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1.
Plast Reconstr Surg ; 145(2): 303-311, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31985608

RESUMO

BACKGROUND: The authors compared long-term health care use and cost in women undergoing immediate autologous breast reconstruction and implant-based breast reconstruction. METHODS: This study was conducted using the OptumLabs Data Warehouse, which contains deidentified retrospective administrative claims data, including medical claims and eligibility information from a large U.S. health insurance plan. Women who underwent autologous or implant-based breast reconstruction between January of 2004 and December of 2014 were included. The authors compared 2-year use rates and predicted costs of care. Comparisons were tested using the t test. RESULTS: Overall, 12,296 women with immediate breast reconstruction were identified; 4257 with autologous (35 percent) and 8039 with implant-based (65 percent) breast reconstruction. The proportion of autologous breast reconstruction decreased from 47.2 percent in 2004 to 32.7 percent in 2014. The mean predicted reconstruction cost of autologous reconstruction was higher than that of implant-based reconstruction in both unilateral and bilateral surgery. Similar results for mean predicted 2-year cost of care were seen in bilateral procedures. However, in unilateral procedures, the 2-year total costs were higher for implant-based than for autologous reconstruction. Two-year health care use rates were higher for implant-based reconstruction than for autologous reconstruction for both unilateral and bilateral procedures. Women undergoing unilateral implant-based reconstruction had higher rates of hospital admissions (30.3 versus 23.1 per 100; p < 0.01) and office visits (2445.1 versus 2283.6 per 100; p < 0.01) than those who underwent autologous reconstruction. Emergency room visit rates were similar between the two methods. Bilateral procedures yielded similar results. CONCLUSION: Although implant-based breast reconstruction is a less expensive index operation than autologous breast reconstruction, it was associated with higher health care use, resulting in similar total cost of care over 2 years.


Assuntos
Implante Mamário/métodos , Neoplasias da Mama/cirurgia , Mamoplastia/métodos , Adolescente , Adulto , Assistência Ambulatorial/economia , Assistência Ambulatorial/estatística & dados numéricos , Implante Mamário/economia , Implantes de Mama/economia , Implantes de Mama/estatística & dados numéricos , Neoplasias da Mama/economia , Custos e Análise de Custo , Serviço Hospitalar de Emergência/economia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Utilização de Instalações e Serviços , Feminino , Hospitalização/economia , Hospitalização/estatística & dados numéricos , Humanos , Mamoplastia/economia , Pessoa de Meia-Idade , Estudos Retrospectivos , Transplante Autólogo/economia , Transplante Autólogo/estatística & dados numéricos , Estados Unidos , Adulto Jovem
2.
BMC Health Serv Res ; 19(1): 657, 2019 Sep 11.
Artigo em Inglês | MEDLINE | ID: mdl-31511009

RESUMO

BACKGROUND: A key challenge for most systems is how to provide effective access to urgent and emergency care across rural and urban populations. Tensions about the placement and scope of hospital emergency services are longstanding in Irish political life and there has been recent reform to centralise hospital services in some regions. The focus of this paper is a system approach to examine the geographic variation in resourcing and utilisation of such care across GP practices, out-of-hours care, ambulance services, Emergency Departments and Local Injury Units in Ireland. METHODS: We used a cross-sectional study design to evaluate variation in resource allocation by aggregating geographic funding to various elements of the urgent and emergency care system and assessing patterns in hospital resource utilisation across the population. Expenditure, staffing, access and activity data were gathered from government sources, individual facilities and service providers, health professional bodies, private firms and central statistics. Data on costs and activity in 2014 are collated and presented at both county and regional levels. Analyses focus on resources spent on urgent and emergency care across geographic areas, the role of population concentration in allocation, the relationship between pre-hospital spending and in-hospital spending, and the utilisation of hospital-based emergency care resources by residents of each county. RESULTS: An array of funding mechanisms exists, resulting in a fragmented approach to the resourcing of urgent and emergency care. There are large differences in spending per capita at the county-level, ranging from between €50 and €200 per capita; however, these are less pronounced regionally. Distribution of hospital emergency care resources is highly skewed to the North East of the country, and away from the recently reconfigured South and Mid-West regions. CONCLUSIONS: This analysis advances the traditional approach of evaluating individual services or hospital resourcing. There are notable differences in utilisation of hospital-based emergency care resources at the regional level, indicating that populations within those regions which have been reconfigured have lower utilisation of hospital resources. There is a clear case for more integration in decision-making around funding and consideration of key principles, such as equity, to guide that process.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Acesso aos Serviços de Saúde/estatística & dados numéricos , Alocação de Recursos/estatística & dados numéricos , Estudos Transversais , Serviço Hospitalar de Emergência/economia , Sistemas de Informação Geográfica , Acesso aos Serviços de Saúde/economia , Humanos , Irlanda/epidemiologia , Alocação de Recursos/economia
3.
Urology ; 134: 109-115, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31487509

