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1.
Health Technol Assess ; 25(21): 1-68, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-33764295

RESUMO

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the virus that causes coronavirus disease 2019. At the time of writing (October 2020), the number of cases of COVID-19 had been approaching 38 million and more than 1 million deaths were attributable to it. SARS-CoV-2 appears to be highly transmissible and could rapidly spread in hospital wards. OBJECTIVE: The work undertaken aimed to estimate the clinical effectiveness and cost-effectiveness of viral detection point-of-care tests for detecting SARS-CoV-2 compared with laboratory-based tests. A further objective was to assess occupancy levels in hospital areas, such as waiting bays, before allocation to an appropriate bay. PERSPECTIVE/SETTING: The perspective was that of the UK NHS in 2020. The setting was a hypothetical hospital with an accident and emergency department. METHODS: An individual patient model was constructed that simulated the spread of disease and mortality within the hospital and recorded occupancy levels. Thirty-two strategies involving different hypothetical SARS-CoV-2 tests were modelled. Recently published desirable and acceptable target product profiles for SARS-CoV-2 point-of-care tests were modelled. Incremental analyses were undertaken using both incremental cost-effectiveness ratios and net monetary benefits, and key patient outcomes, such as death and intensive care unit care, caused directly by COVID-19 were recorded. RESULTS: A SARS-CoV-2 point-of-care test with a desirable target product profile appears to have a relatively small number of infections, a low occupancy level within the waiting bays, and a high net monetary benefit. However, if hospital laboratory testing can produce results in 6 hours, then the benefits of point-of-care tests may be reduced. The acceptable target product profiles performed less well and had lower net monetary benefits than both a laboratory-based test with a 24-hour turnaround time and strategies using data from currently available SARS-CoV-2 point-of-care tests. The desirable and acceptable point-of-care test target product profiles had lower requirement for patients to be in waiting bays before being allocated to an appropriate bay than laboratory-based tests, which may be of high importance in some hospitals. Tests that appeared more cost-effective also had better patient outcomes. LIMITATIONS: There is considerable uncertainty in the values for key parameters within the model, although calibration was undertaken in an attempt to mitigate this. The example hospital simulated will also not match those of decision-makers deciding on the clinical effectiveness and cost-effectiveness of introducing SARS-CoV-2 point-of-care tests. Given these limitations, the results should be taken as indicative rather than definitive, particularly cost-effectiveness results when the relative cost per SARS-CoV-2 point-of-care test is uncertain. CONCLUSIONS: Should a SARS-CoV-2 point-of-care test with a desirable target product profile become available, this appears promising, particularly when the reduction on the requirements for waiting bays before allocation to a SARS-CoV-2-infected bay, or a non-SARS-CoV-2-infected bay, is considered. The results produced should be informative to decision-makers who can identify the results most pertinent to their specific circumstances. FUTURE WORK: More accurate results could be obtained when there is more certainty on the diagnostic accuracy of, and the reduction in time to test result associated with, SARS-CoV-2 point-of-care tests, and on the impact of these tests on occupancy of waiting bays and isolation bays. These parameters are currently uncertain. FUNDING: This report was commissioned by the National Institute for Health Research (NIHR) Evidence Synthesis programme as project number 132154. This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 21. See the NIHR Journals Library website for further project information.


Assuntos
/diagnóstico , Serviço Hospitalar de Emergência/organização & administração , Admissão do Paciente , Testes Imediatos/economia , Testes Imediatos/normas , /epidemiologia , Análise Custo-Benefício , Serviço Hospitalar de Emergência/economia , Serviço Hospitalar de Emergência/normas , Reações Falso-Negativas , Reações Falso-Positivas , Humanos , Medicina Estatal , Reino Unido
2.
JAMA Netw Open ; 4(3): e2037334, 2021 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-33646311

RESUMO

Importance: There has been a significant increase in the implementation and dissemination of geriatric emergency department (GED) programs. Understanding the costs associated with patient care would yield insight into the direct financial value for patients, hospitals, health systems, and payers. Objective: To evaluate the association of GED programs with Medicare costs per beneficiary. Design, Setting, and Participants: This cross-sectional study included data on Medicare fee-for-service beneficiaries at 2 hospitals implementing Geriatric Emergency Department Innovations in Care Through Workforce, Informatics, and Structural Enhancement (GEDI WISE) (Mount Sinai Medical Center [MSMC] and Northwestern Memorial Hospital [NMH]) from January 1, 2013, to November 30, 2016. Analyses were conducted and refined from August 28, 2018, to November 20, 2020, using entropy balance to account for observed differences between the treatment and comparison groups. Interventions: Treatment included consultation with a transitional care nurse (TCN) or a social worker (SW) trained for the GEDI WISE program at a beneficiary's first ED visit (index ED visit). The comparison group included beneficiaries who were never seen by either a TCN or an SW during the study period. Main Outcomes and Measures: The main outcome evaluated was prorated total Medicare payer expenditures per beneficiary over 30 and 60 days after the index ED visit encounter. Results: Of the total 24 839 unique Medicare beneficiaries, 4041 were seen across the 2 EDs; 1947 (17.4%) at MSMC and 2094 (15.4%) at the NMH received treatment from either a GED TCN and/or a GED SW. The mean (SD) age of beneficiaries at MSMC was 78.8 (8.5) years and at NMH was 76.4 (7.7) years. Most patients at both hospitals were female (6821 [60.8%] at MSMC and 8023 [58.9%] at NMH) and White (7729 [68.9%] at MSMC and 9984 [73.3%] at NMH). Treatment was associated with statistically significant mean savings per beneficiary of $2436 (95% CI, $1760-$3111; P < .001) at one ED and $2905 (95% CI, $2378-$3431; P < .001) at the other ED in the 30 days after the index ED visit. The association between treatment and mean cumulative savings at 60 days after the index ED visit per beneficiary was also significant: $1200 (95% CI, $231-$2169; P = .02) at one ED and $3202 (95% CI, $2452-$3951; P < .001) at the other ED. Conclusions and Relevance: Among Medicare fee-for-service beneficiaries, receipt of ED-based geriatric treatment by a TCN and/or an SW was associated with lower Medicare expenditures. These estimated cost savings may be used when calculating or considering the bundled value and potential reimbursement per patient for GED care programs.


