A model for calculating the hospital costs for pediatric endoscopy

Colon cleansing protocol in children: research conditions vs. clinical practice

BACKGROUND AND STUDY AIMS

 Colon preparation rates are the limiting factor for a successful diagnostic colonoscopy in children. Different colon cleansing protocols have been published for use in children. Unfortunately, the applicability of those published research protocols has not been formally evaluated in routine clinical practice. We investigated the success rate of our previously published colon cleansing protocol as utilized in our clinical practice.

PATIENTS AND METHODS

 This was a retrospective study. In the clinical practice, the colon cleansing protocol included PEG-3350 at a dose of 2 g/kg/day plus Dulcolax (Bisacodyl, Boehringer Ingelheim, TX USA) 5 mg/day for 2 days. Adequate colon preparation was graded between 1 - 5, as previously described, and grade ≥ 4.0 was considered an adequate preparation. Patients were instructed to complete a questionnaire that included PEG-3350 dose, number of stools per day, consistency of each stool, and side effects (vomiting, abdominal pain). Clinical and endoscopic results were compared between the protocol under research conditions and routine practice.

RESULTS

 The success rate of the colon preparation in our clinical practice was similar to the results observed under our research protocol (75 % vs. 73.6 %). Moreover, the total number of stools, stool consistency, and the intubation rate of the terminal ileum were also similar. We concluded, that in our experience, the colon cleansing protocol used under research conditions was effective and appropriate for use in routine clinical practice.

CONCLUSION

 We recommend testing each new protocol under the routine conditions of clinical practice to confirm its applicability for general practitioners.

The diagnostic yield of upper endoscopy procedures in children- is it cost effective?

Upper endoscopy is an invaluable tool for the diagnosis and treatment of various gastrointestinal symptoms in children. Over the years, the number of endoscopic procedures performed in different medical centers has increased considerably and the cost associated with the procedure has become unsustainable. Recently, the US government has investigated this topic and has suggested steps to reduce the cost and use of endoscopic procedures in the adult population, changes that have not been accepted favorably by the American Gastroenterology Associations (AGA). In the present report, we evaluate the diagnostic yield of the procedure in children and suggest steps to reduce the annual number of upper endoscopic procedures in children. The diagnostic yield and the cost-effectiveness of the procedure are also discussed.

Resource-intensive endoscopic procedures: do the dollars make sense?

BACKGROUND

The rapid development of endoscopic technologies over the past decade has led to an increased utilization of resource-intensive endoscopic procedures in clinical practice. These procedures are technically challenging, time consuming, and typically involve major equipment-related costs.

OBJECTIVE

To determine the economics associated with performing resource-intensive endoscopic procedures in a tertiary-referral center

DESIGN

A retrospective practice database review.

SETTING

A single, North American tertiary-referral medical center.

PATIENTS

All the patients whose initial contacts with the medical center were as outpatients for an EUS, EMR, or ERCP between July and November 2004.

MAIN OUTCOME MEASUREMENTS

Hospital charges, the cost of providing services, revenue, and net income from all services provided through June 2006.

RESULTS

Seventy patients were tracked. During the review period, these 70 patients generated a total of $2.9 million, or $42,126 per patient, in hospital charges. The net profit was $407,263 ($5790 per patient). Endoscopic services alone resulted in a loss of $424 per patient. Surgical services generated just over $300,000 in net profit.

CONCLUSIONS

Economics for only resource-intensive endoscopic procedures are not financially viable under the current health care reimbursement system. The first step to removing disincentives to performing these cost-effective procedures would appear to be an insistence that reimbursement be weighted equitably to ensure reasonable profitability.

Sedation of the pediatric and adolescent patient for GI procedures

There remains no ideal sedative for pediatric and adolescent patients undergoing gastrointestinal procedures. Instead, pediatric gastroenterologists must consider many factors, including patient age, medical history, clinical status, anxiety level, as well as targeted sedation level, to select the appropriate methods and agents to achieve optimal sedation for endoscopy. The two primary types of sedation are endoscopist-administered intravenous (IV) sedation and anesthesiologist-administered general anesthesia. If IV sedation is used, pediatric endoscopists must be prepared for children to become agitated, adding to stress for both patients and clinical staff. General anesthesia provides the advantage of complete patient immobility but also entails increased costs and utilization of hospital resources. Technical advances in electronic monitoring, both in the pediatric endoscopy suite and operating room settings, are contributing to increased patient safety. Nevertheless, sedation-related events, independent of type of sedation or regimen, represent the most common complications of pediatric endoscopy.

Cost analysis of ERCP in a university hospital

BACKGROUND

A detailed analysis of the costs of ERCP is needed to provide medical staff, hospital administrators, and health care insurers with a solid basis for decision making.

METHODS

An incremental cost analysis was performed from the hospital perspective. Cost calculations were based on a prospective registration of materials, labor time, and equipment needed to perform 204 ERCPs in a tertiary care center.

RESULTS

Annual fixed cost related to the organization of the ERCP-unit amounted to $136,213. Variable costs per procedure, including labor and material costs, amounted to $344 and $961 for diagnostic and therapeutic procedures, respectively. Average reimbursement was $221. For the actual situation in our unit, with about 900 procedures yearly and a ratio diagnostic versus therapeutic procedures of 35 to 65, a net yearly loss because of the performance of ERCP activities amounts to $608,038. Theoretical measures to decrease costs could reduce this loss to $394,798, with an average loss of $439 per procedure.