RESUMO

OBJECTIVE: To examine the potential of LACE+ scores, in patients undergoing urologic surgery, to predict short-term undesirable outcomes. METHODS: Coarsened exact matching was used to assess the predictive value of the LACE+ index among all urologic surgery cases over a 2-year period (2016-2018) at 1 health system (n = 9824). Study subjects were matched on characteristics not assessed by LACE+, including duration of surgery and race, among others. For comparison of outcomes, matched populations were compared by LACE+ quartile with Q4 as the referent group: Q4 vs Q1, Q4 vs Q2, Q4 vs Q3. RESULTS: Seven hundred and twenty-two patients were matched for Q1-Q4; 1120 patients were matched for Q2-Q4; 2550 patients were matched for Q3-Q4. Escalating LACE+ score significantly predicted increased readmission (2.86% vs 4.91% for Q2 vs Q4; P = .012) and Emergency Room (ER) visits at 30 days postop (5.69% vs 11.37% for Q1 vs Q4, 4.11% vs 11.45% for Q2 vs Q4, 8.29% vs 13.32% for Q3 vs Q4; P <.001 for all). Increasing LACE score did not predict reoperation within 30 days or rate of death over follow-up within 30 postoperative days. CONCLUSION: The results of this study suggest that the LACE+ index is suitable as a prediction model for important patient outcomes in a urologic surgery population including unanticipated readmission and ER evaluation.


Assuntos
Serviço Hospitalar de Emergência , Readmissão do Paciente , Complicações Pós-Operatórias , Procedimentos Cirúrgicos Urológicos , Adulto , Idoso , Continuidade da Assistência ao Paciente/normas , Serviço Hospitalar de Emergência/economia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Masculino , Sobremedicalização/prevenção & controle , Pessoa de Meia-Idade , Duração da Cirurgia , Readmissão do Paciente/economia , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/terapia , Prognóstico , Reoperação/estatística & dados numéricos , Estados Unidos/epidemiologia , Procedimentos Cirúrgicos Urológicos/efeitos adversos , Procedimentos Cirúrgicos Urológicos/estatística & dados numéricos
4.
BMC Health Serv Res ; 19(1): 609, 2019 Aug 29.
Artigo em Inglês | MEDLINE | ID: mdl-31464616

RESUMO

BACKGROUND: There are a number of limitations to the present primary eye care system in the UK. Patients with minor eye conditions typically either have to present to their local hospital or GP, or face a charge when visiting eye care professionals (optometrists). Some areas of the UK have commissioned enhanced community services to alleviate this problem; however, many areas have not. The present study is a needs assessment of three areas (Leeds, Airedale and Bradford) without a Minor Eye Conditions Service (MECS), with the aim of determining whether such a service is clinically or economically viable. METHOD: A pro forma was developed for optometrists and practice staff to complete when a patient presented whose reason for attending was due to symptoms indicative of a problem that could not be optically corrected. This form captured the reason for visit, whether the patient was seen, the consultation funding, the outcome and where the patient would have presented to if the optometrists could not have seen them. Optometrists were invited to participate via Local Optical Committees. Results were submitted via a Google form or a Microsoft Excel document and were analysed in Microsoft Excel. RESULTS: Seventy-five percent of patients were managed in optometric practice. Nine and 16% of patients required subsequent referral to their General Practitioner or hospital ophthalmology department, respectively. Should they not have been seen, 34% of patients would have presented to accident and emergency departments and 59% to their general practitioner. 53% of patients paid privately for the optometrist appointment, 28% of patients received a free examination either through use of General Ophthalmic Service sight tests (9%) or optometrist good will (19%) and 19% of patients did not receive a consultation and were redirected to other providers (e.g. pharmacy, accident and emergency or General Practitioner). 88% of patients were satisfied with the level of service. Cost-analyses revealed a theoretical cost saving of £3198 to the NHS across our sample for the study period, indicating cost effectiveness. CONCLUSIONS: This assessment demonstrates that a minor eye condition service in the local areas would be economically and clinically viable and well received by patients.


Assuntos
Oftalmopatias/diagnóstico , Oftalmopatias/terapia , Determinação de Necessidades de Cuidados de Saúde , Análise Custo-Benefício , Emergências/economia , Serviço Hospitalar de Emergência/economia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Tratamento de Emergência/economia , Tratamento de Emergência/estatística & dados numéricos , Inglaterra , Oftalmopatias/economia , Clínicos Gerais/economia , Clínicos Gerais/estatística & dados numéricos , Hospitais/estatística & dados numéricos , Humanos , Oftalmologia/estatística & dados numéricos , Optometria/estatística & dados numéricos , Satisfação do Paciente , Atenção Primária à Saúde/economia , Atenção Primária à Saúde/estatística & dados numéricos , Encaminhamento e Consulta/economia , Encaminhamento e Consulta/estatística & dados numéricos
5.
N Z Med J ; 132(1501): 57-63, 2019 08 30.
Artigo em Inglês | MEDLINE | ID: mdl-31465328

