Lowering hospital charges in the trauma intensive care unit while maintaining quality of care by increasing resident and attending physician awareness

Surgical teaching does not increase the risk of intraoperative adverse events

INTRODUCTION

Training and teaching are cornerstones in developing surgical skills. The present study aimed to compare intraoperative outcomes of colonic resections among fellows, consultants, and supervised trainees.

METHODS

Data of consecutive colonic resections including demographics, surgical details, and intraoperative outcomes were recorded in a prospectively maintained institutional database. All procedures were standardized and divided in three groups according to the main surgeons experience (fellow or consultant) and whether the procedure was taught. After weighting by inverse treatment probability, intraoperative adverse events including reactive conversion, blood loss, and operating time were compared between these three groups.

RESULTS

Six hundred sixty-four colectomies were analyzed between January 2014 and October 2017. Among them, 289 (43.5%) were taught. After weighted propensity score analysis, there was no difference between the three groups (fellow taken as reference), for intraoperative adverse event rate (odd ratio (OR) consultant 1.448 (IQR 0.728-2.878), p = 0.282; OR teaching 0.689 (IQR 0.295-1.609), p = 0.381), operating time (beta coefficient 0.76 (- 21.91-23.42), p = 0.947; beta coefficient - 10.79 (- 28.34-6.75), p = 0.919), conversion rates (OR 0.748 (0.329-1.515), p = 0.412; OR 1.025 (0.537-1.954), p = 0.940), pre-emptive conversion (OR 1.994 (0.198-20.032), p = 0.552; OR 0.659 (0.145-2.991), p = 0.583), intraoperative blood loss (beta coefficient 21.19 (- 25.87-68.25), p = 0.368; beta coefficient - 12.34 (- 56.13-31.44), p = 0.573), intraoperative transfusion (OR 1.962 (0.813-4.735), p = 0.127; OR 0.670 (0.260-1.727), p = 0.397), and rates of unusual bleeding (OR 1.273 (0.698-2.321), p = 0.422; OR 0.572 (0.290-1.126), p = 0.099). Time to preemptive conversion was shorter when procedures were performed by consultants (beta coefficient - 25.51 (- 47.71 to - 3.31), p = 0.025), while no difference was found for the teaching group (beta coefficient 4.48 (- 30.95-40.62), p = 0.788).

CONCLUSION

Within a standardized teaching environment, colonic resections were safely performed regardless of the surgical setting in the present cohort. Teaching does not increase intraoperative adverse events.

Prospective Observational Study on High-Value Care Topics Discussed on Multidisciplinary Rounds

OBJECTIVES

Establishing a high-value care (HVC) culture within an institution requires a multidisciplinary commitment and participation. Bedside rounds provide an ideal environment for role modeling and learning behaviors that promote an HVC culture. However, little is understood regarding the types of HVC discussions that take place at the bedside and who participates in those discussions.

METHODS

A prospective observational study at a tertiary-care, university-affiliated, free-standing children's hospital. The prevalence of HVC discussions was captured by using the HVC Rounding Tool, a previously developed instrument with established validity evidence. For each observed HVC discussion, raters recorded who initiated the discussion and a description of the topic.

RESULTS

Raters observed 660 patient encounters over 59 separate dates. Of all patient encounters, 29% (191 of 660; 95% confidence interval: 26%-33%) included at least 1 observed HVC discussion. The attending physician or fellow initiated 41% of all HVC discussions, followed by residents or medical students (31%), families (12%), and nurses (7%).

CONCLUSIONS

Despite a recent focus on improving health care value and educating trainees in the practice of HVC, our study demonstrated that bedside discussions of HVC are occurring with a limited frequency at our institution and that attending physicians initiate the majority of discussions. The capacity of the nonphysician team members to contribute to establishing and sustaining an HVC culture may be underused. Multi-institutional studies are necessary to determine if this is a national trend and whether discussions have an impact on patient outcomes and hospital costs.