CONCLUSIONS

This analysis of costs related to performance of ERCPs clearly shows that ERCP is not sufficiently reimbursed. From our model, it appears that increasing the reimbursement rate for therapeutic procedures to $600 per procedure would generate a net positive balance.

Deep sedation with inhaled sevoflurane for pediatric outpatient gastrointestinal endoscopy

BACKGROUND

Sevoflurane is an inhaled anesthetic agent with ideal properties for achieving deep sedation during pediatric outpatient gastrointestinal endoscopy. This is a comparison of experience with this gas and other sedation methods used in the authors' hospital.

METHODS

Retrospective chart review and statistical analysis of data from children receiving inhaled sevoflurane administered by an anesthesiologist through laryngeal insufflation, intravenous propofol, or intravenous midazolam-fentanyl-ketamine in any combination to achieve deep sedation for outpatient gastrointestinal endoscopy. Anesthesia was administered in a dedicated procedure room. The intravenous drugs were administered by pediatric intensivists in the intensive care unit. The same endoscopist performed all the procedures.

RESULTS

A total of 248 procedures were reviewed (midazolam-fentanyl-ketamine 67, propofol 114, and sevoflurane 67). All patients were adequately sedated with sevoflurane, and no intravenous access was required. Time (in minutes) to awakening (midazolam-fentanyl-ketamine 47.15, propofol 36.12, sevoflurane 5.70), discharge (midazolam-fentanyl-ketamine 141.99, propofol 91.20, sevoflurane 53.34), and total time, including induction and procedure (midazolam-fentanyl-ketamine 163.97, propofol 119.40, sevoflurane 73.93), were significantly lower for sevoflurane (P < 0.01). The complication rate for sevoflurane (4.5%) was lower (P < 0.05) than for midazolam-fentanyl-ketamine (13.4%) and for propofol (17.5%). Charges for room use and medications were also lower for sevoflurane (P < 0.01). The total charges for sedation (U.S.$) were comparable for sevoflurane (688.10) and propofol (723.08) but were higher for midazolam-fentanyl-ketamine (855.10, P < 0.01).

CONCLUSIONS

Deep sedation with inhaled sevoflurane for pediatric outpatient gastrointestinal endoscopy is as safe as conventional sedation techniques, potentially less expensive, increases endoscopy unit productivity, and eliminates the inconvenience associated with obtaining intravenous access in children.

Disposable versus reusable biopsy forceps: a prospective cost evaluation

BACKGROUND

There is growing advocacy for the use of disposable medical accessories to reduce the risks of infection transmission. Their purchase costs can, however, be considered as prohibitive in an endoscopy unit operating under a cost-containment program. We therefore compared the costs of reusable and disposable biopsy forceps.

METHODS

From October 1995 to September 1997, biopsies were obtained in 7740 sessions. The evaluation of costs included purchase prices, repairs, cleaning (chemicals, equipment, technician time) and autoclaving costs in a centralized sterilization unit. For comparison, the lowest purchase price for disposable biopsy forceps was $26.90 in 1997.

RESULTS

A mean of 12 new reusable forceps were purchased every year for a total purchase price of $5460. A total of 315 biopsy sessions were performed per forceps (mean time life of 3 years per forceps, including 3 repairs). Yearly repair cost was $3308, equipment $1002, chemicals $3250, central sterilization $8333, and technician salary $4373. Total cost was $25,726 and cost per biopsy session was $6.65.

CONCLUSIONS

Total purchase and reprocessing costs for reusable biopsy forceps were 25% of those of disposable devices. The use of disposable biopsy forceps would have led to a yearly extra cost of $78,377 in the operation of our endoscopy unit.

Clinical and economic outcomes of individuals with severe peptic ulcer hemorrhage and nonbleeding visible vessel: an analysis of two prospective clinical trials

OBJECTIVE

We report the clinical outcomes and direct medical costs of 155 patients with severe peptic ulcer hemorrhage and a nonbleeding visible vessel at emergency endoscopy treated with endoscopic hemostasis or medical-surgical therapy.

METHODS

In two consecutive, prospective, randomized, controlled trials, patients were randomly assigned to endoscopic hemostasis (heater probe, bipolar electrocoagulation, or injection sclerosis) or medical-surgical treatment. Study endpoints included the incidence of severe ulcer rebleeding and emergency surgery, length of hospital stay, blood transfusion requirements, mortality rate, and direct costs of utilized health care. Direct medical costs were estimated using combined fixed and variable institutional costs for consumed resources and Medicare reimbursement rates.

RESULTS

Compared with medical-surgical treatment, endoscopically treated patients had significantly lower rates of severe ulcer rebleeding (p = 0.004), emergency surgery (p = 0.002 and p = 0.019, 0.024), and blood transfusions (p = 0.025). Observed inter-trial differences in ulcer rebleeding rates may be partially explained in a multivariate model by covariates of comorbid disease and inpatient ulcer bleeding. In both trials, length of hospital stay, mortality rates, and treatment-related complications were similar. Estimated median direct costs per patient differed: The first trial had lower costs with endoscopic hemostasis ($4254, vs $4620 for electrocoagulation and $5909 for medical-surgical treatment), yet the second trial yielded lower costs with medical-surgical treatment ($3169, vs $3477 for injection sclerosis and $4098 for heater probe).

CONCLUSIONS

Compared with medical-surgical therapy, endoscopic hemostasis for severe ulcer hemorrhage and a nonbleeding visible vessel yielded significantly better patient outcomes and was safe. This procedure may or may not yield lower direct medical costs and cost savings.