RESUMO

AIM: To highlight the growing cost of electric-scooter (e-scooter) related injuries necessitating surgical intervention by the Auckland City Hospital Orthopaedic Department. METHODS: Retrospective audit of operations by the Auckland City Hospital Orthopaedic Department from 15 October 2018 up to and inclusive of 22 February 2019. Inclusion criteria was that the direct cause of injury necessitating surgery was secondary to an e-scooter accident. Further demographic data was collected including injury sustained and operation details. The surgical costs were calculated, including anaesthetic time, surgical time, staffing, implants used and inpatient stay as well as clinic follow-up. RESULTS: Over the 19-week period of this study there were 21 patients requiring 23 operations as a direct result of e-scooters. The summative anaesthetic, theatre suite and staffing costs of these operations was $162,901. Implants required to fix the fractures totalled $39,898. Ninety-three inpatient nights and 61 follow-up clinic appointments were required incurring an additional expense of $141,639 and $16,119 respectively. Overall, these 23 cases cost a total of $360,557. The extrapolated loss of income was $44,368 secondary to these injuries. This represents a total economic cost of $404,925, or $19,282 per person. CONCLUSION: This study highlights that there can be serious consequences of e-scooter travel. High energy trauma not previously associated with scooter injuries is becoming increasingly prevalent as a result of readily available e-scooters. Many of the injuries identified represent significant morbidity to patients in terms of pain, lengthy rehabilitation and loss of income. Furthermore, the socioeconomic costs for DHBs continues to climb and adds to the acute surgical burden in an already busy healthcare system. The hazards of e-scooters should not be underestimated by both the general public and policy-makers.


Assuntos
Acidentes de Trânsito , Serviço Hospitalar de Emergência , Hospitalização , Veículos Off-Road/estatística & dados numéricos , Procedimentos Ortopédicos , Ferimentos e Lesões , Acidentes de Trânsito/economia , Acidentes de Trânsito/prevenção & controle , Acidentes de Trânsito/estatística & dados numéricos , Adolescente , Serviço Hospitalar de Emergência/economia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Custos de Cuidados de Saúde/estatística & dados numéricos , Hospitalização/economia , Hospitalização/estatística & dados numéricos , Humanos , Aplicação da Lei/métodos , Masculino , Nova Zelândia , Procedimentos Ortopédicos/economia , Procedimentos Ortopédicos/estatística & dados numéricos , Fatores de Risco , População Urbana , Ferimentos e Lesões/economia , Ferimentos e Lesões/epidemiologia , Ferimentos e Lesões/etiologia , Ferimentos e Lesões/cirurgia , Adulto Jovem
6.
Int J Public Health ; 64(9): 1283-1290, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31297557

RESUMO

OBJECTIVES: This study evaluates the impact of the Belgian Poison Centre (BPC) on national healthcare expenses for calls from the public for unintentional poisonings. METHODS: The probability of either calling the BPC, consulting a general practitioner (GP) or consulting an emergency department (ED) was examined in a telephone survey (February-March 2016). Callers were asked what they would have done in case of unavailability of the BPC. The proportion and cost for ED-ambulatory care, ED 24-h observation or hospitalisation were calculated from individual invoices. A cost-benefit analysis was performed. RESULTS: Unintentional cases (n = 485) from 1045 calls to the BPC were included. After having called the BPC, 92.1% did not seek further medical help, 4.2% consulted a GP and 3.7% went to an ED. In the absence of the BPC, 13.8% would not have sought any further help, 49.3% would have consulted a GP and 36.9% would have gone to the hospital. The cost-benefit ratio of the availability of the BPC as versus its absence was estimated at 5.70. CONCLUSIONS: Financial savings can be made if people first call the BPC for unintentional poisonings.


Assuntos
Análise Custo-Benefício/estatística & dados numéricos , Serviço Hospitalar de Emergência/economia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Centros de Controle de Intoxicações/economia , Centros de Controle de Intoxicações/estatística & dados numéricos , Envenenamento/economia , Bélgica , Humanos
8.
J Surg Res ; 244: 122-129, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31284141

RESUMO

BACKGROUND: The objective of this study was to evaluate clinical outcomes, costs, and clinician and parent satisfaction after implementation of a protocol to discharge patients from the emergency department (ED) after successful reduction of uncomplicated ileocolic intussusception. MATERIALS AND METHODS: In March 2017, an intussusception management protocol was implemented for children presenting with ultrasound findings of ileocolic intussusception. Those meeting inclusion criteria were observed after successful radiological reduction in the ED and discharged after 6 h with resolution of symptoms. Retrospective chart review was completed for cases before and after protocol implementation for clinical outcomes and costs. Clinicians and parents were surveyed to assess overall satisfaction. RESULTS: Charts were reviewed before (42 encounters, 37 patients) and after (30 encounters, 23 patients) protocol implementation. After implementation, admission rates decreased from 95% (40/42) to 23% (7/30; P < 0.001) and antibiotic use was eliminated (91% to 0%, P < 0.001). There was no difference in recurrence rates (17% versus 23%, P = 0.44). Median total length of stay decreased from 18.87 to 9.52 h (P < 0.001), whereas median ED length of stay increased from 4.37 to 9.87 h (P < 0.001). In addition, there was an overall hospital cost saving of over $2000 ($9595 ± 3424 to $7465 ± 3723; P = 0.009) per encounter. Clinicians and parents were overall satisfied with the protocol and parents showed no changes in patient satisfaction with protocol implementation. CONCLUSIONS: An intussusception protocol can facilitate early discharge from the ED and improve patient care without increased risk of recurrence. Additional benefits include decreased hospital- and patient-related costs, elimination of antibiotic use, and parent as well as clinician satisfaction.


