission (1.6% vs 6.8%, P=0.001). The total cost to the health care system during the perioperative period was $26,730 with fast-track EVAR vs $30,730 with standard EVAR. Total perioperative health care costs were $4000 (95% CI: $3130-$4830) lower with fast-track EVAR vs standard EVAR, with $2980 in savings to hospitals and $1030 savings to health care payers. Conclusion: A fast-track EVAR protocol using a 14 Fr stent graft resulted in shorter procedure time, lower intensive care utilization, faster discharge, lower incidence of MAE, lower readmission rates, and lower perioperative costs compared to standard EVAR.


Assuntos
Aneurisma da Aorta Abdominal/economia , Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/economia , Procedimentos Endovasculares/economia , Custos Hospitalares , Avaliação de Processos e Resultados em Cuidados de Saúde/economia , Alta do Paciente/economia , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Prótese Vascular/economia , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Redução de Custos , Análise Custo-Benefício , Cuidados Críticos/economia , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Feminino , Humanos , Tempo de Internação/economia , Masculino , Duração da Cirurgia , Readmissão do Paciente/economia , Desenho de Prótese , Sistema de Registros , Retratamento/economia , Stents/economia , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
6.
PLoS One ; 14(9): e0222671, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31539397

RESUMO

BACKGROUND: Little is known about outpatient health services use following critical illness and intensive care. We examined the association of intensive care with outpatient consultations and quality of life in a population-based sample. METHODS: Cross-sectional analysis of data from 6,686 participants of the Study of Health in Pomerania (SHIP), which consists of two independent population-based cohorts. Statistical modeling was done using Poisson regression, negative binomial and generalized linear models for consultations, and a fractional response model for quality of life (EQ-5D-3L index value), with results expressed as prevalence ratios (PR) or percent change (PC). Entropy balancing was used to adjust for observed confounding. RESULTS: ICU treatment in the previous year was reported by 139 of 6,686 (2,1%) participants, and was associated with a higher probability (PR 1.05 [CI:1.03;1.07]), number (PC +58.0% [CI:22.8;103.2]) and costs (PC +64.1% [CI:32.0;103.9]) of annual outpatient consultations, as well as with a higher number of medications (PC +37.8% [CI:17.7;61.5]). Participants with ICU treatment were more likely to visit a specialist (PR 1.13 [CI:1.09; 1.16]), specifically internal medicine (PR 1.67 [CI:1.45;1.92]), surgery (PR 2.42 [CI:1.92;3.05]), psychiatry (PR 2.25 [CI:1.30;3.90]), and orthopedics (PR 1.54 [CI:1.11;2.14]). There was no significant effect regarding general practitioner consultations. ICU treatment was also associated with lower health-related quality of life (EQ-5D index value: PC -13.7% [CI:-27.0;-0.3]). Furthermore, quality of life was inversely associated with outpatient consultations in the previous month, more so for participants with ICU treatment. CONCLUSIONS: Our findings suggest that ICU treatment is associated with an increased utilization of outpatient specialist services, higher medication intake, and impaired quality of life.


Assuntos
Assistência Ambulatorial/estatística & dados numéricos , Cuidados Críticos/estatística & dados numéricos , Custos de Cuidados de Saúde/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Qualidade de Vida , Adulto , Idoso , Assistência Ambulatorial/economia , Cuidados Críticos/economia , Estudos Transversais , Feminino , Alemanha , Humanos , Masculino , Pessoa de Meia-Idade , Distribuição de Poisson , Adulto Jovem
8.
Pancreatology ; 19(6): 828-833, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31383574

