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1.
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
2.
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
3.
Am Surg ; 86(9): 1078-1082, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32845734

RESUMO

BACKGROUND: Enhanced recovery after surgery (ERAS) protocols are widely utilized for elective colorectal surgery to improve outcomes and decrease costs, but few studies have evaluated the impact of ERAS protocols on cost with respect to anatomic site of resection. This study evaluated the impact of ERAS protocol on elective colon resections by site and longitudinal impact over time. METHODS: A single-center retrospective cohort study of 598 consecutive patients undergoing elective colorectal resection before and after implementation of ERAS protocol from 2013 to 2017 was performed. The primary outcomes were length of stay (LOS) and cost. Comparative and multivariate inferential statistics were used to assess additional outcomes. RESULTS: A total of 598 patients (100 pre-ERAS vs 498 post-ERAS) were evaluated with an overall median LOS of 4 days for right and left colectomies and 3 days for transverse colectomies. When comparing type of resection before and after ERAS protocol introduction, an increased LOS for left hemicolectomies from 3.09 to 4.03 days (P = .047) was noted, with all other comparisons failing to reach statistical significance. Over time, an initial decrease in LOS for MIS approach after protocol introduction was observed; however, this effect diminished in the ensuing years and had no significant effect overall. Total cost of care was significantly increased post-ERAS for all cohorts except transverse colectomies. No further statistically significant differences were found. CONCLUSION: After an initial improvement in outcomes, continued utilization of ERAS protocols demonstrated no improvement in LOS compared to pre-ERAS data and increased cost overall for patients regardless of site of resection.


Assuntos
Colectomia/economia , Recuperação Pós-Cirúrgica Melhorada , Fidelidade a Diretrizes , Custos Hospitalares , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Colectomia/métodos , Custos e Análise de Custo , Procedimentos Cirúrgicos Eletivos/economia , Procedimentos Cirúrgicos Eletivos/métodos , Feminino , Seguimentos , Humanos , Tempo de Internação/economia , Tempo de Internação/tendências , Masculino , Pessoa de Meia-Idade , Período Pós-Operatório , Estudos Retrospectivos , Adulto Jovem
4.
Can J Cardiol ; 36(11): 1826-1829, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32841675

RESUMO

Although the incidence of ST-elevation myocardial infarction (STEMI) is on the decline, management of patients who present with STEMI continues to require significant health care resources. Earlier hospital discharge in low-risk patients who present with STEMI has been an area of focus in an attempt to reduce health care costs. As a result, discharge within 48-72 hours after successful primary percutaneous coronary intervention has increasingly become routine practice. Moreover, the current COVID-19 pandemic has led to enormous pressure on health care systems to find ways to increase bed capacity, preserve resources, and reduce the risk of exposure to patients and health care workers. In response to this goal, the Ottawa Heart Institute has developed and implemented a novel Very Early Hospital Discharge (VEHD) protocol. The VEHD protocol is a simple, 4-step algorithm designed to accurately and efficiently identify low-risk STEMI patients who can be safely discharged between 20 and 36 hours after successful primary percutaneous coronary intervention. When deemed eligible for VEHD predischarge tasks are completed by the treating medical and nursing team and the patient is discharged home. Follow-up is completed remotely via virtual care (48 hours, 7 days, 30 days), and in the outpatient cardiology clinic (4-6 weeks). Amid a worldwide COVID-19 pandemic we believe the VEHD protocol is a crucial step in maintaining exceptional quality of care, in terms of patient satisfaction and clinical outcomes, while concurrently decreasing the risk of nosocomial infections, and reducing resource utilization.


Assuntos
Protocolos Clínicos , Assistência Perioperatória , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Humanos , Tempo de Internação/economia , Alta do Paciente/economia , Intervenção Coronária Percutânea , Assistência Perioperatória/normas , Medição de Risco , Infarto do Miocárdio com Supradesnível do Segmento ST/economia
5.
Surgery ; 168(4): 625-630, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32762874

RESUMO

BACKGROUND: Laparoscopic cholecystectomy has reached nearly universal adoption in the management of gallstone-related disease. With advances in operative technology, robotic-assisted cholecystectomy has been used increasingly in many practices, but few studies have examined the adoption of robotic assistance for inpatient cholecystectomy and the temporal outcomes on a national scale. The present study aimed to identify trends in utilization, as well as outcomes and factors associated with the use of robotic-assisted cholecystectomy. METHODS: The 2008 to 2017 database of the National Inpatient Sample was used to identify patients undergoing inpatient cholecystectomy. Independent predictors of the use of robotic assistance for cholecystectomy were identified using multivariable logistic regression adjusting for patient and hospital characteristics. RESULTS: Of an estimated 3,193,697 patients undergoing cholecystectomy, 98.7% underwent laparoscopic cholecystectomy and 1.3% robotic-assisted cholecystectomy. Rates of robotic-assisted cholecystectomy increased from 0.02% in 2008 to 3.2% in 2017 (nptrend < .001). Compared with laparoscopic cholecystectomy, patients undergoing robotic-assisted cholecystectomy had a greater burden of comorbidities as measured by the Elixhauser index (2.2 vs 1.9, P < .001). Although mortality rates were similar, robotic-assisted cholecystectomy was associated with greater complication rates (15.5% vs 11.7%, P < .001), most notably gastrointestinal-related complications (3.7% vs 1.5%, P < .001). On multivariable regression, robotic-assisted cholecystectomy was associated with increased costs of hospitalization (ß: $2,398, P < .001). CONCLUSION: Using the largest national database available, we found a dramatic increase in the use of robotic-assisted cholecystectomy with no difference in mortality or duration of hospital stay, but there was a statistically significant increase in complications and costs. These findings warrant further investigation.