Assuntos
Protocolos Clínicos/normas , Implementação de Plano de Saúde , Doenças do Íleo/terapia , Intussuscepção/terapia , Satisfação Pessoal , Pré-Escolar , Serviço Hospitalar de Emergência/economia , Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/normas , Enema , Feminino , Custos Hospitalares/estatística & dados numéricos , Humanos , Doenças do Íleo/economia , Lactente , Recém-Nascido , Intussuscepção/economia , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Masculino , Alta do Paciente/normas , Avaliação de Programas e Projetos de Saúde , Melhoria de Qualidade , Estudos Retrospectivos , Prevenção Secundária/economia , Prevenção Secundária/organização & administração , Prevenção Secundária/normas , Inquéritos e Questionários/estatística & dados numéricos
9.
Artigo em Inglês | MEDLINE | ID: mdl-31277347

RESUMO

BACKGROUND: Seasonal influenza causes significant morbidity worldwide and has a substantial economic impact on the healthcare system. OBJECTIVE: To assess the cost-benefit relation of implementing a real-time influenza test in emergency rooms (ER) of German hospitals. METHODS: A deterministic decision-analytic model was developed simulating the incremental costs of using the Solana® Influenza A+B test, compared to those of using conventional clinical judgement alone to confirm or exclude influenza in adult ILI (influenza-like illness) patients, in German ER, prior to hospitalization. Direct costs were evaluated from the hospital perspective, considering resource use directly related to influenza testing and treatment, as well as indirect costs incurred by nosocomial influenza transmission. RESULTS: Through base-case analysis and assuming an influenza prevalence of 42.6%, real-time testing with Solana® reduced average costs of hospitalized ILI patients by €132.61, per tested patient. Moreover, the Solana® saved €6.9 per tested patient in favor of the hospital. In probabilistic sensitivity analysis, under all reasonable assumptions, implementing the Solana® saved on average €144.13 as compared to applying the clinical-judgement-only strategy, thus, it was found to be constantly less expensive. CONCLUSIONS: Using highly sensitive and specific real-time influenza tests in ILI patients at German ER might significantly reduce hospital expenditures.


Assuntos
Serviço Hospitalar de Emergência/economia , Influenza Humana/diagnóstico , Influenza Humana/economia , Análise Custo-Benefício , Técnicas e Procedimentos Diagnósticos , Humanos
10.
West J Emerg Med ; 20(4): 541-548, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31316691

RESUMO

Introduction: Advanced practice providers (APP), including physicians' assistants and nurse practitioners, have been increasingly incorporated into emergency department (ED) staffing over the past decade. There is scant literature examining resource utilization and the cost benefit of having APPs in the ED. The objectives of this study were to compare resource utilization in EDs that use APPs in their staffing model with those that do not and to estimate costs associated with the utilized resources. Methods: In this five-year retrospective secondary data analysis of the Emergency Department Benchmarking Alliance (EDBA), we compared resource utilization rates in EDs with and without APPs in non-academic EDs. Primary outcomes were hospital admission and use of computed tomography (CT), radiography, ultrasound, and magnetic resonance imaging (MRI). Costs were estimated using the 2014 physician fee schedule and inpatient payments from the Centers for Medicare and Medicaid Services. We measured outcomes as rates per 100 visits. Data were analyzed using a mixed linear model with repeated measures, adjusted for annual volume, patient acuity, and attending hours. We used the adjusted net difference to project utilization costs between the two groups per 1000 visits. Results: Of the 1054 EDs included in this study, 79% employed APPs. Relative to EDs without APPs, EDs staffing APPs had higher resource utilization rates (use per 100 visits): 3.0 more admissions (95% confidence interval [CI], 2.0-4.1), 1.7 more CTs (95% CI, 0.2-3.1), 4.5 more radiographs (95% CI, 2.2-6.9), and 1.0 more ultrasound (95% CI, 0.3-1.7) but comparable MRI use 0.1 (95% CI, -0.2-0.3). Projected costs of these differences varied among the resource utilized. Compared to EDs without APPs, EDs with APPs were estimated to have 30.4 more admissions per 1000 visits, which could accrue $414,717 in utilization costs. Conclusion: EDs staffing APPs were associated with modest increases in resource utilization as measured by admissions and imaging studies.