RESUMO

BACKGROUND: Use of minimally invasive techniques has reduced mortality in walled-off pancreatic necrosis (WON) but may be costly. The aim of this study was to evaluate the actual costs associated with the endoscopic management of patients with WON. METHODS: We included a retrospective cohort of WON patients treated with endoscopic, transgastric drainage and necrosectomy (ETDN) during 2013-2014. Costs were calculated for six sub-areas based on a micro-costing model. Students T-test and non-parametric analysis of variance were performed to evaluate costs in relation to disease etiology and outcome. RESULTS: We included 58 patients (50% men, median age 57 years). The most common etiologies were gallstones (57%) and alcohol (19%). Nine patients (16%) died during admission. The median length of stay was 50 days (IQR 31 days). Eighteen patients (31%) needed treatment in our intensive care unit with a median length of stay of 16 days (IQR 31 days). The mean costs and standard deviation of costs (SD) per patient were: diagnostic imaging $2,431 ($2,301), laboratory tests $3,579 ($2,477), blood products $982 ($1,734), endoscopic treatment $3,794 ($1,777), medicine $5,440 ($6,656), and ward cost $41,260 ($35,854). The mean total cost was $57,486 ($46,739). Post-ERCP pancreatitis and mortality predicted higher costs. CONCLUSIONS: This study sheds light on the different costs associated with endoscopic treatment of WON. As nearly three quarters of the costs are related to ward care, initiatives aimed at reducing the length of hospital stay may have a great impact on making endoscopic treatment more cost effective.


Assuntos
Endoscopia/economia , Pancreatite Necrosante Aguda/economia , Custos e Análise de Custo , Cuidados Críticos/economia , Cuidados Críticos/estatística & dados numéricos , Diagnóstico por Imagem/economia , Drenagem , Endoscopia/mortalidade , Feminino , Mortalidade Hospitalar , Humanos , Estimativa de Kaplan-Meier , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/economia , Procedimentos Cirúrgicos Minimamente Invasivos/mortalidade , Pancreatite Necrosante Aguda/mortalidade , Pancreatite Necrosante Aguda/cirurgia , Estudos Retrospectivos , Stents , Análise de Sobrevida , Resultado do Tratamento
9.
J Healthc Risk Manag ; 39(2): 31-40, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31469484

RESUMO

The New York City Department of Health and Mental Hygiene (DOHMH) implemented Project INSPIRE, an integrated model of hepatitis C care coordination and telementoring services, from 2014 to 2017. We evaluated the use of chronic care management (CCM) codes to sustain the intervention. DOHMH data were collected as part of a Healthcare Innovation Award from the Centers for Medicare & Medicaid Services (CMS). A retrospective cohort medical billing study was conducted by assigning INSPIRE activities to procedure codes in both facility and nonfacility settings. Rates for procedures were extracted from the CMS's 2018 fee schedules and added across the eligibility periods for Medicare enrollees. Reimbursement was adjusted on the basis of expected patient attrition and compared to costs. The minimum number needed to treat (NNT) to break even was calculated in each setting. Facility reimbursement was higher than costs, whereas nonfacility reimbursement was lower (both P < .01). The NNT was 23 patients in facilities and 33 patients in nonfacilities; 24 patients per care coordinator were treated annually in INSPIRE. CCM fees alone were insufficient to fully reimburse the costs in either setting. Implementation of an appropriate risk financing strategy is necessary to mitigate financial shortfalls when providing CCM services in facility settings.


Assuntos
Cuidados Críticos/economia , Cuidados Críticos/estatística & dados numéricos , Gastos em Saúde/estatística & dados numéricos , Hepatite C/economia , Hepatite C/terapia , Medicare/economia , Medicare/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Centers for Medicare and Medicaid Services, U.S./estatística & dados numéricos , Estudos de Coortes , Feminino , Humanos , Masculino , Cidade de Nova Iorque , Estudos Retrospectivos , Estados Unidos
10.
J Vasc Surg ; 69(6): 1863-1873.e1, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31159987