Assuntos
Colecistectomia Laparoscópica/tendências , Cálculos Biliares/cirurgia , Procedimentos Cirúrgicos Robóticos/tendências , Colecistectomia Laparoscópica/efeitos adversos , Colecistectomia Laparoscópica/economia , Feminino , Custos Hospitalares , Mortalidade Hospitalar , Humanos , Tempo de Internação/economia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Utilização de Procedimentos e Técnicas , Estudos Retrospectivos , Fatores de Risco , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Procedimentos Cirúrgicos Robóticos/economia , Estados Unidos
6.
Eur J Vasc Endovasc Surg ; 60(5): 655-662, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32800479

RESUMO

OBJECTIVE: The suggested high costs of endovascular aneurysm repair (EVAR) hamper the choice of insurance companies and financial regulators for EVAR as the primary option for elective abdominal aortic aneurysm (AAA) repair. However, arguments used in this debate are impeded by time related aspects such as effect modification and the introduction of confounding by indication, and by asymmetric evaluation of outcomes. Therefore, a re-evaluation minimising the impact of these interferences was considered. METHODS: A comparative analysis was performed evaluating a period of exclusive open repair (OR; 1998-2000) and a period of established EVAR (2010-2012). Data from four hospitals in The Netherlands were collected to estimate resource use. Actual costs were estimated by benchmark cost prices and a literature review. Costs are reported at 2019 prices. A break even approach, defining the costs for an endovascular device at which cost equivalence for EVAR and OR is achieved, was applied to cope with the large variation in endovascular device costs. RESULTS: One hundred and eighty-six patients who underwent elective AAA repair between 1998 and 2000 (OR period) and 195 patients between 2010 and 2012 (EVAR period) were compared. Cost equivalence for OR and EVAR was reached at a break even price for an endovascular device of €13 190. The main cost difference reflected the longer duration of hospital stay (ward and Intensive Care Unit) of OR (€11 644). Re-intervention rates were similar for OR (24.2%) and EVAR (24.6%) (p = .92). CONCLUSION: Cost equivalence for EVAR and OR occurs at a device cost of €13 000 for EVAR. Hence, for most routine repairs, EVAR is not costlier than OR until at least the five year follow up.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/economia , Análise Custo-Benefício , Procedimentos Cirúrgicos Eletivos/economia , Procedimentos Endovasculares/economia , Complicações Pós-Operatórias/economia , Assistência ao Convalescente/economia , Assistência ao Convalescente/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/economia , Aneurisma da Aorta Abdominal/mortalidade , Prótese Vascular/economia , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Implante de Prótese Vascular/métodos , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Procedimentos Cirúrgicos Eletivos/instrumentação , Procedimentos Cirúrgicos Eletivos/métodos , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Feminino , Mortalidade Hospitalar , Humanos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Países Baixos/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Reoperação/economia , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Stents/economia , Fatores de Tempo , Resultado do Tratamento
7.
Milbank Q ; 98(3): 908-974, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32820837