Assuntos
Serviço Hospitalar de Emergência/economia , Planos de Pagamento por Serviço Prestado , Serviços de Saúde para Idosos/economia , Custos Hospitalares , Hospitais , Medicare , Assistência ao Paciente/economia , Idoso , Idoso de 80 Anos ou mais , Redução de Custos , Estudos Transversais , Serviços Médicos de Emergência , Avaliação Geriátrica , Humanos , Encaminhamento e Consulta/economia , Serviço Social/economia , Cuidado Transicional/economia , Estados Unidos
3.
N Z Med J ; 134(1531): 44-49, 2021 03 26.
Artigo em Inglês | MEDLINE | ID: mdl-33767475

RESUMO

INTRODUCTION: The published rate of readmission in major trauma patients in New Zealand has been recorded at 11%. The rate of re-attendances to emergency departments (ED) is currently not reported, but potentially adds significant burden to the healthcare system. The rate, costs and resource implications of these representations have not previously been described in New Zealand. AIM: The aim of this study was to define the rate, costs and resource implications of unplanned representations, re-attendance to ED and readmission in patients who have suffered from major trauma in Northland. METHOD: We undertook a four-year retrospective study including all patients who re-attended the emergency department or who were readmitted within 30 days following discharge after major trauma presentation in Northland. Actual patient costs were calculated using in-hospital patient level costing. Length of hospital stay and utilisation of higher-level care facilities were obtained from the hospital's clinical results reporting system and data warehouse. RESULTS: 420 patients formed the primary cohort. There were 90 total representations in 63 patients (15%). The number of re-attendances to ED and readmissions was 52 (12%) and 38 (9%) respectively. The total cost associated with representation in the primary cohort was $220,914, or $55,229 per year. Median cost of re-attendance to ED was $334, and median cost of readmission was $3,643. Mean length of stay in those admitted was 1.9 days. CONCLUSION: This study defined the rate, costs and resource implications of re-attendance to ED and readmissions in patients following admission due to major trauma. This data will help guide quality improvement and reduce costs.


Assuntos
Cuidados Críticos/economia , Serviço Hospitalar de Emergência/economia , Hospitalização/economia , Readmissão do Paciente/economia , Ferimentos e Lesões/economia , Ferimentos e Lesões/terapia , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Nova Zelândia , Estudos Retrospectivos
4.
J Hosp Med ; 16(4): 223-226, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-33734985

RESUMO

Children's hospitals responded to COVID-19 by limiting nonurgent healthcare encounters, conserving personal protective equipment, and restructuring care processes to mitigate viral spread. We assessed year-over-year trends in healthcare encounters and hospital charges across US children's hospitals before and during the COVID-19 pandemic. We performed a retrospective analysis, comparing healthcare encounters and inflation-adjusted charges from 26 tertiary children's hospitals reporting to the PROSPECT database from February 1 to June 30 in 2019 (before the COVID-19 pandemic) and 2020 (during the COVID-19 pandemic). All children's hospitals experienced similar trends in healthcare encounters and charges during the study period. Inpatient bed-days, emergency department visits, and surgeries were lower by a median 36%, 65%, and 77%, respectively, per hospital by the week of April 15 (the nadir) in 2020 compared with 2019. Across the study period in 2020, children's hospitals experienced a median decrease of $276 million in charges.