RESUMO

BACKGROUND: The overall use of intensive care units (ICUs) in the United States has been steadily increasing and is associated with tremendous health care costs. We suspect that the burden of ICU utilization after elective infrainguinal lower extremity bypass (LEB) procedures is high, despite relatively low risks of complications in the immediate postoperative period. We sought to identify the burden of ICU utilization after elective LEB in patients with claudication. METHODS: We queried the Premier Healthcare Database for all adult patients undergoing first recorded elective infrainguinal LEB for claudication from 2009 to 2015. Baseline characteristics and ICU utilization on postoperative day 0 (POD 0) were identified for each patient using Premier room and board chargemaster codes. A bivariate logistic regression was performed and postestimation concordance statistics were calculated to identify predictors of postoperative ICU vs regular surgical floor admission immediately after surgery. RESULTS: There were 6010 patients who met the selection criteria, of whom 2772 (46.1%) were admitted to the ICU and 3238 (53.9%) to the regular surgical floor on POD 0. Whereas patient-level factors were responsible for minor differences found in postoperative admission to the ICU after elective LEB, hospital characteristics made up the majority of variation in admission practices. Specifically, patients undergoing elective infrainguinal LEB in rural, nonteaching, small hospitals and those in certain geographic regions were more likely to be admitted to the ICU than to the floor (all, P < .001). Patient-level factors were poorly predictive of admission to the ICU immediately postoperatively, with C statistics ranging from 0.50 to 0.53. In contrast, hospital-level factors had higher C statistics ranging from 0.51 to 0.66, with geographic location being the strongest predictor of post-LEB ICU admission. There were no significant differences in the incidence of postoperative wound complications, major adverse limb events, major adverse cardiac events, or in-hospital mortality between groups (all, P ≥ .32). The median total hospital cost was $2340 higher for ICU compared with floor admission ($13,273 [interquartile range, $10,136-$17,883] vs $10,927 [interquartile range, $8342-$14,523]; P < .001). CONCLUSIONS: Nearly half of patients are admitted to an ICU directly after elective infrainguinal LEB for claudication. This practice is associated with significantly higher hospital cost and is predominantly influenced by hospital-level rather than by patient-level factors. Perioperative morbidity and mortality were similar regardless of postoperative disposition. To minimize ICU utilization, postoperative care intensity should be determined by clinical severity of the patient rather than by hospital routine.


Assuntos
Cuidados Críticos/economia , Custos Hospitalares , Claudicação Intermitente/economia , Claudicação Intermitente/cirurgia , Extremidade Inferior/irrigação sanguínea , Doença Arterial Periférica/economia , Doença Arterial Periférica/cirurgia , Enxerto Vascular/economia , Idoso , Bases de Dados Factuais , Procedimentos Cirúrgicos Eletivos , Feminino , Humanos , Unidades de Terapia Intensiva/economia , Claudicação Intermitente/diagnóstico , Claudicação Intermitente/mortalidade , Masculino , Pessoa de Meia-Idade , Admissão do Paciente/economia , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/mortalidade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Enxerto Vascular/efeitos adversos , Enxerto Vascular/mortalidade
11.
Semin Respir Crit Care Med ; 40(1): 137-144, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-31060095

RESUMO

Costs of care in the intensive care unit are a frequent area of concern in our current health care system. Utilization of critical care services in the United States, particularly near the end of life, has been steadily increasing and will continue to do so. Acute respiratory distress syndrome (ARDS) is a common and important complication of critical illness. Patients with ARDS frequently experience prolonged hospitalizations and consume significant health care resources. Many patients are discharged with functional limitations and require significant postdischarge services. These patients have a high susceptibility to new complications which require significant additional health care resources. There is a slowly growing literature on the cost-effectiveness of the treatment of ARDS; despite its high costs, treatment remains a cost-effective intervention by most societal standards. However, when ARDS leads to prolonged mechanical ventilation, treatment may become less cost-effective. In addition, the provision of extracorporeal life support adds another layer of complexity to these cases. Small reductions in intensive care unit length of stay may benefit patients, but they do not lead to significant reductions in overall hospital costs. Early discharge to postacute care facilities can reduce hospital costs but is unlikely to significantly decrease costs for an entire episode of illness. Improved effectiveness of communication between clinicians and patients or their surrogates could help avoid costly interventions with poor expected outcomes. However, the most significant cost-saving interventions are early recognition and treatment of conditions to potentially prevent the development of this serious complication.