Surgical Cost Disclosure May Reduce Operating Room Expenditures

Health care expenditures are rising in the United States. Recent policy changes are attempting to reduce spending through the development of value-based payment systems that rely heavily on cost transparency. This study was conducted to investigate whether cost disclosure influences surgeons to reduce operating room expenditures. Beginning in 2012, surgeon scorecards were distributed at a regional health care system. The scorecard reported the actual direct supply cost per case for a specific procedure and compared each surgeon's data with those of other surgeons in the same subspecialty. Rotator cuff repair was chosen for analysis. Actual direct supply cost per case was calculated quarterly and collected over a 2-year period. Surgeons were given a questionnaire to determine their interest in the scorecard. Actual direct supply cost per rotator cuff repair procedure decreased by $269 during the study period. A strong correlation (R²=0.77) between introduction of the scorecards and cost containment was observed. During the study period, a total of $39,831 was saved. Of the surgeons who were queried, 89% were interested in the scorecard and 56% altered their practice as a result. Disclosure of surgical costs may be an effective way to control operating room spending. The findings suggest that providing physicians with knowledge about their surgical charges can alter per-case expenditures. [Orthopedics. 2017; 40(2):e269-e274.].

Awareness of surgical costs: a multicenter cross-sectional survey

BACKGROUND

Resource scarcity continues to be an important problem in modern surgical practice. Studies in North America and Europe have found that medical professionals have limited understanding of the costs of medical care. No cost awareness studies have been undertaken in Australasia or specifically focusing on the surgical team. This study determined the cost of a range of commonly used diagnostic tests, procedures, and hospital resources associated with care of the surgical patient. The surgical teams' awareness of these costs was then assessed in a multicenter cross-sectional survey.

METHODS

In total, 14 general surgical consultants, 14 registrars, and 25 house officers working in three New Zealand hospitals were asked to estimate the costs of 14 items commonly associated with patient care. Cost estimations were considered correct if within 25% plus or minus of the actual cost. Accuracy was assessed by calculating the median, mean, and absolute percentage discrepancy.

RESULTS

A total of 57 surveys were completed. Of which, four were incomplete and were not included in the analysis. Cost awareness was generally poor, and members of the surgical team were rarely able to estimate the costs to within 25%. The mean absolute percentage error was 0.87 (95% CI: 0.58-1.18) and underestimates were most common. There was no significant difference in estimate accuracy between consultants, registrars, or house officers, or between consultants working in both public/private practice compared with those working in public practice alone.

CONCLUSION

There is poor awareness of surgical costs among consultant surgeons, registrars, and junior physicians working in Australasia.

Teaching cost-conscious medicine: impact of a simple educational intervention on appropriate abdominal imaging at a community-based teaching hospital

BACKGROUND

Rising costs pose a major threat to US health care. Residency programs are being asked to teach residents how to provide cost-conscious medical care.

METHODS

An educational intervention incorporating the American College of Radiology appropriateness criteria with lectures on cost-consciousness and on the actual hospital charges for abdominal imaging was implemented for residents at Scripps Mercy Hospital in San Diego, CA. We hypothesized that residents would order fewer abdominal imaging examinations for patients with complaints of abdominal pain after the intervention. We analyzed the type and number of abdominal imaging studies completed for patients admitted to the inpatient teaching service with primary abdominal complaints for 18 months before (738 patients) and 12 months following the intervention (632 patients).

RESULTS

There was a significant reduction in mean abdominal computed tomography (CT) scans per patient (1.7-1.4 studies per patient, P < .001) and total abdominal radiology studies per patient (3.1-2.7 studies per patient, P  =  .02) following the intervention. The avoidance of charges solely due to the reduction in abdominal CT scans following the intervention was $129 per patient or $81,528 in total.

CONCLUSIONS

A simple educational intervention appeared to change the radiologic test-ordering behavior of internal medicine residents. Widespread adoption of similar interventions by residency programs could result in significant savings for the health care system.

The impact of residents, interns, and attendings on inpatient laboratory ordering patterns: a report from one university's hospitalist service

PURPOSE

To examine the laboratory test ordering patterns of interns to determine the effects of more senior residents' and attendings' supervision on trainees' patterns and residents' perceptions of control in test ordering.

METHOD

In a 2007 cohort study of 2,066 patients cared for by 85 interns, 56 residents, and 27 attendings on the University of Pennsylvania general medical hospitalist service, the authors studied variation in laboratory test utilization and costs in 10,908 patient-days. Ordinary least squares regression was used to partition variance among supervised and supervising physicians. Interns and residents were surveyed about their perceived control over lab test ordering.