Assuntos
/economia , Assistência à Saúde , Custos de Cuidados de Saúde , Hospitais Pediátricos/economia , Pacientes Internados/estatística & dados numéricos , Criança , Assistência à Saúde/economia , Assistência à Saúde/estatística & dados numéricos , Serviço Hospitalar de Emergência/economia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Humanos , Estudos Retrospectivos
5.
JAMA Netw Open ; 4(2): e210055, 2021 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-33625510

RESUMO

Importance: Mobile integrated health care (MIH) is a new model of community-based health care to provide on-site urgent or nonurgent care. Niagara emergency medical services (NEMS) started MIH in 2018 to serve the Niagara region of Ontario, Canada. However, its economic impact is unknown. Objective: To compare time on task and cost between MIH and ambulance delivered by NEMS from a public payer's perspective. Design, Setting, and Participants: This economic evaluation was an analysis of the NEMS databases regarding responses to emergency calls by the NEMS from 2016 to 2019. Emergency calls serviced by MIH in 2018 to 2019 were used as an intervention cohort. Propensity score matching was used to identify a 1:1 matched cohort of calls serviced by regular ambulance response for the same period and 2 years prior. Statistical analyses were performed from January to April 2020. Exposures: MIH compared with matched ambulance services. Main Outcomes and Measures: The main outcomes were the time on task (including time on scene and time at hospital) and costs. Costs were calculated in 2019 Canadian dollars using cost per minute and compared with the 3 ambulance cohorts. Results: In 2018 to 2019, there were 1740 calls serviced by MIH for which a matched ambulance cohort was identified for the same period and 2 years prior. The mean (SD) time on task was 72.7 (51.0) minutes for MIH, compared with 84.1 (52.0) minutes, 84.3 (54.1) minutes, and 79.4 (42.0) minutes for matched ambulance in 2018 to 2019, 2017 to 2018, and 2016 to 2017, respectively. Of calls serviced by MIH, 498 (28.6%) required ED transport (ie, after MIH team assessment, transport to ED was deemed to be necessary or demanded by the patient), compared with 1300 (74.7%) calls serviced by ambulance in 2018 to 2019, 1294 (74.4%) in 2017 to 2018, and 1359 (78.1%) in 2016 to 2017. The mean (SD) total cost per 1000 calls was $122 760 ($78 635) for MIH compared with $294 336 ($97 245), $299 797 ($104 456), and $297 269 ($81 144) for regular ambulance responses in the 3 matched cohorts, respectively. Conclusions and Relevance: Compared with regular ambulance response, MIH was associated with a substantial reduction in the proportion of patients transported to the ED, leading to a substantial saving in total costs. This finding suggests that the MIH model is a promising and viable solution to meeting urgent health care needs in the community, while substantially improving the use of scarce health care resources.


Assuntos
Serviços de Saúde Comunitária/economia , Assistência à Saúde/economia , Serviços Médicos de Emergência/economia , Unidades Móveis de Saúde/economia , Adulto , Idoso , Idoso de 80 Anos ou mais , Ambulâncias , Assistência Ambulatorial , Serviços de Saúde Comunitária/métodos , Análise Custo-Benefício , Assistência à Saúde/métodos , Serviços Médicos de Emergência/métodos , Serviço Hospitalar de Emergência/economia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Hospitalização/economia , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Ontário , Pontuação de Propensão
6.
Am J Emerg Med ; 42: 55-59, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-33453616

RESUMO

BACKGROUND: Between October 2019 and February 2020, massive crowds protested in Lebanon against economic collapse. Various less than lethal weapons including riot control agents and rubber bullets were used by law enforcement, which led to several traumatic and chemical injuries among victims. This study describes the clinical presentation, management, outcome, and healthcare costs of injuries. METHODS: A retrospective review of the hospital records of all the casualties presenting to the Emergency Department of the American University of Beirut Medical Center between October 17th, 2019, and February 29th, 2020, was conducted. RESULTS: A total of 313 casualties were evaluated in the ED, with a mean age of 30.2 +/- 9.6 years and a predominance of males (91.1%). Most were protestors (71.9%) and arrived through EMS (43.5%) at an influx rate of one patient presenting every 2.7-8 min. Most patients (91.1%) presented with an Emergency Severity Index of 3. Most patients (77.6%) required imaging with 10% having major findings including fractures and hemorrhages. Stones, rocks, and tear gas canisters (30.7%) were the most common mechanism of injury. Musculoskeletal injuries were most common (62.6%), followed by lacerations (44.7%). The majority (93.3%) were treated and discharged home and 3.2% required hospital admission, with 2.6% requiring surgery. CONCLUSION: Less-than-lethal weapons can cause severe injuries and permanent morbidity. The use of riot control agents needs to be better controlled, and users need to be well trained in order to avoid misuse and to lessen the morbidity, mortality, and financial burden.


Assuntos
Serviço Hospitalar de Emergência , Tumultos , Ferimentos e Lesões/terapia , Adulto , Estudos Transversais , Serviço Hospitalar de Emergência/economia , Feminino , Fraturas Ósseas/terapia , Hemorragia/terapia , Custos Hospitalares , Humanos , Lacerações/terapia , Aplicação da Lei/métodos , Líbano , Masculino , Sistema Musculoesquelético/lesões , Estudos Retrospectivos , Ferimentos e Lesões/economia
7.
PLoS One ; 16(1): e0244097, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33434228