Assuntos
Serviço Hospitalar de Emergência/economia , Profissionais de Enfermagem , Assistentes Médicos , Diagnóstico por Imagem/economia , Diagnóstico por Imagem/estatística & dados numéricos , Humanos , Admissão do Paciente/economia , Admissão do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Estados Unidos
11.
Emerg Med J ; 36(9): 548-553, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31311785

RESUMO

OBJECTIVE: It is often asserted that the crowding phenomenon in emergency departments (ED) can be explained by an increase in visits considered as non-urgent. The aim of our study was to quantify the increase in ED visit rates and to determine whether this increase was explained by non-severe visit types. METHODS: This observational study covers all ED visits between 2002 and 2015 by adult inhabitants of the Midi-Pyrénées region in France. Their characteristics were collected from the emergency visit summaries. We modelled the visit rates per year using linear regression models, and an increase was considered significant when the 95% CIs did not include zero. The severity of the patients' condition during ED visit was determined through the 'Clinical Classification of Emergency' score. Non-severe visits were those where the patient was stable, and the physician deemed no intervention necessary. Intermediate-severity visits concerned patients who were stable but requiring diagnostic or therapeutic procedures. RESULTS: The 37 studied EDs managed >7 million visits between 2002 and 2015. There was an average increase of +4.83 (95% CI 4.33 to 5.32) visits per 1000 inhabitants each year. The increase in non-severe visit types was +0.88 (95% CI 0.42 to 1.34) per 1000 inhabitants, while the increase in intermediate-severity visit types was +3.26 (95% CI 2.62 to 3.91) per 1000 inhabitants. This increase affected all age groups and all sexes. DISCUSSION: It appears that the increase in ED use is not based on an increase in non-severe visit types, with a greater impact of intermediate-severity visit types requiring diagnostic or therapeutic procedures in ED.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Índice de Gravidade de Doença , Adolescente , Adulto , Fatores Etários , Idoso , Aglomeração/psicologia , Serviço Hospitalar de Emergência/economia , Feminino , França , Pesquisas sobre Serviços de Saúde/estatística & dados numéricos , Política de Saúde/economia , Humanos , Masculino , Pessoa de Meia-Idade , Aceitação pelo Paciente de Cuidados de Saúde/psicologia , Admissão do Paciente/estatística & dados numéricos , Sistema de Registros/estatística & dados numéricos , Fatores Sexuais , Adulto Jovem
12.
J Med Econ ; 22(9): 960-966, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31234676

RESUMO

Objective: Migraine is a common, disabling condition typically characterized by severe headache, nausea, and/or light and sound sensitivity. This study assessed migraine-related health resource utilization (HRU) occurring in the emergency room/accident & emergency department (ER/A&E) setting among European patients with 4 or more migraine days per month. Methods: Patient-level clinical and HRU data were collected via chart extraction by ER/A&E physicians in France, Germany, Italy, and Spain. Eligible patients had 4 or more migraine days in the month prior to a migraine-related ER/A&E visit and a history of migraine, among other criteria. The index date for each patient was defined as the date of an ER/A&E visit for migraine on or after January 1, 2013. Physician and ER/A&E characteristics, patient and disease characteristics, treatment history, migraine-medication used, and migraine-related HRU (i.e. procedures) during the ER/A&E visit were assessed. Descriptive analyses were conducted in the pooled population, and a sensitivity analysis was performed by country. Results: A total of 467 eligible patient's charts (120 in France, 120 in Germany, 107 in Italy, and 120 in Spain) were provided by 136 physicians (36 in France, 36 in Germany, 28 in Italy, and 36 in Spain). On average, patients spent nearly 8 hours in the ER/A&E. Approximately 82% of patients received a blood test, 62% received an electrocardiography, and 46% received a cranial computerized tomography scan. Despite the majority of patients already using acute or prophylactic treatment upon visiting the ER/A&E, almost all patients were administered or prescribed migraine treatment during the visit. Approximately 21% of patients were admitted to the hospital, and over half of patients were referred to a neurologist or headache specialist. Conclusions: European patients who had four or more migraine days in the month prior to a migraine-related ER/A&E visit had high HRU associated with the visit.


Assuntos
Serviço Hospitalar de Emergência/economia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Transtornos de Enxaqueca/economia , Transtornos de Enxaqueca/terapia , Adulto , Fatores Etários , Diagnóstico por Imagem , Europa (Continente) , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores Sexuais , Fatores Socioeconômicos , Falha de Tratamento
13.
J Am Acad Orthop Surg ; 27(13): e612-e621, 2019 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-31232799

RESUMO

INTRODUCTION: Emergency departments (EDs) and emergency medicine and orthopaedic residencies can be faced with financial challenges while caring for patients. Procedures performed by residents are a potentially viable source of revenue that may make orthopaedic coverage of the ED a financially viable service line. METHODS: A custom text-mining program was created and validated, which allowed evaluation of all orthopaedic resident notes. Procedures performed in the ED were quantified, allowing for the calculation of professional fee billing data. The patients with distal radius fractures were followed after fracture reduction through final outpatient clinic follow-up to identify additional professional fee billing. RESULTS: Over a 1-year period, more than $445,000 in uncaptured professional fees charged was identified in the 12 most common Current Procedural Terminology codes for splint application and fracture reduction in the ED. More than $395,000 of outpatient professional revenue was received for patients who had reduction of distal radius fractures in the ED. CONCLUSION: A notable, previously unrecognized and uncaptured source of revenue was identified and quantified. Professional fee billing for distal radius fracture reduction in the ED did not have a negative effect on outpatient professional fee revenue received for these patients.