Assuntos
Cuidados Críticos/métodos , Custos de Cuidados de Saúde/estatística & dados numéricos , Síndrome do Desconforto Respiratório do Adulto/terapia , Análise Custo-Benefício , Cuidados Críticos/economia , Estado Terminal , Oxigenação por Membrana Extracorpórea/economia , Oxigenação por Membrana Extracorpórea/métodos , Custos Hospitalares/estatística & dados numéricos , Humanos , Unidades de Terapia Intensiva/economia , Respiração Artificial/economia , Respiração Artificial/métodos , Síndrome do Desconforto Respiratório do Adulto/economia , Fatores de Tempo
12.
Anesth Analg ; 128(6): 1129-1136, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31094777

RESUMO

BACKGROUND: Postoperative residual neuromuscular blockade continues to be a frequent occurrence with a reported incidence rate of up to 64%. However, the effect of postoperative residual neuromuscular blockade on health care utilization remains unclear. We conducted a retrospective cohort study to investigate the effects of postoperative residual neuromuscular blockade on hospital costs (primary outcome), intensive care unit admission rate, and hospital length of stay (secondary outcomes). METHODS: We performed a prespecified secondary analysis of data obtained in 2233 adult patients undergoing surgery under general anesthesia. Postoperative residual neuromuscular blockade was defined as a train-of-four ratio <0.9 in the postanesthesia care unit (PACU). Our confounder model adjusted for a variety of patient, surgical, and anesthesia-related factors. We fitted truncated negative binomial regression models for hospital cost and hospital length of stay analyses and a logistic regression model for our intensive care unit admission analysis. RESULTS: Overall, 457 (20.5%) patients in our cohort had residual neuromuscular blockade on admission to the PACU. Postoperative residual neuromuscular blockade was not independently associated with increased hospital costs (adjusted incidence rate ratio, 1.04, CI, 0.98-1.11; P = .22). There were significantly higher odds of intensive care unit admission in those with postoperative residual neuromuscular blockade compared to those without (adjusted odds ratio, 3.03, CI, 1.33-6.87; P < .01). Further, we found a trend toward increased hospital length of stay in patients with postoperative residual neuromuscular blockade (adjusted incidence rate ratio, 1.09; P = .06). Sensitivity analysis using the same model in the day of surgery admissions and ambulatory surgery confirmed our findings. CONCLUSIONS: Postoperative residual neuromuscular blockade at PACU admission was not significantly associated with increased hospital costs, but was associated with higher rates of intensive care unit admission. These findings support the view that clinicians should continue to work to reduce the rate of postoperative residual neuromuscular blockade.


Assuntos
Cuidados Críticos/economia , Cuidados Críticos/métodos , Recuperação Demorada da Anestesia/economia , Unidades de Terapia Intensiva , Adulto , Idoso , Atracúrio/efeitos adversos , Atracúrio/análogos & derivados , Interpretação Estatística de Dados , Feminino , Humanos , Incidência , Tempo de Internação/economia , Masculino , Pessoa de Meia-Idade , Bloqueio Neuromuscular/efeitos adversos , Admissão do Paciente , Período Pós-Operatório , Estudos Prospectivos , Estudos Retrospectivos , Rocurônio/efeitos adversos , Resultado do Tratamento , Brometo de Vecurônio/efeitos adversos
13.
Crit Care Clin ; 35(3): 407-414, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31076041

RESUMO

Conceptualizing, designing, implementing, and sustaining a successful critical care telemedicine program is a complex undertaking. All of these steps must be fully accomplished as a joint effort between a host facility and the telemedicine service provider. Important administrative considerations that must be incorporated into planning and execution steps include managing change. We briefly discuss critical aspects of establishing a sustainable business model, and aligning the critical care telemedicine program with institutional vision, goals, and mission. Discussed are important telemedicine provider infrastructure, key personnel considerations, and how a program defines and measures value.