RESUMO

Policy Points Evidence suggests that bundled payment contracting can slow the growth of payer costs relative to fee-for-service contracting, although bundled payment models may not reduce absolute costs. Bundled payments may be more effective than fee-for-service payments in containing costs for certain medical conditions. For the most part, Medicare's bundled payment initiatives have not been associated with a worsening of quality in terms of readmissions, emergency department use, and mortality. Some evidence suggests a worsening of other quality measures for certain medical conditions. Bundled payment contracting involves trade-offs: Expanding a bundle's scope and duration may better contain costs, but a more comprehensive bundle may be less attractive to providers, reducing their willingness to accept it as an alternative to fee-for-service payment. CONTEXT: Bundled payments have been promoted as an alternative to fee-for-service payments that can mitigate the incentives for service volume under the fee-for-service model. As Medicare has gained experience with bundled payments, it has widened their scope and increased their duration. However, there have been few reviews of the empirical literature on the impact of Medicare's bundled payment programs on cost, resource use, utilization, and quality. METHODS: We examined the history and features of 16 of Medicare's bundled payment programs involving hospital-initiated episodes of care and conducted a literature review of articles about those programs. Database and additional searches yielded 1,479 articles. We evaluate the studies' methodological quality and summarize the quantitative findings about Medicare expenditures and quality of care from 37 studies that used higher-quality research designs. FINDINGS: Medicare's bundled payment initiatives have varied in their design features, such as episode scope and duration. Many initiatives were associated with little to no reduction in Medicare expenditures, unless large pricing discounts for providers were negotiated in advance. Initiatives that included post-acute care services were associated with lower expenditures for certain conditions. Hospitals may have been able to reduce internal production costs with help from physicians via gainsharing. Most initiatives were not associated with significant changes in quality of care, as measured by readmission and mortality rates. Of the significant changes in readmission rates, the results were mixed, showing increases and decreases associated with bundled payments. Some evidence suggested that worse patient outcomes were associated bundled payments, although most results were not statistically significant. Results on case-mix selection were mixed: Several initiatives were associated with reductions in episode severity, whereas others were associated with little change. CONCLUSIONS: Bundled payments for hospital-initiated episodes may be a good alternative to fee-for-service payments. Bundled payments can help slow the growth of payer spending, although they do not necessarily reduce absolute spending. They are associated with lower provider production costs, and there is no overwhelming evidence of compromised quality. However, designing a bundled payment contract that is attractive to both providers and payers proves to be a challenge.


Assuntos
Hospitalização/economia , Medicare/economia , Pacotes de Assistência ao Paciente/economia , Mecanismo de Reembolso , Redução de Custos/economia , Redução de Custos/métodos , Redução de Custos/estatística & dados numéricos , Custos Hospitalares/organização & administração , Custos Hospitalares/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Humanos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Medicare/organização & administração , Medicare/estatística & dados numéricos , Pacotes de Assistência ao Paciente/estatística & dados numéricos , Mecanismo de Reembolso/economia , Mecanismo de Reembolso/estatística & dados numéricos , Estados Unidos
8.
PLoS One ; 15(8): e0236695, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32785282

RESUMO

The goal of this study is to investigate the effectiveness of the neonatal diagnosis-related group scheme in patients affected by respiratory distress syndrome. The variable costs of individual patients in the same group are examined. This study uses the data of infants (N = 243) hospitalized in the Neonatal Intensive Care Unit of the Gaslini Children's Hospital in Italy in 2016. The care unit's operating and management costs are employed to estimate the average cost per patient. Operating costs include those related to personnel, drugs, medical supplies, treatment tools, examinations, radiology, and laboratory services. Management costs relate to administration, maintenance, and depreciation cost of medical equipment. Cluster analysis and Tobit regression are employed, allowing for the assessment of the total cost per patient per day taking into account the main cost determinants: birth weight, gestational age, and discharge status. The findings highlight great variability in the costs for patients in the same diagnosis-related group, ranging from a minimum of €267 to a maximum of €265,669. This suggests the inefficiency of the diagnosis-related group system. Patients with very low birth weight incurred costs approximately twice the reimbursement set by the policy; a loss of €36,420 is estimated for every surviving baby with a birth weight lower than 1,170 grams. On the contrary, at term, newborns cost about €20,000 less than the diagnosis-related group reimbursement. The actual system benefits hospitals that mainly treat term infants with respiratory distress syndrome and penalizes hospitals taking care of very low birth weight patients. As a result, strategic behavior and "up-coding" might occur. We conduct a cluster analysis that suggests a birth weight adjustment to determine new fees that would be fairer than the current costs.


Assuntos
Grupos Diagnósticos Relacionados/economia , Unidades de Terapia Intensiva Neonatal/economia , Síndrome do Desconforto Respiratório do Recém-Nascido/economia , Feminino , Idade Gestacional , Custos Hospitalares/estatística & dados numéricos , Humanos , Lactente , Recém-Nascido , Recém-Nascido de muito Baixo Peso/fisiologia , Itália/epidemiologia , Tempo de Internação/economia , Masculino , Síndrome do Desconforto Respiratório do Recém-Nascido/diagnóstico , Síndrome do Desconforto Respiratório do Recém-Nascido/fisiopatologia , Fatores de Risco
9.
PLoS One ; 15(8): e0236480, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32813687