Assuntos
Serviço Hospitalar de Emergência/economia , Seguro Saúde/economia , Procedimentos Ortopédicos/economia , Fraturas do Rádio/economia , Fraturas do Rádio/cirurgia , Codificação Clínica , Current Procedural Terminology , Humanos , Mecanismo de Reembolso
15.
Ann R Coll Surg Engl ; 101(7): 479-486, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31155901

RESUMO

INTRODUCTION: We aimed to enhance the emergency general surgical service in our high-volume centre in order to reduce four-hour target breaches, to expedite senior decision making and to avoid unnecessary admissions. MATERIALS AND METHODS: The aggregation of marginal gains theory was applied. A dual consultant on-call system was established by the incremental employment of five emergency general surgeons with a specialist interest in colorectal or oesophagogastric surgery. A surgical ambulatory care unit, which combines consultant-led clinical review with dedicated next-day radiology slots, and a dedicated working week half-day gastrointestinal urgent theatre session were instituted to facilitate ambulatory care pathways. RESULTS: The presence of two consultant surgeons being on call during weekday working hours decreased the four-hour target breaches and allowed consultant presence in the surgical ambulatory care clinic and the gastrointestinal urgent theatre list. Of 1371 surgical ambulatory care clinic appointments within 30 months, 1135 (82.7%) avoided a hospital admission, corresponding to savings of £309,752 . The coordinated functioning of the surgical ambulatory care clinic and the gastrointestinal urgent theatre list resulted in statistically significantly reduced hospital stays for patients operated for abscess drainage (gastrointestinal urgent theatre median 11 hours (interquartile range 3, 38) compared with emergency median 31 hours (interquartile range 24, 53), P < 0.001) or diagnostic laparoscopy/appendicectomy (gastrointestinal urgent theatre median 52 hours (interquartile range 41, 71) compared with emergency median 61 hours (interquartile range 43, 99), P = 0.005). Overnight surgery was reduced with only surgery that was absolutely necessary occurring out of hours. CONCLUSION: The expansion of the 'traditional' on-call surgical team, the establishment of the surgical ambulatory care clinic and the gastrointestinal urgent theatre list led to marginal gains with a reduction in unnecessary inpatient stays, expedited decision making and improved financial efficiency.


Assuntos
Instituições de Assistência Ambulatorial/organização & administração , Cuidados Críticos/organização & administração , Serviço Hospitalar de Emergência/organização & administração , Hospitais com Alto Volume de Atendimentos , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Adulto , Idoso , Instituições de Assistência Ambulatorial/economia , Consultores , Serviço Hospitalar de Emergência/economia , Inglaterra , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Admissão do Paciente/estatística & dados numéricos , Jornada de Trabalho em Turnos/estatística & dados numéricos , Centro Cirúrgico Hospitalar/economia , Centro Cirúrgico Hospitalar/organização & administração , Procedimentos Cirúrgicos Operatórios/economia , Carga de Trabalho/estatística & dados numéricos , Adulto Jovem
16.
J Coll Physicians Surg Pak ; 29(7): 658-660, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31253219

RESUMO

OBJECTIVE: To determine the cost analysis of emergency department (ED) visits by geriatric patients living in nursing homes. STUDY DESIGN: Cross-sectional study. METHODOLOGY: Medical records of geriatric patients living in nursing homes who were admitted to the emergency department of the Hospital, between 2011 and 2015, were retrospectively reviewed. Number of visits, reason, and cost of treatment was determined. RESULTS: In total 63 patients (21 females [33.3%], 42 males [66.6%]) with mean age of 76.3 ± 8.16 years were included. The total number of emergency department visits by those 63 patients was 243. Twenty-three (9.5%) of the total emergency department visits were due to trauma. Six patients (9.5%) were admitted to the emergency department with cardiopulmonary arrest. The mean cost of each patient was $358.30 (53.90 - 1734.10), the maximum cost was $10,095.10, and the minimum cost was $7.42. CONCLUSION: Emergency department visits and hospitalisation are common among elderly patients living in nursing homes. However, emergency department visits by this frail population put a heavy burden on the economy. Essential measures should be taken to reduce the financial burden of emergency department visits and hospitalisation of this geriatric population.