RESUMO

Emergency Departments (EDs) worldwide are confronted with rising patient volumes causing significant strains on both Emergency Medicine and entire healthcare systems. Consequently, many EDs are in a situation where the number of patients in the ED is temporarily beyond the capacity for which the ED is designed and resourced to manage-a phenomenon called Emergency Department (ED) crowding. ED crowding can impair the quality of care delivered to patients and lead to longer patient waiting times for ED doctor's consult (time to provider) and admission to the hospital ward. In Singapore, total ED attendance at public hospitals has grown significantly, that is, roughly 5.57% per year between 2005 and 2016 and, therefore, emergency physicians have to cope with patient volumes above the safe workload. The purpose of this study is to create a virtual ED that closely maps the processes of a hospital-based ED in Singapore using system dynamics, that is, a computer simulation method, in order to visualize, simulate, and improve patient flows within the ED. Based on the simulation model (virtual ED), we analyze four policies: (i) co-location of primary care services within the ED, (ii) increase in the capacity of doctors, (iii) a more efficient patient transfer to inpatient hospital wards, and (iv) a combination of policies (i) to (iii). Among the tested policies, the co-location of primary care services has the largest impact on patients' average length of stay (ALOS) in the ED. This implies that decanting non-emergency lower acuity patients from the ED to an adjacent primary care clinic significantly relieves the burden on ED operations. Generally, in Singapore, there is a tendency to strengthen primary care and to educate patients to see their general practitioners first in case of non-life threatening, acute illness.


Assuntos
Simulação por Computador , Serviço Hospitalar de Emergência/estatística & dados numéricos , Análise Custo-Benefício , Aglomeração , Serviço Hospitalar de Emergência/economia , Humanos , Tempo de Internação , Política Organizacional , Admissão do Paciente , Alta do Paciente , Transferência de Pacientes , Médicos/estatística & dados numéricos , Médicos/provisão & distribução , Atenção Primária à Saúde/economia , Encaminhamento e Consulta , Singapura
8.
PLoS One ; 15(12): e0244852, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33382838

RESUMO

BACKGROUND: In response to the coronavirus diseases 2019 (COVID-19) pandemic, the Japanese government declared a state of emergency on April 7, 2020. Six days earlier, the Japan Surgical Society had recommended postponing elective surgical procedures. Along with the growing public fear of COVID-19, hospital visits in Japan decreased. METHODS: Using claims data from the Quality Indicator/Improvement Project (QIP) database, this study aimed to clarify the impact of the first wave of the pandemic, considered to be from March to May 2020, on case volume and claimed hospital charges in acute care hospitals during this period. To make year-over-year comparisons, we considered cases from July 2018 to June 2020. RESULTS: A total of 2,739,878 inpatient and 53,479,658 outpatient cases from 195 hospitals were included. In the year-over-year comparisons, total claimed hospital charges decreased in April, May, June 2020 by 7%, 14%, and 5%, respectively, compared to the same months in 2019. Our results also showed that per-case hospital charges increased during this period, possibly to compensate for the reduced case volumes. Regression results indicated that the hospital charges in April and May 2020 decreased by 6.3% for hospitals without COVID-19 patients. For hospitals with COVID-19 patients, there was an additional decrease in proportion with the length of hospital stay of COVID-19 patients including suspected cases. The mean additional decrease per COVID-19 patient was estimated to 5.5 million JPY. CONCLUSION: It is suggested that the hospitals treating COVID-19 patients were negatively incentivized.


Assuntos
Serviço Hospitalar de Emergência/economia , Hospitais , Tempo de Internação/economia , Pandemias , /economia , /terapia , Procedimentos Cirúrgicos Eletivos , Feminino , Humanos , Japão/epidemiologia , Masculino
9.
Obstet Gynecol ; 136(5): 995-1000, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33030870

RESUMO

OBJECTIVE: To assess total time for evaluation of women with first-trimester pregnancy concerns in an early pregnancy unit compared with an emergency department (ED) within a single safety net hospital system. METHODS: We performed a retrospective cohort study at Denver Health Medical Center from May 1, 2017, to April 30, 2018. All patients who presented to the early pregnancy unit and a random sample of patients who presented to the ED were identified, stratified by month. Patients were eligible if they were aged 12-55 years, hemodynamically stable, in the first trimester with a positive pregnancy test, and without a prior ultrasonogram. Evaluation time was calculated as difference between registration or check-in and the discharge time. We extracted patient demographics, reproductive histories, presenting symptoms, diagnosis, and management plans at time of discharge from the electronic medical record. Descriptive statistics and multivariate analyses were performed. Lastly, a preliminary analysis of total charges was conducted. RESULTS: Of 250 patients originally identified, 165 met inclusion criteria (79 from the early pregnancy unit and 86 from the ED). There was no statistical difference in race, ethnicity, or insurance type between groups. Median evaluation time was significantly reduced in the early pregnancy unit compared with the ED (45 minutes [interquartile range 31-61] vs 236 minutes [interquartile range 173-307], respectively, P<.001). After adjusting for patient characteristics and clinical presentation, the average total evaluation time among patients in the early pregnancy unit (36 minutes) was 80% lower compared with patients in the ED (180 minutes). Median evaluation charges were significantly less for patients in the early pregnancy unit compared with those in the ED ($586.22 [interquartile range 384.83-757.34] vs $1,350.97 [interquartile range 975.77-3,553.62], respectively, P<.001). CONCLUSION: Time and charges for evaluation of women with first-trimester pregnancy concerns were significantly lower in an early pregnancy unit compared with an ED. Early pregnancy units should be considered as an alternative care model for patients in the first trimester of pregnancy in the United States.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Complicações na Gravidez/diagnóstico , Cuidado Pré-Natal/estatística & dados numéricos , Provedores de Redes de Segurança/estatística & dados numéricos , Adulto , Serviço Hospitalar de Emergência/economia , Feminino , Humanos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Alta do Paciente/economia , Alta do Paciente/estatística & dados numéricos , Gravidez , Complicações na Gravidez/economia , Primeiro Trimestre da Gravidez , Cuidado Pré-Natal/economia , Cuidado Pré-Natal/métodos , Estudos Retrospectivos , Fatores de Tempo , Estados Unidos , Adulto Jovem
10.
PLoS One ; 15(9): e0238100, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32886675