RESULTS

Forty-five percent (95% confidence interval [CI]: 39-53) of the variation in laboratory test utilization was attributable to interns' ordering, 26% (95% CI: 21-34) to residents, and 9% (95% CI: 7-16) to attendings; 20% (95% CI: 6-25) could not be uniquely attributed to a particular level of the care team. Similar results were obtained for variation in laboratory costs. Interns underestimated their control over laboratory test utilization, residents overestimated their control, and both groups had inaccurate assessments of their utilization relative to peers.

CONCLUSIONS

Attending faculty had relatively little impact on laboratory ordering patterns. This may reflect a consistent baseline impact of attending physicians on laboratory use, but it may also represent a missed opportunity to reduce practice variation and improve patient care. Observing variation in trainee practice patterns in the face of different supervisors represents a new approach to measuring the supervision in clinical settings.

A review of cost-effectiveness, cost-containment and economics curricula in graduate medical education

OBJECTIVE

Numerous studies performed over the last 30 years suggest that doctors have poor knowledge of the costs of medical care. In most graduate medical education programmes, trainees do not receive formal training in cost-effective medical practice.

METHODS

Comprehensive literature search of electronic bibliographic databases for articles that describe health economics, cost-containment and cost-effectiveness curricula in graduate medical education. Critical appraisal of the literature and qualitative description is presented. Heterogeneity of curricula precluded quantitative summary of data.

RESULTS

We identified 40 articles that met the inclusion criteria for this review. Internal medicine residents were the targeted learners in 27 studies (68%); Family Medicine and Surgery residents were each targeted in five studies (13%); Rehabilitation, Paediatrics and Emergency Medicine residents were each targeted in one study. In general, the methodological quality of the included studies was poor to moderate and mostly targeted knowledge of health economics or cost-containment as opposed to targeting cost-effectiveness. In terms of describing the standard curricular components, studies sufficiently described the different educational strategies (e.g. didactics, interactive, experiential, self-directed) and the component of learner assessment, but lacked the description of other elements such as needs assessment and curriculum evaluation.

CONCLUSION

Cost-effectiveness curricula in graduate medical education are lacking and clearly needed.

Physician awareness of diagnostic and nondrug therapeutic costs: a systematic review

OBJECTIVES

The aim of this study was to investigate doctors' knowledge of the relative and absolute costs of diagnostic tests, medical consumables (e.g., syringes or intravenous tubing), and healthcare visits as well as to determine factors influencing awareness.

METHODS

For this systematic review, we searched the Cochrane Library, EconoLit, EMBASE, and MEDLINE; reviewed reference lists; and had contact with authors. Studies were included if either doctors or trainees were surveyed, there were >10 survey respondents, costs of diagnostic or therapeutic items were estimated, results were expressed quantitatively, and a clear description was provided of how authors defined Accurate Estimates and determined True Cost. Two authors reviewed each article for eligibility and extracted data independently. Cost accuracy outcomes were summarized, but data were not combined due to extensive heterogeneity.

RESULTS

Fourteen articles were included in the final analysis. Cost accuracy was low; 33 percent of estimates were within 20 percent or 25 percent of true cost and 50 percent were within 50 percent or in the 50-200 percent range of the true cost. Country, year of study, level of training, and specialty did not impact accuracy. The cost of items appears to have no impact on the accuracy (Fisher's exact test, p = .41) or pattern of estimation (binomial test, p = .92).

CONCLUSIONS

Doctors have a limited understanding of diagnostic and nondrug therapeutic costs, and we could not identify anything that impacts understanding of these costs. More focus is required in the education of physicians about costs and the access to cost information.

Physician awareness of drug cost: a systematic review

BACKGROUND

Pharmaceutical costs are the fastest-growing health-care expense in most developed countries. Higher drug costs have been shown to negatively impact patient outcomes. Studies suggest that doctors have a poor understanding of pharmaceutical costs, but the data are variable and there is no consistent pattern in awareness. We designed this systematic review to investigate doctors' knowledge of the relative and absolute costs of medications and to determine the factors that influence awareness.