Assuntos
Cuidados Críticos/organização & administração , Telemedicina/organização & administração , Cuidados Críticos/economia , Cuidados Críticos/métodos , Humanos , Modelos Econômicos , Determinação de Necessidades de Cuidados de Saúde , Telemedicina/economia , Telemedicina/métodos
14.
PLoS One ; 14(5): e0216743, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31071199

RESUMO

BACKGROUND: The in-hospital treatment of patients with traumatic brain injury (TBI) is considered to be expensive, especially in patients with severe TBI (s-TBI). To improve future treatment decision-making, resource allocation and research initiatives, this study reviewed the in-hospital costs for patients with s-TBI and the quality of study methodology. METHODS: A systematic search was performed using the following databases: PubMed, MEDLINE, Embase, Web of Science, Cochrane library, CENTRAL, Emcare, PsychINFO, Academic Search Premier and Google Scholar. Articles published before August 2018 reporting in-hospital acute care costs for patients with s-TBI were included. Quality was assessed by using a 19-item checklist based on the CHEERS statement. RESULTS: Twenty-five out of 2372 articles were included. In-hospital costs per patient were generally high and ranged from $2,130 to $401,808. Variation between study results was primarily caused by methodological heterogeneity and variable patient and treatment characteristics. The quality assessment showed variable study quality with a mean total score of 71% (range 48% - 96%). Especially items concerning cost data scored poorly (49%) because data source, cost calculation methodology and outcome reporting were regularly unmentioned or inadequately reported. CONCLUSIONS: Healthcare consumption and in-hospital costs for patients with s-TBI were high and varied widely between studies. Costs were primarily driven by the length of stay and surgical intervention and increased with higher TBI severity. However, drawing firm conclusions on the actual in-hospital costs of patients sustaining s-TBI was complicated due to variation and inadequate quality of the included studies. Future economic evaluations should focus on the long-term cost-effectiveness of treatment strategies and use guideline recommendations and common data elements to improve study quality.


Assuntos
Lesões Encefálicas Traumáticas/economia , Lesões Encefálicas Traumáticas/terapia , Custos Hospitalares , Cuidados Críticos/economia , Custos Hospitalares/estatística & dados numéricos , Humanos , Tempo de Internação/economia , Índices de Gravidade do Trauma
15.
Neurosurg Focus ; 46(4): E5, 2019 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-30933922

RESUMO

OBJECTIVEThe purpose of this study was to compare total cost and length of stay (LOS) between spine surgery patients enrolled in an enhanced perioperative care (EPOC) pathway and patients receiving traditional perioperative care (TRDC).METHODSAll spine surgery candidates were screened for inclusion in the EPOC pathway. This cohort was compared to a retrospective cohort of patients who received TRDC and a concurrent group of patients who met inclusion criteria but did not receive the EPOC (no pathway care [NOPC] group). Direct and indirect costs as well as hospital and intensive care LOSs were analyzed between the 3 groups.RESULTSTotal costs after pathway implementation decreased by $19,344 in EPOC patients compared to a historical cohort of patients who received TRDC and $5889 in a concurrent cohort of patients who did not receive EPOC (NOPC group). Hospital and intensive care LOS were significantly lower in EPOC patients compared to TRDC and NOPC patients.CONCLUSIONSThe implementation of a multimodal EPOC pathway decreased LOS and cost in major elective spine surgeries.