RESUMO

BACKGROUND: The Affordable Care Act led to improvements in reporting a usual source of care, but it is unclear whether patients are changing their usual source of care in response to coverage gains. We assess whether prior insurance instability is associated with changes in use of emergency and office-based care after the Marketplace and Medicaid expansion were introduced. METHODS: Our study draws from the 2013-14 Medical Expenditure Panel Survey, identifying a cohort of non-elderly adults with full-year health insurance coverage in 2014. We use linear and multinomial logistic regression to assess the relationship between insurance instability prior to 2014 (uninsured for 1-11 months, ≥12 months) and person-level changes in use of health care after gaining coverage (change in ED and office visits from 2013 to 2014) with continuously insured individuals serving as a comparison group. RESULTS: Being uninsured for at least one year prior to gaining full-year coverage in 2014 was associated with a 33% increase in ED visits (0.06 visits, p<0.01) and a 47% increase in office visits (1.10 visits, p<0.01), driven by those gaining public coverage. We found no evidence of substitution across settings in the short term, often a stated goal of expansion. CONCLUSION: The long-term uninsured may have substantial health needs and pent-up demand for health care, seeing more physicians across multiple settings in the year after gaining coverage as they seek to get unmanaged conditions under control. Closing the gap in primary care use between the previously uninsured and those with health insurance coverage may help improve long-term health outcomes.


Assuntos
Serviço Hospitalar de Emergência/economia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Cobertura do Seguro/estatística & dados numéricos , Atenção Primária à Saúde/economia , Atenção Primária à Saúde/estatística & dados numéricos , Adolescente , Adulto , Estudos de Coortes , Feminino , Pesquisas sobre Serviços de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Patient Protection and Affordable Care Act , Adulto Jovem
12.
Value Health ; 23(8): 1003-1011, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32828211

RESUMO

OBJECTIVES: The prevalence of hepatitis is high in emergency department (ED) attendees in the United Kingdom, with a prevalence of up to 2% for hepatitis B (HBV) HBsAg, and 2.9% for hepatitis C (HCV) RNA. The aim of this paper is to perform an economic evaluation of opt-out ED-based HCV and HBV testing. METHODS: A Markov model was developed to analyze the cost-effectiveness of opt-out HCV and HBV testing in EDs in the UK. The model used data from UK studies of ED testing to parameterize the HCV and HBV prevalence (1.4% HCV RNA, 0.84% HBsAg), test costs, and intervention effects (contact rates and linkage to care). For HCV, we used an antibody test cost of £3.64 and RNA test cost of £68.38, and assumed direct-acting antiviral treatment costs of £10 000. For HBV, we used a combined HBsAg and confirmatory test cost of £5.79. We also modeled the minimum prevalence of HCV (RNA-positive) and HBV (HBsAg) required to make ED testing cost-effective at a £20 000 willingness to pay per quality-adjusted life-year threshold. RESULTS: In the base case, ED testing was highly cost-effective, with HCV and HBV testing costing £8019 and £9858 per quality-adjusted life-year gained, respectively. HCV and HBV ED testing remained cost-effective at 0.25% HCV RNA or HBsAg prevalence or higher. CONCLUSIONS: Emergency department testing for HCV and HBV is highly likely to be cost-effective in many areas across the UK depending on their prevalence. Ongoing studies will help evaluate ED testing across different regions to inform testing guidelines.


Assuntos
Serviço Hospitalar de Emergência/organização & administração , Hepatite B/diagnóstico , Hepatite C/diagnóstico , Programas de Rastreamento/organização & administração , Análise Custo-Benefício , Serviço Hospitalar de Emergência/economia , Custos Hospitalares , Humanos , Cadeias de Markov , Programas de Rastreamento/economia , Programas de Rastreamento/métodos , Modelos Econométricos , Reino Unido
13.
Am Surg ; 86(6): 665-674, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32683972