Assuntos
Serviço Hospitalar de Emergência/economia , Custos de Cuidados de Saúde , Hospitalização/economia , Casas de Saúde , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Custos e Análise de Custo , Estudos Transversais , Feminino , Humanos , Masculino , Estudos Retrospectivos , Turquia
17.
Pediatrics ; 143(6)2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31118219

RESUMO

OBJECTIVES: After the Affordable Care Act (ACA) took full effect in 2014, 900 000 children obtained health insurance. Researchers have found variable effects of insurance on adult emergency department (ED) use, but the effect in pediatric patients is unknown. We examined ED visit rates before and after 2014 among children. METHODS: We used estimates of ED visit counts from the Nationwide Emergency Department Sample and population estimates from the American Community Survey in a cross-sectional, retrospective study of ED visit rates among children. We compared the trend in ED visit rates before (2009-2013) and after (2014-2016) the ACA took full effect, controlling for age, sex, and census region. RESULTS: The mean ED use rate was 35.2 visits per 100 children from 2009 to 2013 and 36.6 from 2014 to 2016. ED visit rates increased by 1.1% per year pre-2014 and 9.8% from 2014 to 2016 (incidence rate ratio 1.09, 95% confidence interval 1.03-1.15, P = .005). Results did not vary significantly when insurance was included as a control variable. CONCLUSIONS: There was no immediate change in pediatric ED visit rates the year after the ACA took full effect in 2014, but the rate of change from 2014 to 2016 was significantly higher than previous rate trends. In our model, increased pediatric insurance coverage neither drove nor counteracted the observed trends.


Assuntos
Serviço Hospitalar de Emergência/tendências , Cobertura do Seguro/tendências , Aceitação pelo Paciente de Cuidados de Saúde , Patient Protection and Affordable Care Act/tendências , Adolescente , Criança , Pré-Escolar , Estudos Transversais , Serviço Hospitalar de Emergência/economia , Feminino , Humanos , Lactente , Recém-Nascido , Cobertura do Seguro/economia , Masculino , Patient Protection and Affordable Care Act/economia , Estudos Retrospectivos
18.
J Manag Care Spec Pharm ; 25(6): 688-695, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31134865

RESUMO

BACKGROUND: Medication therapy management (MTM) programs are designed to improve clinical outcomes and enhance appropriate medication use. Comprehensive medication reviews (CMRs) and targeted medication reviews (TMRs) are 2 broad interventions defined within MTM services. While MTM services have been extensively researched, there are few comparisons of CMR versus non-CMR interventions. Given the variability in MTM interventions and lack of a consistent TMR definition in the literature, this study sought to compare CMRs and TMRs that were clearly defined based on Centers for Medicare & Medicaid Services (CMS) criteria. OBJECTIVES: To (a) compare acute inpatient admissions and emergency department (ED) visits between patients participating in MTM services (CMR, TMR, or both) and eligible nonparticipating patients and (b) examine the effect of receiving TMR services on medication adherence. METHODS: This was a retrospective cohort study of patients with Medicare Part D coverage who received MTM services and a 1:1 propensity score-matched control group. Participants had to be eligible for MTM services in 2014 or 2015 based on CMS requirements. CMRs were offered to all MTM-eligible patients, while TMRs were completed based on clinical rules that helped identify medication-related problems (MRPs). The date of MTM intervention, or eligibility for the control group, was considered the index date. Participants had to be continuously enrolled in a Medicare Advantage plan that included prescription drug coverage during the study period and have at least 6 months of data before and after the index date. Medical and pharmacy claims were assessed to examine trend-adjusted inpatient admissions and ED visits from pre-index to post-index date for participants and matched controls. RESULTS: In 2014 and 2015, receipt of TMR interventions was associated with statistically significant reductions in acute inpatient admissions. In 2014, there were 55.2 fewer admits per 1,000 individuals (95% CI = 29-81) and 30.8 fewer admits per 1,000 individuals in 2015 (95% CI = 20-42). Receipt of CMR-only interventions was associated with fewer acute inpatient admissions only when coupled with preidentification of MRPs (36.8 [95% CI = 25-49] fewer admits per 1,000 individuals). In 2015, there were significant reductions in ED visits for participants receiving TMR-only interventions or TMR/CMR interventions (26.1 [95% CI = 11-41] and 12.0 [95% CI = 1-23] fewer ED visits per 1,000 individuals, respectively). In both years, a larger percentage (0.4% for oral diabetes medications; 7.7% for antihypertensives; 3.0% for statins) of MTM participants had greater improvements in medication adherence in the post-index period compared with controls. CONCLUSIONS: Receiving MTM services targeted at resolution of MRPs (TMR or CMR/TMR) resulted in positive reductions in health care utilization and increases in medication adherence. Given the importance of optimal medication utilization, this study highlights the need for additional focus on resolution of MRPs through TMRs and CMRs that can support improved clinical outcomes. DISCLOSURES: No outside funding supported this study. Researchers completed the work as part of their employment with Humana. All authors are or were employees of Humana at the time of the study. There are no other conflicts of interest to disclose. This study was previously presented at AMCP Nexus 2017 on October 16, 2017, in Dallas, TX.