RESUMO

BACKGROUND: The Government of Ontario, Canada, announced hospital funding reforms in 2011, including Quality-based Procedures (QBPs) involving pre-set funds for managing patients with specific diagnoses/procedures. A key goal was to improve quality of care across the jurisdiction. METHODS: Interrupted time series evaluated the policy change, focusing on four QBPs (congestive heart failure, hip fracture surgery, pneumonia, prostate cancer surgery), on patients hospitalized 2010-2017. Outcomes included return to hospital or death within 30 days, acute length of stay (LOS), volume of admissions, and patient characteristics. RESULTS: At 2 years post-QBPs, the percentage of hip fracture patients who returned to hospital or died was 3.13% higher in absolute terms (95% CI: 0.37% to 5.89%) than if QBPs had not been introduced. There were no other statistically significant changes for return to hospital or death. For LOS, the only statistically significant change was an increase for prostate cancer surgery of 0.33 days (95% CI: 0.07 to 0.59). Volume increased for congestive heart failure admissions by 80 patients (95% CI: 2 to 159) and decreased for hip fracture surgery by 138 patients (95% CI: -183 to -93) but did not change for pneumonia or prostate cancer surgery. The percentage of patients who lived in the lowest neighborhood income quintile increased slightly for those diagnosed with congestive heart failure (1.89%; 95% CI: 0.51% to 3.27%) and decreased for those who underwent prostate cancer surgery (-2.08%; 95% CI: -3.74% to -0.43%). INTERPRETATION: This policy initiative involving a change to hospital funding for certain conditions was not associated with substantial, jurisdictional-level changes in access or quality.


Assuntos
Administração Financeira/economia , Hospitalização/economia , Hospitais , Análise de Séries Temporais Interrompida/economia , Adulto , Idoso , Idoso de 80 Anos ou mais , Economia Hospitalar , Feminino , Insuficiência Cardíaca/economia , Fraturas do Quadril/economia , Fraturas do Quadril/cirurgia , Humanos , Tempo de Internação/economia , Masculino , Pessoa de Meia-Idade , Ontário/epidemiologia , Pneumonia/economia , Neoplasias da Próstata/economia , Neoplasias da Próstata/cirurgia
10.
Surgery ; 168(4): 753-759, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32611513

RESUMO

BACKGROUND: Despite the introduction of several measures to reduce incidence, postoperative infections have been reported to increase. We aimed to assess trends in the incidence and impact of postoperative infections using a recent national cohort. METHODS: Patients undergoing the most commonly performed elective inpatient procedures in 9 surgical specialties were identified from the 2006 to 2014 National Inpatient Sample. Diagnostic coding was utilized to identify patients with postoperative infections. To adjust for patient and operative differences in assessing outcomes, an inverse probability of treatment weighing protocol was used. RESULTS: Of an estimated 23,696,588 patients, 1,213,182 (5.1%) developed postoperative infections. Skin and soft tissue operations had the highest burden (12.9%) and endocrine the lowest (1.3%). During the study period, we found decreasing incidence, case fatality, and incremental cost of postoperative infections. Infection was associated with increased in-hospital mortality (1.4 vs 0.4%, P < .001), duration of stay (7.6 vs 3.7 days, P < .001), and costs ($27,597 vs $17,985, P < .001). Annually, postoperative infections led to an average incremental cost burden exceeding $700 million in the United States alone. CONCLUSION: During the study period there was a substantial decrease in the burden of postoperative infections. Despite encouraging trends, postoperative infections continue to serve as a suitable quality improvement target, particularly in specialties with a high burden of infections.


Assuntos
Procedimentos Cirúrgicos Eletivos/efeitos adversos , Infecções/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Adulto , Idoso , Efeitos Psicossociais da Doença , Feminino , Custos Hospitalares , Mortalidade Hospitalar , Humanos , Tempo de Internação/economia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Infecção da Ferida Cirúrgica/epidemiologia , Estados Unidos/epidemiologia
11.
J Stroke Cerebrovasc Dis ; 29(8): 104996, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32689626

RESUMO

GOAL: This study aimed to compare the length of stay, saved days and service costs associated with an early supported discharge model of care for mild, moderate and severe stroke survivors, to standard treatment. MATERIALS AND METHODS: A two centre cohort study, employing a quasi-experimental design with a control group of convenience. Forty-four participants were recruited when they were deemed suitable for discharge home with intensive rehabilitation and services, with three dropouts from the treatment group (treatment n = 28, control n = 13). There were no significant differences between the groups for gender, age, Functional Independence Measure, Berg Balance Test and Modified Ranking Scale total scores at baseline. There were also no significant differences between the groups for subsequent readmissions or complications. Length of stay was measured by the days between admission and discharge from both inpatient and community services. Costs were measured by daily amounts calculated for this service. FINDINGS: The treatment group spent significantly fewer days on the acute and inpatient rehabilitation wards, with over half avoiding subacute admission altogether. However, the control group spent significantly fewer days receiving intensive rehabilitation. The treatment group cost less on average per patient, but was not significantly different in terms of overall costs per admission. CONCLUSION: Stroke survivors receiving an early supported discharge model of care spent fewer days in hospital, frequently avoided subacute admission and incurred less cost per patient than those receiving standard treatment. These findings indicate that early supported discharge reduces length of inpatient stay, for a similar cost to standard treatment.