RESUMO

BACKGROUND: Mortality and complications are not well defined nationally for emergency general surgery (EGS) patients presenting with underlying all-cause liver disease (LD). STUDY DESIGN: We analyzed the 2012-2014 National Inpatient Sample for adults (aged ≥ 18 years) with a primary EGS diagnosis. Underlying LD included International Classification of Diseases, Ninth Revision, Clinical Modification codes for alcoholic and viral hepatitis, malignancy, congenital etiologies, and cirrhosis. The primary outcome was mortality; secondary outcomes included complications, operative intervention, and costs. RESULTS: Of the 6.8 million EGS patients, 358 766 (5.3%) had underlying LD. 59.1% had cirrhosis, 6.7% had portal hypertension, and 13.7% had ascites. Compared with other EGS patients, EGS-LD patients had higher mean costs ($12 847 vs $10 234, P < .001). EGS-LD patients were less likely to have surgery (26.1% vs 37.0%, P < .001) but for those who did, mortality was higher (4.8% vs 1.8%, P < .001). Risk factors for mortality included ascites (adjusted odds ratio [aOR] = 2.68, P < .001), dialysis (aOR = 3.44, P < .001), sepsis (aOR = 8.97, P < .001), and respiratory failure requiring intubation (aOR = 10.40, P < .001). Odds of death increased in both surgical (aOR = 4.93, P < .001) and non-surgical EGS-LD patients (aOR = 2.56, P < .001). CONCLUSIONS: Underlying all-cause LD among EGS patients is associated with increased in-hospital mortality, even in the absence of surgical intervention.


Assuntos
Serviço Hospitalar de Emergência , Tratamento de Emergência , Cirurgia Geral/estatística & dados numéricos , Hepatopatias/mortalidade , Adolescente , Adulto , Idoso , Serviço Hospitalar de Emergência/economia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Tratamento de Emergência/economia , Tratamento de Emergência/estatística & dados numéricos , Feminino , Humanos , Hepatopatias/economia , Hepatopatias/cirurgia , Masculino , Pessoa de Meia-Idade , Razão de Chances , Complicações Pós-Operatórias/etiologia
14.
Value Health ; 23(6): 697-704, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32540226

RESUMO

OBJECTIVES: Hospice use reduces costly aggressive end-of-life (EOL) care (eg, repeated hospitalizations, intensive care unit care, and emergency department visits). Nevertheless, associations between hospice stays and EOL expenditures in prior research have been inconsistent. We examined the differential associations between hospice stay duration and EOL expenditures among newly diagnosed patients with cancer, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and dementia. METHODS: In the Surveillance, Epidemiology, and End Results-Medicare data, we identified 240 246 decedents diagnosed with the aforementioned conditions during 2001 to 2013. We used zero-inflated negative binomial regression models to examine the differential associations between hospice length of services and EOL expenditures incurred during the last 90, 180, and 360 days of life. RESULTS: For the last 360 days of expenditures, hospice stays beyond 30 days were positively associated with expenditures for decedents with COPD, CHF, and dementia but were negatively associated for cancer decedents (all P<.001) after adjusting for demographic and medical covariates. In contrast, for the last 90 days of expenditures, hospice stay duration and expenditures were consistently negatively associated for each of the 4 patient disease groups. CONCLUSIONS: Longer hospice stays were associated with lower 360-day expenditures for cancer patients but higher expenditures for other patients. We recommend that Medicare hospice payment reforms take distinct disease trajectories into account. The relationship between expenditures and hospice stay length also depended on the measurement duration, such that measuring expenditures for the last 6 months of life or less overstates the cost-saving benefit of lengthy hospice stays.


Assuntos
Gastos em Saúde/estatística & dados numéricos , Cuidados Paliativos na Terminalidade da Vida/economia , Medicare/economia , Assistência Terminal/economia , Idoso , Idoso de 80 Anos ou mais , Serviço Hospitalar de Emergência/economia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Cuidados Paliativos na Terminalidade da Vida/estatística & dados numéricos , Hospitalização/economia , Hospitalização/estatística & dados numéricos , Humanos , Unidades de Terapia Intensiva/economia , Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Masculino , Medicare/estatística & dados numéricos , Programa de SEER , Assistência Terminal/estatística & dados numéricos , Fatores de Tempo , Estados Unidos
15.
Value Health ; 23(6): 705-709, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32540227

RESUMO

OBJECTIVE: Trauma care provides value to the critically injured. Our aim was to assess whether trauma team involvement adds value to the care of minimally injured patients and to define its costs. METHODS: Minimally injured patients admitted to a trauma center were propensity matched and compared by involvement versus no involvement of the trauma service (TS). Demographics, injury severity, complications, length of emergency department stay, mortality, and hospital costs and charges were studied. RESULTS: A total of 1253 patients were enrolled, with 308 propensity matched to the following groups: TS (n = 102) and no TS (n = 206). TS demonstrated a 30% increase in total charges and costs with no difference in complications. TS did demonstrate decreased time in the emergency department but had an increased delay to operation. Findings were similar when stratified for only lower extremity injuries. CONCLUSIONS: TS involvement for minimally injured patients does not increase value. Reducing TS involvement while avoiding trauma undertriage may reduce costs to the healthcare system without affecting outcomes.