Assuntos
Procedimentos Cirúrgicos Eletivos/economia , Recuperação Pós-Cirúrgica Melhorada , Procedimentos Neurocirúrgicos/economia , Assistência Perioperatória/economia , Coluna Vertebral/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Redução de Custos , Cuidados Críticos/economia , Feminino , Custos Hospitalares , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente , Estudos Retrospectivos
16.
Crit Care Med ; 47(7): 885-893, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-30985390

RESUMO

OBJECTIVES: To measure the impact of staged implementation of full versus partial ABCDE bundle on mechanical ventilation duration, ICU and hospital lengths of stay, and cost. DESIGN: Prospective cohort study. SETTING: Two medical ICUs within Montefiore Healthcare Center (Bronx, NY). PATIENTS: One thousand eight hundred fifty-five mechanically ventilated patients admitted to ICUs between July 2011 and July 2014. INTERVENTIONS: At baseline, spontaneous (B)reathing trials (B) were ongoing in both ICUs; in period 1, (A)wakening and (D)elirium (AD) were implemented in both full and partial bundle ICUs; in period 2, (E)arly mobilization and structured bundle (C)oordination (EC) were implemented in the full bundle (B-AD-EC) but not the partial bundle ICU (B-AD). MEASUREMENTS AND MAIN RESULTS: In the full bundle ICU, 95% patient days were spent in bed before EC (period 1). After EC was implemented (period 2), 65% of patients stood, 54% walked at least once during their ICU stay, and ICU-acquired pressure ulcers and physical restraint use decreased (period 1 vs 2: 39% vs 23% of patients; 30% vs 26% patient days, respectively; p < 0.001 for both). After adjustment for patient-level covariates, implementation of the full (B-AD-EC) versus partial (B-AD) bundle was associated with reduced mechanical ventilation duration (-22.3%; 95% CI, -22.5% to -22.0%; p < 0.001), ICU length of stay (-10.3%; 95% CI, -15.6% to -4.7%; p = 0.028), and hospital length of stay (-7.8%; 95% CI, -8.7% to -6.9%; p = 0.006). Total ICU and hospital cost were also reduced by 24.2% (95% CI, -41.4% to -2.0%; p = 0.03) and 30.2% (95% CI, -46.1% to -9.5%; p = 0.007), respectively. CONCLUSIONS: In a clinical practice setting, the addition of (E)arly mobilization and structured (C)oordination of ABCDE bundle components to a spontaneous (B)reathing, (A)wakening, and (D) elirium management background led to substantial reductions in the duration of mechanical ventilation, length of stay, and cost.


Assuntos
Cuidados Críticos/organização & administração , Unidades de Terapia Intensiva/organização & administração , Pacotes de Assistência ao Paciente/métodos , Guias de Prática Clínica como Assunto/normas , Respiração Artificial , Idoso , Cuidados Críticos/economia , Cuidados Críticos/normas , Delírio/epidemiologia , Delírio/terapia , Deambulação Precoce/métodos , Feminino , Custos Hospitalares , Humanos , Unidades de Terapia Intensiva/economia , Unidades de Terapia Intensiva/normas , Masculino , Pessoa de Meia-Idade , Pacotes de Assistência ao Paciente/economia , Equipe de Assistência ao Paciente/organização & administração , Lesão por Pressão/prevenção & controle , Estudos Prospectivos , Respiração , Restrição Física/normas
17.
Eur Heart J Acute Cardiovasc Care ; 8(7): 660-666, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30977391