Assuntos
Custos Hospitalares , Tempo de Internação/economia , Alta do Paciente/economia , Reabilitação do Acidente Vascular Cerebral/economia , Acidente Vascular Cerebral/economia , Acidente Vascular Cerebral/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Redução de Custos , Análise Custo-Benefício , Avaliação da Deficiência , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ensaios Clínicos Controlados não Aleatórios como Assunto , Índice de Gravidade de Doença , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Vitória
12.
Surgery ; 168(4): 737-742, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32641277

RESUMO

BACKGROUND: We compared the clinical outcomes and cost-efficiency of surgical approaches (sternotomy-open, video assisted thoracoscopic surgery, and robotic assisted thoracic surgery) for thymectomy. METHODS: This is a retrospective review of 220 consecutive patients who underwent thymectomy between January 1, 2007, and January 31, 2017. Surgical approach was determined by the surgeon, but we only included cases that could be resected using any of the 3 approaches. RESULTS: Open approach was used in 69 patients, whereas minimally invasive technique was used in 151 (97, video assisted thoracoscopic surgery; 54, robotic assisted thoracic surgery). Open surgery was associated with greater total hospital cost ($22,847 ± $20,061 vs $14,504 ± $10,845, P < .001). Open group also revealed longer duration of intensive care unit (1.2 ± 2.8 vs 0.2 ± 1.3 days, P < .001) and hospital stay (4.3 ± 4.0 vs 2.0 ± 2.6 days, P < .001). There were no differences in major adverse clinical outcomes. Long-term recurrence-free survival after resection of thymoma was similar between the groups. CONCLUSION: Minimally invasive techniques were equally efficacious compared with the open approach in the resection of the thymus. Additionally, their use was associated with decreased hospital duration of stay and reduced cost. Hence the use of minimally invasive approaches should be encouraged in the resection of thymus.


Assuntos
Análise Custo-Benefício , Custos Hospitalares , Timectomia/economia , Timectomia/métodos , Adulto , Pesquisa Comparativa da Efetividade , Intervalo Livre de Doença , Feminino , Humanos , Tempo de Internação/economia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Procedimentos Cirúrgicos Robóticos/economia , Cirurgia Torácica Vídeoassistida/efeitos adversos , Cirurgia Torácica Vídeoassistida/economia , Timectomia/efeitos adversos , Timoma/cirurgia , Neoplasias do Timo/cirurgia , Resultado do Tratamento
13.
PLoS One ; 15(7): e0236122, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32673371

RESUMO

OBJECTIVE: To determine the predictive factors of postoperative hospital stay and total hospital medical cost among patients who underwent total laryngectomy. METHODS: A total of 213 patients who underwent total laryngectomy in a tertiary referral center for tumor ablation were enrolled retrospectively between January 2009 and May 2018. Statistical analyses including Pearson's chi-squared test were used to determine whether there was a significant difference between each selected clinical factors and outcomes. The outcomes of interest including postoperative length of hospital stay and inpatient total medical cost. Logistic regression analyses were performed to reveal the relationship between clinical factors and postoperative length of hospital stay or total inpatient medical cost. RESULTS: Preoperative radiotherapy (p = 0.007), method of wound closure (p < 0.001), postoperative serum albumin level (p = 0.025), and postoperative serum hemoglobin level (p = 0.04) were significantly associated with postoperative hospital stay in univariate analysis. Postoperative hypoalbuminemia (odds ratio [OR]: 2.477; 95% confidence interval [CI]: 1.189-5.163; p = 0.015) and previous radiotherapy history (OR 2.194; 95% CI: 1.228-3.917; p = 0.008) are independent predictors of a longer postoperative hospital stay in multiple regression analysis. With respect to total inpatient medical cost, method of wound closure (p < 0.001), preoperative serum albumin level (p = 0.04), postoperative serum albumin level (p < 0.001), and history of liver cirrhosis (p = 0.037) were significantly associated with total inpatient medical cost in univariate analysis. Postoperative hypoalbuminemia (OR: 6.671; 95% CI: 1.927-23.093; p = 0.003) and microvascular free flap reconstruction (OR: 5.011; 95% CI: 1.657-15.156; p = 0.004) were independent predictors of a higher total inpatient medical cost in multiple regression analysis. CONCLUSIONS: Postoperative albumin status is a significant factor in predicting prolonged postoperative hospital stay and higher inpatient medical cost among patients who undergo total laryngectomy. In this cohort, the inpatient medical cost was 48% higher and length of stay after surgery was 35% longer among hypoalbuminemia patients.