METHODS AND FINDINGS

Our search strategy included The Cochrane Library, EconoLit, EMBASE, and MEDLINE as well as reference lists and contact with authors who had published two or more articles on the topic or who had published within 10 y of the commencement of our review. Studies were included if: either doctors, trainees (interns or residents), or medical students were surveyed; there were more than ten survey respondents; cost of pharmaceuticals was estimated; results were expressed quantitatively; there was a clear description of how authors defined "accurate estimates"; and there was a description of how the true cost was determined. Two authors reviewed each article for eligibility and extracted data independently. Cost accuracy outcomes were summarized, but data were not combined in meta-analysis because of extensive heterogeneity. Qualitative data related to physicians and drug costs were also extracted. The final analysis included 24 articles. Cost accuracy was low; 31% of estimates were within 20% or 25% of the true cost, and fewer than 50% were accurate by any definition of cost accuracy. Methodological weaknesses were common, and studies of low methodological quality showed better cost awareness. The most important factor influencing the pattern and accuracy of estimation was the true cost of therapy. High-cost drugs were estimated more accurately than inexpensive ones (74% versus 31%, Chi-square p < 0.001). Doctors consistently overestimated the cost of inexpensive products and underestimated the cost of expensive ones (binomial test, 89/101, p < 0.001). When asked, doctors indicated that they want cost information and feel it would improve their prescribing but that it is not accessible.

CONCLUSIONS

Doctors' ignorance of costs, combined with their tendency to underestimate the price of expensive drugs and overestimate the price of inexpensive ones, demonstrate a lack of appreciation of the large difference in cost between inexpensive and expensive drugs. This discrepancy in turn could have profound implications for overall drug expenditures. Much more focus is required in the education of physicians about costs and the access to cost information. Future research should focus on the accessibility and reliability of medical cost information and whether the provision of this information is used by doctors and makes a difference to physician prescribing. Additionally, future work should strive for higher methodological standards to avoid the biases we found in the current literature, including attention to the method of assessing accuracy that allows larger absolute estimation ranges for expensive drugs.

Managing Overutilization, Quality of Care, and Sustainable Health Care Outcomes in Oman

The health care system in Oman is facing a major challenge in managing escalating health care costs. One of the reasons for the dramatic increase in health care cost is overutilization. This article explores the problem of overutilization in Oman and its effect on sustaining the quality of health care. A review of the literature is used to develop a comprehensive model in controlling overutilization that is more applicable to the health system in Oman. Efforts to control costs and increase quality are discussed for possible implementation.

Improving the ICU: part 2

ICUs are a vital but troubled component of modern health-care systems. Improving ICU performance requires that we shift from a paradigm that concentrates on individual performance, to a systems-oriented approach that emphasizes the need to assess and improve the ICU systems and processes that hinder the ability of individuals to perform their jobs well. This second part of a two-part treatise establishes a practical framework for performance improvement and examines specific strategies to improve ICU performance, including the use of information systems.

Economic aspects of severe sepsis: a review of intensive care unit costs, cost of illness and cost effectiveness of therapy

Severe sepsis remains both an important clinical challenge and an economic burden in intensive care. An estimated 750,000 cases occur each year in the US alone (300 cases per 100,000 population). Lower numbers are estimated for most European countries (e.g. Germany and Austria: 54-116 cases per year per 100,000). Sepsis patients are generally treated in intensive care units (ICUs) where close supervision and intensive care treatment by a competent team with adequate equipment can be provided. Staffing costs represent from 40% to >60% of the total ICU budget. Because of the high proportion of fixed costs in ICU treatment, the total cost of ICU care is mainly dependent on the length of ICU stay (ICU-LOS). The average total cost per ICU day is estimated at approximately 1200 Euro for countries with a highly developed healthcare system (based on various studies conducted between 1989 and 2001 and converted at 2003 currency rates). Patients with infections and severe sepsis require a prolonged ICU-LOS, resulting in higher costs of treatment compared with other ICU patients. US cost-of-illness studies focusing on direct costs per sepsis patient have yielded estimates of 34,000 Euro, whereas European studies have given lower cost estimates, ranging from 23,000 Euro to 29,000 Euro. Direct costs, however, make up only about 20-30% of the cost of illness of severe sepsis. Indirect costs associated with severe sepsis account for 70-80% of costs and arise mainly from productivity losses due to mortality. Because of increasing healthcare cost pressures worldwide, economic issues have become important for the introduction of new innovations. This is evident when introducing new biotechnology products, such as drotrecogin-alpha (activated protein C), into specific therapy for severe sepsis. Data so far suggest that when drotrecogin-alpha treatment is targeted to those patients most likely to achieve the greatest benefit, the drug is cost effective by the standards of other well accepted life-saving interventions.

Is late antibiotic prophylaxis effective in the prevention of secondary pancreatic infection?