Assuntos
Medicare Part D/estatística & dados numéricos , Adesão à Medicação/estatística & dados numéricos , Conduta do Tratamento Medicamentoso/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Farmácias/organização & administração , Idoso , Idoso de 80 Anos ou mais , Uso de Medicamentos/economia , Uso de Medicamentos/estatística & dados numéricos , Serviço Hospitalar de Emergência/economia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Masculino , Medicare Part D/economia , Conduta do Tratamento Medicamentoso/economia , Pessoa de Meia-Idade , Admissão do Paciente/economia , Admissão do Paciente/estatística & dados numéricos , Farmácias/economia , Farmácias/estatística & dados numéricos , Estudos Retrospectivos , Estados Unidos
19.
Health Serv Res ; 54(4): 739-751, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31070263

RESUMO

OBJECTIVE: To estimate the effects of the health insurance exchange and Medicaid coverage expansions on hospital inpatient and emergency department (ED) utilization rates, cost, and patient illness severity, and also to test the association between changes in outcomes and the size of the uninsured population eligible for coverage in states. DATA SOURCES: Healthcare Cost and Utilization Project State Inpatient and Emergency Department Databases, 2011-2015, Nielsen Demographic Data, and the American Community Survey. STUDY DESIGN: Retrospective study using fixed-effects regression to estimate the effects in expansion and nonexpansion states by age/sex demographic groups. FINDINGS: In Medicaid expansion states, rates of uninsured inpatient discharges and ED visits fell sharply in many demographic groups. For example, uninsured inpatient discharge rates across groups, except young females, decreased by ≥39 percent per capita on average in expansion states. In nonexpansion states, uninsured utilization rates remained unchanged or increased slightly (0-9.2 percent). Changes in all-payer and private insurance rates were more muted. Changes in inpatient costs per discharge were negative, and all-payer inpatient costs per discharge declined <6 percent in most age/sex groups. The size of the uninsured population eligible for coverage was strongly associated with changes in outcomes. For example, among males aged 35-54 years in expansion states, there was a 0.793 percent decrease in the uninsured discharge rate per unit increase in the coverage expansion ratio (the ratio of the size of the population eligible for coverage to the size of the previously covered population within an age/sex/payer/geographic group). CONCLUSIONS: Significant shifts in cost per discharge and patient severity were consistent with selective take-up of insurance. The "treatment intensity" of expansions may be useful for anticipating future effects.


Assuntos
Serviço Hospitalar de Emergência/economia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Necessidades e Demandas de Serviços de Saúde/estatística & dados numéricos , Custos Hospitalares/estatística & dados numéricos , Patient Protection and Affordable Care Act/legislação & jurisprudência , Adulto , Fatores Etários , Feminino , Acesso aos Serviços de Saúde/estatística & dados numéricos , Humanos , Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Masculino , Medicaid/estatística & dados numéricos , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Pessoa de Meia-Idade , Alta do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Índice de Gravidade de Doença , Fatores Sexuais , Fatores Socioeconômicos , Estados Unidos , Adulto Jovem
20.
PLoS One ; 14(5): e0217508, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31125382

RESUMO

OBJECTIVES: Sepsis presents a major burden to the emergency department (ED). Because empiric inappropriate antimicrobial therapy (IAAT) is associated with increased mortality, rapid molecular assays may decrease IAAT and improve outcomes. We evaluated the cost-effectiveness of molecular testing as an adjunct to blood cultures in patients with severe sepsis or septic shock evaluated in the ED. METHODS: We developed a decision analysis model with primary outcome the incremental cost-effectiveness ratio expressed in terms of deaths averted. Costs were dependent on the assay price and the patients' length of stay (LOS). Three base-case scenarios regarding the difference in LOS between patients receiving appropriate (AAT) and IAAT were described. Sensitivity analyses regarding the assay cost and sensitivity, and its ability to guide changes from IAAT to AAT were performed. RESULTS: Under baseline assumptions, molecular testing was cost-saving when the LOS differed by 4 days between patients receiving IAAT and AAT (ICER -$7,302/death averted). Our results remained robust in sensitivity analyses for assay sensitivity≥52%, panel efficiency≥39%, and assay cost≤$270. In the extreme case that the LOS of patients receiving AAT and IAAT was the same, the ICER remained≤$20,000/death averted for every studied sensitivity (i.e. 0.5-0.95), panel efficiency≥34%, and assay cost≤$313. For 2 days difference in LOS, the bundle approach was dominant when the assay cost was≤$135 and the panel efficiency was≥77%. CONCLUSIONS: The incorporation of molecular tests in the management of sepsis in the ED has the potential to improve outcomes and be cost-effective for a wide range of clinical scenarios.


Assuntos
Sepse/terapia , Choque Séptico/terapia , Hemocultura/economia , Análise Custo-Benefício , Técnicas de Apoio para a Decisão , Gerenciamento Clínico , Serviço Hospitalar de Emergência/economia , Custos de Cuidados de Saúde , Humanos , Tempo de Internação/economia , Patologia Molecular/economia , Sepse/economia , Choque Séptico/economia , Resultado do Tratamento
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