Assuntos
Análise Custo-Benefício , Hospitais/estatística & dados numéricos , Laringectomia/economia , Tempo de Internação/economia , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade
14.
Am Surg ; 86(7): 848-855, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32726131

RESUMO

OBJECTIVES: Colorectal care bundles for surgical site infections (CRCB-SSIs) have been shown to reduce SSIs following elective colorectal surgery (CRS). There are limited data evaluating the effect of CRCB-SSI at Academic Disproportionate Share Hospitals (ADSH) with significant rates of urgent and emergent cases. METHODS: A CRCB-SSI was implemented in April 2016. We reviewed medical records of all patients undergoing colon resections between August 2015 and December 2017. Patients were divided into preimplementation and postimplementation groups. The primary endpoint was the SSI rate, and the secondary endpoint included types of SSI (superficial, deep, organ space). Univariable and multivariable analyses were performed. A subset analysis was performed in elective cases. RESULTS: We analyzed a total of 417 patients. Of these, 116 (28%) and 301 (72%) patients were in the preimplementation and postimplementation groups, respectively. The rate of SSI decreased from 30.1% to 15.9% in the postimplementation group (P = .0012); however, it was not statistically significant after adjusting for baseline differences (relative risk [RR] 0.65; 95% CI 0.41-1.02).The elective subset included 219 patients. The rate of SSI in this cohort decreased from 25% to 10.5% in the postimplementation group (P = .0012) and remained significant following multivariable analysis (RR 0.41, 95% CI 0.19- 0.88). There were no differences in the subtypes of SSI. DISCUSSION: While the CRCB-SSI was effective in decreasing the postoperative SSI rate for elective cases, its effect on the overall patient population was limited. CRCB-SSIs are not enough to bring SSI rates to accepted rates in high-risk patients such as those seen at ADSH.


Assuntos
Neoplasias Colorretais/cirurgia , Cirurgia Colorretal/efeitos adversos , Custos Hospitalares , Avaliação de Resultados em Cuidados de Saúde , Pacotes de Assistência ao Paciente/economia , Infecção da Ferida Cirúrgica/epidemiologia , Centros Médicos Acadêmicos , Adulto , Idoso , Análise de Variância , Estudos de Coortes , Neoplasias Colorretais/economia , Cirurgia Colorretal/economia , Cirurgia Colorretal/métodos , Bases de Dados Factuais , Procedimentos Cirúrgicos Eletivos/economia , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Feminino , Humanos , Tempo de Internação/economia , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Cuidados Pós-Operatórios/economia , Cuidados Pós-Operatórios/métodos , Melhoria de Qualidade , Estudos Retrospectivos , Medição de Risco , Infecção da Ferida Cirúrgica/diagnóstico , Infecção da Ferida Cirúrgica/terapia , Estados Unidos
15.
Pediatrics ; 146(2)2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32699067

RESUMO

OBJECTIVES: (1) To identify a resource use inflection point (RU-IP) beyond which patients in the NICU no longer received NICU-level care, (2) to quantify variability between hospitals in patient-days beyond the RU-IP, and (3) to describe risk factors associated with reaching an RU-IP. METHODS: We evaluated infants admitted to any of the 43 NICUs over 6 years. We determined the day that each patient's total daily standardized cost was <10% of the mean first-day NICU room cost and remained within this range through discharge (RU-IP). We compared days beyond an RU-IP, the total standardized cost of hospital days beyond the RU-IP, and the percentage of patients by hospital beyond the RU-IP. RESULTS: Among 80 821 neonates, 80.6% reached an RU-IP. In total, there were 234 478 days after the RU-IP, representing 24.3% of the total NICU days and $483 281 268 in costs. Variability in the proportion of patients reaching an RU-IP was 33.1% to 98.7%. Extremely preterm and very preterm neonates, patients discharged with home health care services, or patients receiving mechanical ventilation, extracorporeal membrane oxygenation, or feeding support exhibited fewer days beyond the RU-IP. Conversely, receiving methadone was associated with increased days beyond the RU-IP. CONCLUSIONS: Identification of an RU-IP may allow health care systems to identify readiness for discharge from the NICU earlier and thereby save significant NICU days and health care dollars. These data reveal the need to identify best practices in NICUs that consistently discharge infants more efficiently. Once these best practices are known, they can be disseminated to offer guidance in creating quality improvement projects to provide safer and more predictable care across hospitals for patients of all socioeconomic statuses.


Assuntos
Unidades de Terapia Intensiva Neonatal/economia , Tempo de Internação/economia , Alta do Paciente , Oxigenação por Membrana Extracorpórea , Feminino , Serviços Hospitalares de Assistência Domiciliar , Hospitais Pediátricos , Humanos , Lactente Extremamente Prematuro , Recém-Nascido , Recém-Nascido Prematuro , Masculino , Metadona/administração & dosagem , Apoio Nutricional , Tratamento de Substituição de Opiáceos , Respiração Artificial , Estudos Retrospectivos , Estados Unidos/epidemiologia
16.
PLoS One ; 15(6): e0233457, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32603361