RESUMO

AIMS: Registries have reported large inter-hospital differences in intensive care unit admission rates for patients with acute heart failure, but little is known about the potential economic impact of over-admission of low-risk patients with heart failure to higher cost intensive care units. We described the variability in intensive care unit admission practices, the provision of critical care therapies, and estimated the potential national cost savings if all hospitals adopted low intensive care unit admission practices for patients admitted with heart failure. METHODS: Using a national population health dataset, we identified 349,693 heart failure admission hospitalisations with a primary diagnosis of heart failure between 2007 and 2016. Hospitals were categorised as low (first quartile), medium (second and third quartile) and high (fourth quartiles) intensive care unit utilisation. RESULTS: The mean intensive care unit admission rate was 16.4% (inter-hospital range 0.3-51%) including 5.4% in low, 14.5% in medium and 30% in high utilisation hospitals. Intensive care unit therapies in low, medium and high intensive care unit utilisation hospitals were 54.5%, 45.1% and 24.1% (P<0.001), respectively and the inhospital mortality rate was not significantly different. The proportion of hospital costs incurred by intensive care unit care was 7.8% in low, 19.8% in medium and 28.2% in high (P<0.001) admission hospitals. The potential cost savings of altering intensive care unit utilisation practices for patients with heart failure was CAN$234.8m over the study period. CONCLUSIONS: In a national cohort of patients hospitalised with heart failure, we observed that low intensive care unit utilisation centres had lower hospital costs with no differences in mortality rates. The development of standardised admission criteria for high-cost and high acuity intensive care unit beds could reduce costs to the healthcare system.


Assuntos
Cuidados Críticos/economia , Custos de Cuidados de Saúde/tendências , Insuficiência Cardíaca/economia , Hospitalização/economia , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Canadá/epidemiologia , Feminino , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/terapia , Humanos , Masculino , Morbidade/tendências , Estudos Retrospectivos
18.
Am J Hosp Palliat Care ; 36(11): 1020-1025, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30991816

RESUMO

BACKGROUND: Patients with terminal conditions are often admitted to the emergency department (ED) for acute medical services, but studies have suggested that multiple ED admissions may negatively impact end-of-life (EOL) care. Research have shown that incorporating palliative care (PC) is integral to optimal EOL care, but it is an aspect of medical practice that is often neglected. The current study sought to provide an overview of health outcomes and hospital costs of patients with cancer admitted to The Ottawa Hospital and/or received acute medical services during their final 2 weeks of life. Cost comparisons and estimates were made between hospital and hospice expenditures. METHODS: We conducted a retrospective chart review of palliative patients who died at The Ottawa Hospital in 2012. A total of 130 patients who visited the ED within 2 weeks of death were included in the analyses. RESULTS: In this cohort of patients, 71% of admitted patients did not have advanced care directives and 85% experienced a metastasis, but only 18% had a PC medical doctor. Patients were hospitalized, on average, for 7 days and hospitalization costs exceeded the estimated hospice cost by approximately 2.5 times (Can$1 041 170.00 at Can$8009.00/patient vs Can$401 570.00 at Can$3089.00/patient, respectively). CONCLUSION: Our study highlighted the importance of PC integration in high-risk patients, such as those in oncology. Patients in our sample had minimal PC involvement, low advanced care directives, and accrued high costs. Based on our analyses, we concluded that these patients would have likely benefited more from hospice care rather than hospitalization.


Assuntos
Cuidados Críticos/economia , Cuidados Paliativos na Terminalidade da Vida/economia , Enfermagem de Cuidados Paliativos na Terminalidade da Vida/economia , Mortalidade Hospitalar , Neoplasias/enfermagem , Enfermagem Oncológica/economia , Assistência Terminal/economia , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Cuidados Críticos/estatística & dados numéricos , Feminino , Cuidados Paliativos na Terminalidade da Vida/estatística & dados numéricos , Enfermagem de Cuidados Paliativos na Terminalidade da Vida/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Enfermagem Oncológica/estatística & dados numéricos , Ontário , Estudos Retrospectivos , Assistência Terminal/estatística & dados numéricos
19.
Curr Opin Anaesthesiol ; 32(2): 123-128, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30817383