Assuntos
Serviço Hospitalar de Emergência/economia , Custos Hospitalares/estatística & dados numéricos , Centros de Traumatologia/economia , Ferimentos e Lesões/terapia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Análise Custo-Benefício , Custos de Cuidados de Saúde/estatística & dados numéricos , Humanos , Escala de Gravidade do Ferimento , Tempo de Internação , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Tempo , Ferimentos e Lesões/economia , Ferimentos e Lesões/fisiopatologia , Adulto Jovem
16.
Rev Invest Clin ; 72(3): 127-134, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32584321

RESUMO

Background: The coronavirus disease 2019 (COVID-19) has been declared a global pandemic. Older adults have been found as a vulnerable group for developing severe forms of disease and increased mortality. Objective: The objective of the study was to propose a pathway to assist the decision-making process for hospital resource allocation for older adults with COVID-19 using simple geriatric assessment-based tools. Methods: We reviewed the available literature at this point of the COVID-19 outbreak, focusing in older adult care to extract key recommendations for those health-care professionals who will be treating older adults in the hospital emergency ward (HEW) in developing countries during the COVID-19 pandemic. Results: We listed a series of easy recommendations for non-geriatrician doctors in the HEW and suggested simple tools for hospital resource allocation during critical care evaluation of older adults with COVID-19 in low- and middle-income countries. Conclusions: Age must not be used as the sole criterion for resource allocation among older adults with COVID-19. Simple and efficient tools are available to identify components of the comprehensive geriatric assessment, which could be useful to predict outcomes and provide high-quality care that would fit the particular needs of older adults in resource-limited settings amidst this global pandemic.


Assuntos
Betacoronavirus , Tomada de Decisão Clínica , Infecções por Coronavirus , Países em Desenvolvimento , Serviço Hospitalar de Emergência , Pandemias , Pneumonia Viral , Alocação de Recursos/normas , Atividades Cotidianas , Idoso , Idoso de 80 Anos ou mais , Infecções por Coronavirus/economia , Infecções por Coronavirus/epidemiologia , Países em Desenvolvimento/economia , Serviço Hospitalar de Emergência/economia , Feminino , Idoso Fragilizado , Avaliação Geriátrica/métodos , Humanos , Masculino , Pandemias/economia , Preferência do Paciente , Pneumonia Viral/economia , Pneumonia Viral/epidemiologia , Prognóstico , Alocação de Recursos/ética , Triagem , Populações Vulneráveis
17.
Prev Med ; 139: 106186, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32593730

RESUMO

OBJECTIVE: Explore the impact of the Great Recession on domestic violence (DV) related hospitalizations and emergency department (ED) visits in California. METHODS: Hospital and ED data were drawn from California's Office of Statewide Health Planning and Development (OSHPD). DV-related hospitalizations and ED visits in California were analyzed between January 2000 and September 2015 (53,596), along with total medical costs. Time series were divided into pre-recession (Jan 2000-Nov 2007) and recession/post-recession (Dec 2007-Sept 2015) periods. RESULTS: The medical cost of DV-related hospitalizations alone was estimated as $1,136,165,861. A dramatic increase in DV episodes was found potentially associated with the Great Recession. The number of ED visits per month tripled from pre- to post-recession (104.9 vs. 290.6), along with an increased number of hospitalizations (77.1 vs. 95.6); African Americans and Native Americans were disproportionally impacted. In addition, psychiatric comorbidities, severe DV episodes, in-hospital mortality and charge per hospitalization escalated. The rise in DV hospitalizations and ED visits beginning in December 2007 was mainly attributable to physical abuse episodes in adults; minors had no change in DV trends. DISCUSSION: Recessions are frequent in modern economies and are repeated cyclically. Our study provides critical information on the effects of the 2007 financial crisis on DV-related healthcare service utilization in California. Given the current financial crisis associated with COVID-19, which expert predict could extend for years, the results from this study shine a spotlight on the importance of DV-related screening, prevention and response.


Assuntos
Violência Doméstica/estatística & dados numéricos , Recessão Econômica , Serviço Hospitalar de Emergência/estatística & dados numéricos , Custos de Cuidados de Saúde , Hospitalização/estatística & dados numéricos , Adolescente , Adulto , Idoso , California , Criança , Pré-Escolar , Violência Doméstica/economia , Serviço Hospitalar de Emergência/economia , Utilização de Instalações e Serviços , Feminino , Hospitalização/economia , Humanos , Lactente , Recém-Nascido , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Adulto Jovem
18.
Pediatrics ; 146(1)2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32487592

RESUMO

OBJECTIVES: Management decisions for patients with gastroenteritis affect resource use within pediatric emergency departments (EDs), and algorithmic care using evidence-based guidelines (EBGs) has become widespread. We aimed to determine if the implementation of a dehydration EBG in a pediatric ED resulted in a reduction in intravenous (IV) fluid administration and the cost of care. METHODS: In a single-center quality improvement initiative between 2010 and 2016, investigators aimed to decrease the percentage of patients with gastroenteritis who were rehydrated with IV fluids. The EBG assigned the patient a dehydration score with subsequent rehydration strategy on the basis of presenting signs and symptoms. The primary outcome was proportion of patients receiving IV fluid, which was analyzed using statistical process control methods. The secondary outcome was cost of the episode of care. Balancing measures included ED length of stay, admission rate, and return visit rate within 72 hours. RESULTS: A total of 7145 patients met inclusion criteria with a median age of 17 months. Use of IV fluid decreased from a mean of 15% to 9% postimplementation. Average episode of care-related health care costs decreased from $599 to $410. For our balancing measures, there were improvements in ED length of stay, rate of admission, and rate of return visits. CONCLUSIONS: Implementation of an EBG for patients with gastroenteritis led to a decrease in frequency of IV administration, shorter lengths of stay, and lower health care costs.