RESUMO

BACKGROUND: Chronic diseases are increasingly prevalent in Western countries. Once hospitalised, the chance for another hospitalisation increases sharply with large impact on well-being of patients and costs. The pattern of readmissions is very complex, but poorly understood for multiple chronic diseases. METHODS: This cohort study of administrative discharge data between 2009-2014 from 21 tertiary hospitals (eight USA, five UK, four Australia, four continental Europe) investigated rates and reasons of readmissions to the same hospital within 30 days after unplanned admission with one of the following chronic conditions; heart failure; atrial fibrillation; myocardial infarction; hypertension; stroke; chronic obstructive pulmonary disease (COPD); bacterial pneumonia; diabetes mellitus; chronic renal disease; anaemia; arthritis and other cardiovascular disease. Proportions of readmissions with similar versus different diseases were analysed. RESULTS: Of 4,901,584 admissions, 866,502 (17.7%) were due to the 12 chronic conditions. In-hospital, 43,573 (5.0%) patients died, leaving 822,929 for readmission analysis. Of those, 87,452 (10.6%) had an emergency 30-day readmission, rates ranged from 2.8% for arthritis to 18.4% for COPD. One third were readmitted with the same condition, ranging from 53% for anaemia to 11% for arthritis. Reasons for readmission were due to another chronic condition in 10% to 35% of the cases, leaving 30% to 70% due to reasons other than the original 12 conditions (most commonly, treatment related complications and infections). The chance of being readmitted with the same cause was lower in the USA, for female patients, with increasing age, more co-morbidities, during study period and with longer initial length of stay. CONCLUSION: Readmission in chronic conditions is very common and often caused by diseases other than the index hospitalisation. Interventions to reduce readmissions should therefore focus not only on the primary condition but on a holistic consideration of all the patient's comorbidities.


Assuntos
Alta do Paciente/tendências , Readmissão do Paciente/economia , Readmissão do Paciente/tendências , Idoso , Austrália , Doença Crônica/epidemiologia , Estudos de Coortes , Comorbidade , Europa (Continente) , Feminino , Hospitais , Humanos , Tempo de Internação/economia , Tempo de Internação/tendências , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Alta do Paciente/economia , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Reino Unido , Estados Unidos
17.
Med Care ; 58(8): 722-726, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32692138

RESUMO

BACKGROUND: Childhood obesity is linked with adverse health outcomes and associated costs. Current information on the relationship between childhood obesity and inpatient costs is limited. OBJECTIVE: The objective of this study was to describe trends and quantify the link between childhood obesity diagnosis and hospitalization length of stay (LOS), costs, and charges. RESEARCH DESIGN: We use the National Inpatient Sample data from 2006 to 2016. SUBJECTS: The sample includes hospitalizations among children aged 2-19 years. The treatment group of interest includes child hospitalizations with an obesity diagnosis. MEASURES: Hospital LOS, charges, and costs associated with a diagnosis of obesity. RESULTS: We find increases in obesity-coded hospitalizations and associated charges and costs during 2006-2016. Obesity as a primary diagnosis is associated with a shorter hospital LOS (by 1.8 d), but higher charges and costs (by $20,879 and $6049, respectively); obesity as a secondary diagnosis is associated with a longer LOS (by 0.8 d), and higher charges and costs of hospitalizations (by $3453 and $1359, respectively). The most common primary conditions occurring with a secondary diagnosis of obesity are pregnancy conditions, mood disorders, asthma, and diabetes; the effect of a secondary diagnosis of obesity on LOS, charges, and costs holds across these conditions. CONCLUSIONS: Childhood obesity diagnosis-related hospitalizations, charges, and costs increased substantially during 2006-2016, and obesity diagnosis is associated with higher hospitalization charges and costs. Our findings provide clinicians and policymakers with additional evidence of the economic burden of childhood obesity and further justify efforts to prevent and manage the disease.


Assuntos
Custos de Cuidados de Saúde/normas , Tempo de Internação/economia , Obesidade Pediátrica/economia , Adolescente , Criança , Pré-Escolar , Feminino , Custos de Cuidados de Saúde/estatística & dados numéricos , Hospitalização/economia , Hospitalização/estatística & dados numéricos , Humanos , Lactente , Tempo de Internação/estatística & dados numéricos , Masculino , Obesidade Pediátrica/diagnóstico , Estados Unidos
18.
Am Surg ; 86(6): 643-651, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32683960

RESUMO

BACKGROUND: Cholecystectomy is a common procedure with significantly varied outcomes. We analyzed differences in comorbidities, outcomes, and cost of cholecystectomy by acute care surgery (ACS) versus hepatopancreaticobiliary (HPB) surgery. STUDY DESIGN: Patients were retrospectively identified between 2008 and 2015. Exclusion criteria included the following: (1) part of another procedure; (2) abdominal trauma; (3) ICU admission; vasopressors. RESULTS: One hundred and twenty-six ACS and 122 HPB patients were analyzed. The HPB subset had higher burden of comorbid disease and significantly lower projected 10-year survival (87.4% ACS vs 68.5% HPB, P < .0001). Median lengths of stay were longer in HPB patients (2 vs 5 days, P < .0001) as were readmission rates (30-day 5.6% vs 13.1%, P = .040; 90-day 7.9% vs 20.5%, P = .005). Median cost was higher including operative supply cost ($969.42 vs $1920.66, P < .0001) and total cost of care ($7340.66 vs $19 338.05, P < .0001). A predictive scoring system for difficult gallbladders was constructed and a phone application was created. CONCLUSION: Cholecystectomy in a complicated patient can be difficult with longer hospital stays and higher costs. The utilization of procedure codes to explain disparities is not sufficient. Incorporation of comorbidities needs to be addressed for planning and reimbursement.