RESUMO

PURPOSE OF REVIEW: Many hospitals, particularly large academic centers, have begun to provide 24-h in-house intensive care attending coverage. Proposed advantages for this model include improved patient care, greater provider, nursing and patient satisfaction, better communication, and greater cost-effectiveness. This review will evaluate current evidence with respect to 24/7 coverage, including patient outcomes, cost-effectiveness, and impact on training/education. RECENT FINDINGS: Evidence surrounding 24-h intensivist staffing has been mixed. Although a subset of studies suggest a possible benefit to 24-h intensivist coverage, recent prospective studies have shown no difference in major patient outcomes, including mortality and ICU length of stay between patients in ICUs with and those without 24-h intensivist coverage. SUMMARY: Although some studies cite increased caregiver and patient satisfaction, outcome studies find no consistent effect on patient-centered outcomes such as mortality or length of stay. Downsides to in-house nighttime attending staffing include physician burnout, adverse effects on physician health, decreased trainee autonomy, and effects on trainee specialty choices because of undesirable lifestyle considerations. Tele-ICU and other novel approaches may allow for attending supervision without physical presence.


Assuntos
Cuidados Críticos/organização & administração , Unidades de Terapia Intensiva/organização & administração , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Admissão e Escalonamento de Pessoal/estatística & dados numéricos , Recursos Humanos/organização & administração , Anestesiologia/educação , Anestesiologia/organização & administração , Anestesiologia/estatística & dados numéricos , Análise Custo-Benefício , Cuidados Críticos/economia , Cuidados Críticos/estatística & dados numéricos , Hospitais/estatística & dados numéricos , Humanos , Unidades de Terapia Intensiva/economia , Unidades de Terapia Intensiva/estatística & dados numéricos , Satisfação do Paciente/estatística & dados numéricos , Recursos Humanos/economia , Recursos Humanos/estatística & dados numéricos
20.
Curr Opin Anaesthesiol ; 32(2): 129-135, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30817384

RESUMO

PURPOSE OF REVIEW: The evidence base for telemedicine in the ICU (tele-ICU) is rapidly expanding. The last 2 years have seen important additions to our understanding of when, where, and how telemedicine in the ICU adds value. RECENT FINDINGS: Recent publications and a recent meta-analysis confirm that tele-ICU improves core clinical outcomes for ICU patients. Recent evidence further demonstrates that comprehensive tele-ICU programs have the potential to quickly recuperate their implementation and operational costs and significantly increase case volumes and direct contribution margins particularly if additional logistics and care standardization functions are embedded to optimize ICU bed utilization and reduce complications. Even though the adoption of tele-ICU is increasing and the vast majority of today's medical graduates will regularly use some form of telemedicine and/or tele-ICU, telemedicine modules have not consistently found their way into educational curricula yet. Tele-ICU can be used very effectively to standardize supervision of medical trainees in bedside procedures or point-of-care ultrasound exams, especially during off-hours. Lastly, tele-ICUs routinely generate rich operational data, as well as risk-adjusted acuity and outcome data across the spectrum of critically ill patients, which can be utilized to support important clinical research and quality improvement projects. SUMMARY: The value of tele-ICU to improve patient outcomes, optimize ICU bed utilization, increase financial performance and enhance educational opportunities for the next generation of providers has become more evident and differentiated in the last 2 years.


Assuntos
Análise Custo-Benefício/estatística & dados numéricos , Unidades de Terapia Intensiva/organização & administração , Internato e Residência/organização & administração , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Telemedicina/organização & administração , Anestesiologia/educação , Anestesiologia/métodos , Anestesiologia/estatística & dados numéricos , Cuidados Críticos/economia , Cuidados Críticos/métodos , Cuidados Críticos/organização & administração , Cuidados Críticos/estatística & dados numéricos , Currículo , Humanos , Unidades de Terapia Intensiva/economia , Unidades de Terapia Intensiva/estatística & dados numéricos , Internato e Residência/métodos , Internato e Residência/estatística & dados numéricos , Telemedicina/economia , Telemedicina/estatística & dados numéricos , Carga de Trabalho/economia , Carga de Trabalho/estatística & dados numéricos
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