Assuntos
Desidratação/economia , Serviço Hospitalar de Emergência/economia , Hidratação/economia , Gastroenterite/economia , Recursos em Saúde/tendências , Custos Hospitalares/estatística & dados numéricos , Melhoria de Qualidade , Algoritmos , Criança , Pré-Escolar , Desidratação/etiologia , Desidratação/terapia , Feminino , Hidratação/métodos , Gastroenterite/complicações , Gastroenterite/terapia , Humanos , Lactente , Masculino , Estudos Retrospectivos
19.
Phys Ther ; 100(10): 1782-1792, 2020 09 28.
Artigo em Inglês | MEDLINE | ID: mdl-32478851

RESUMO

OBJECTIVE: The aim of this study was to examine the association between the length of time between an emergency department (ED) visit and the subsequent initiation of physical therapist intervention for low back pain (LBP) on 1-year LBP-related health care utilization (ie, surgery, advanced imaging, injections, long-term opioid use, ED visits) and costs. METHODS: This retrospective cohort study focused on individuals who consulted the ED for an initial visit for LBP. Claims from a single statewide, all-payers database were used. LBP-related health care use and costs for the 12 months after the ED visit were extracted. Poisson and general linear models weighted with inverse probability treatment weights were used to compare the outcomes of patients who attended physical therapy early or delayed after the ED visit. RESULTS: Compared with the delayed physical therapy group (n = 94), the early physical therapy group (n = 171) had a lower risk of receiving lumbar surgery (relative risk [RR] = 0.47, 95% CI = 0.26-0.86) and advanced imaging (RR = 0.72, 95% CI = 0.55-0.95), and they were less likely to have long-term opioid use (RR = 0.45, 95% CI = 0.28-0.76). The early physical therapy group incurred lower costs (mean = $3,806, 95% CI = $1,998-$4,184) than those in the delayed physical therapy group (mean = $8,689, 95% CI = $4,653-$12,727). CONCLUSION: Early physical therapy following an ED visit was associated with a reduced risk of using some types of health care and reduced health care costs in the 12 months following the ED visit. IMPACT STATEMENT: The ED is an entry point into the health care system for patients with LBP. Until now, the impact of the length of time between an ED visit and physical therapy for LBP has not been well understood. This study shows that swift initiation of physical therapy following an ED visit for LBP is associated with lower LBP-related health utilization for some important outcomes and lower LBP-related health care costs.


Assuntos
Serviço Hospitalar de Emergência/economia , Dor Lombar/economia , Dor Lombar/reabilitação , Modalidades de Fisioterapia/economia , Adulto , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Tempo de Internação/economia , Masculino , Pessoa de Meia-Idade , Modalidades de Fisioterapia/estatística & dados numéricos , Estudos Retrospectivos
20.
Am J Emerg Med ; 38(8): 1699.e5-1699.e7, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32482480

RESUMO

INTRODUCTION: A host of variables beyond the control of the ED physician affect ED throughput. In-process time represents the period most directly affected by physician decision-making patterns. This study attempts to evaluate implications of variable decision-making for those patients placed in observation status for throughput and financial implications. METHODS: A retrospective review of all ED admissions to observation status over an 8-month period, for observation decision times (ODT) was performed. The average cost per patient bed hour in the ED, opportunity cost from patients not being seen during excessive ODTs, and the cost of an unfilled bed in an observation unit were estimated. RESULTS: Of 2693 observation cases reviewed, 114 (4.2%) had ODTs longer than two standard deviations above the median. These accumulated ODTs lead to an additional cost of $12,307, or $107 per admission. An additional 45 patients could have been treated during these excess ODTs, from which result an opportunity loss ranging from $32 to $1350 per hour. There is an additional cost of $8036 to maintain empty observation beds in the hospital. CONCLUSION: For those ODTs beyond two standard deviations above the median, there is a direct unreimbursed cost to the hospital, an opportunity cost for patients not seen in those occupied ED beds, and a cost of maintaining unfilled observation beds. Variability in the efficiency of decision-making suggests real consequences in terms of throughput and cost-to-treat.


Assuntos
Tomada de Decisão Clínica , Unidades de Observação Clínica/economia , Serviço Hospitalar de Emergência/economia , Custos Hospitalares/estatística & dados numéricos , Unidades de Observação Clínica/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Humanos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Admissão do Paciente/economia , Admissão do Paciente/estatística & dados numéricos , Alta do Paciente/economia , Alta do Paciente/estatística & dados numéricos , Estudos Retrospectivos
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