Assuntos
Colecistectomia/estatística & dados numéricos , Doenças da Vesícula Biliar/cirurgia , Adulto , Idoso , Colecistectomia/economia , Comorbidade , Feminino , Doenças da Vesícula Biliar/economia , Custos de Cuidados de Saúde/estatística & dados numéricos , Hospitalização/economia , Humanos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/economia , Estudos Retrospectivos , Fatores de Risco , Adulto Jovem
19.
Bone Joint J ; 102-B(7): 959-964, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32600143

RESUMO

AIMS: Currently, the US Center for Medicaid and Medicare Services (CMS) has been testing bundled payments for revision total joint arthroplasty (TJA) through the Bundled Payment for Care Improvement (BPCI) programme. Under the BPCI, bundled payments for revision TJAs are defined on the basis of diagnosis-related groups (DRGs). However, these DRG-based bundled payment models may not be adequate to account appropriately for the varying case-complexity seen in revision TJAs. METHODS: The 2008-2014 Medicare 5% Standard Analytical Files (SAF5) were used to identify patients undergoing revision TJA under DRG codes 466, 467, or 468. Generalized linear regression models were built to assess the independent marginal cost-impact of patient, procedural, and geographic characteristics on 90-day costs. RESULTS: A total of 9,263 patients (DRG-466 = 838, DRG-467 = 4,573, and DRG-468 = 3,842) undergoing revision TJA from 2008 to 2014 were included in the study. Undergoing revision for a dislocation (+$1,221), periprosthetic fracture (+$4,454), and prosthetic joint infection (+$5,268) were associated with higher 90-day costs. Among comorbidities, malnutrition (+$10,927), chronic liver disease (+$3,894), congestive heart failure (+$3,292), anaemia (+$3,149), and coagulopathy (+$2,997) had the highest marginal cost-increase. The five US states with the highest 90-day costs were Alaska (+$14,751), Maryland (+$13,343), New York (+$7,428), Nevada (+$6,775), and California (+$6,731). CONCLUSION: Under the proposed DRG-based bundled payment methodology, surgeons would be reimbursed the same amount of money for revision TJAs, regardless of the indication (periprosthetic fracture, prosthetic joint infection, mechanical loosening) and/or patient complexity. Cite this article: Bone Joint J 2020;102-B(7):959-964.


Assuntos
Artroplastia de Substituição/economia , Grupos Diagnósticos Relacionados/economia , Medicare/economia , Pacotes de Assistência ao Paciente/economia , Reoperação/economia , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Tempo de Internação/economia , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/economia , Complicações Pós-Operatórias/economia , Estudos Retrospectivos , Estados Unidos
20.
BMC Infect Dis ; 20(1): 501, 2020 Jul 11.
Artigo em Inglês | MEDLINE | ID: mdl-32652944

RESUMO

BACKGROUND: Tuberculosis (TB) still causes high economic burden on patients in China, especially for rural patients. Our study aims to explore the risk factors associated with the high costs for TB inpatients in rural China from the aspects of inpatients' socio-demographic and institutional attributes. METHODS: Generalized linear models were utilized to investigate the factors associated with TB inpatients' total costs and out-of-pocket (OOP) expenditures. Quantile regression (QR) models were applied to explore the effect of each factor across the different costs range and identify the risk factors of high costs. RESULTS: TB inpatients with long length of stay and who receive hospitalization services cross provincially, in tertiary and specialized hospitals were likely to face high total costs and OOP expenditures. QR models showed that high total costs occurred in Dingyuan and Funan Counties, but they were not accompanied by high OOP expenditures. CONCLUSIONS: Early diagnosis, standard treatment and control of drug-resistant TB are still awaiting for more efforts from the government. TB inpatients should obtain medical services from appropriate hospitals. The diagnosis and treatment process of TB should be standardized across all designated medical institutions. Furthermore, the reimbursement policy for migrant workers who suffered from TB should be ameliorated.


Assuntos
Tuberculose/economia , Adolescente , Adulto , Idoso , China , Feminino , Custos de Cuidados de Saúde , Gastos em Saúde , Humanos , Pacientes Internados , Tempo de Internação/economia , Masculino , Pessoa de Meia-Idade , Análise de Regressão , População Rural , Centros de Atenção Terciária/economia , Tuberculose/diagnóstico , Tuberculose/terapia , Tuberculose Resistente a Múltiplos Medicamentos/diagnóstico , Tuberculose Resistente a Múltiplos Medicamentos/economia , Tuberculose Resistente a Múltiplos Medicamentos/terapia , Adulto Jovem
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