BACKGROUND

Secondary infection of the inflamed pancreas is the principal cause of death after severe acute pancreatitis (AP). Although patients are not always managed early in the course of AP in clinical practice, prophylactic antibiotics that were used in experimental studies in rats were always initiated early after induction of pancreatitis. The effectiveness of antibiotics initiated later is unknown.

AIM

The aim of this study was to compare the effectiveness of ciprofloxacin and meropenem initiated early versus later in the course of acute necrotizing pancreatitis (ANP) in rats.

METHODS

100 Sprague-Dawley rats were studied. ANP was induced in rats by intraductal injection of 3% taurocholate. Rats were divided randomly into five groups: group I rats received normal saline as a placebo, group II and IV rats received three times daily meropenem 60 mg/kg i.p. at 2 and 24 h, respectively and group III and V rats received twice daily ciprofloxacin 50 mg/kg i.p. at 2 and 24 h, respectively, after induction. At 96 h, all rats were killed for quantitative bacteriologic study. A point-scoring system of histological features was used to evaluate the severity of pancreatitis.

RESULTS

Meropenem and ciprofloxacin initiated 2 h after induction of pancreatitis significantly reduced the prevalence of pancreatic infection (p < 0.001 and p < 0.04, respectively) as compared to controls. Neither of the antibiotics initiated later during the course of AP caused a significant decrease in pancreatic infection in rats (p > 0.05). Although the rats treated early infected less frequently than the rats treated later, the comparison reached statistical significance only in the meropenem group (p < 0.02).

CONCLUSION

Early antibiotic treatment reduces pancreatic infection more efficiently than late antibiotic treatment in ANP in rats.

Teaching resource and information management using an innovative case-based conference

Physicians play a critical role in controlling resource use in medicine. This paper describes an innovative, interdisciplinary conference that teaches housestaff and medical students about resource and information management in the hospital setting. The objectives are to help foster communication between physicians and other members of the health care team, to improve the understanding of hospital reimbursement, and to influence attitudes toward practicing cost effectiveness. The conference structure includes the following components: case presentation by the treating physician and follow-up information provided by the primary care physician, a review of the itemized hospital bill, discussion of coding issues, discussion of hospital reimbursement comparing case data to institutional and state averages, and a summary of key take-home points and lessons.

Physician impact on the total cost of care

BACKGROUND AND OBJECTIVES

Physicians' efforts at cost containment focus on decreased resource utilization and reduced length of stay. Although these efforts appear to be appropriate, little data exist to gauge their success. As such, the goal of this study is to determine trauma service cost allocations and how this information can help physicians to contain costs.

MATERIALS AND METHODS

The authors analyzed the costs for 696 trauma admissions at a level I trauma center for fiscal year 1997. Data were obtained from the hospital costing system. Costs analyzed were variable direct, fixed direct, and Indirect costs. Together, the fixed and indirect costs are referred to as "hospital overhead." Total Cost equals variable direct plus fixed direct plus indirect costs.

RESULTS

The mean variable, fixed, and indirect costs per patient were $7,998, $3,534, and $11,086, respectively. Mean total cost per patient was $22,618.

CONCLUSION

The 35% variable direct cost represents the percentage of total cost that is typically under the immediate influence of physicians, in contrast to the 65% of total cost over which physicians have little control. Physicians must gain a better understanding of cost drivers and must participate in the operations and allocations of institutional fixed direct and indirect costs if the overall cost of care is to be reduced.

Synchronization of radiograph film exposure with the inspiratory pause. Effect on the appearance of bedside chest radiographs in mechanically ventilated patients

The appearance of portable chest radiographs (CXRs) may be affected by changes in ventilation, particularly when patients are mechanically ventilated. Synchronization of the CXR with the ventilatory cycle should limit the influence of respiratory variation on the appearance of the CXR. This study evaluates the effect of synchronizing the CXR film exposure with ventilation on the appearance of the radiograph. Twenty-five patients who remained intubated postoperatively, were mechanically ventilated, and required a CXR were enrolled in this triple-blind, randomized prospective study. Each patient received one radiograph using conventional techniques and another using the interface. The sequence of the two films was randomized, and the two films were taken on the same patient within a few minutes of each other. Hence, each patient served as his own control and the position of the patient, source-film distance, intensity (Kvp), and duration of the exposure (mAs) were identical for the two films. Five board-certified radiologists were then asked to compare paired films for clarity of lines and tubes, definition of the pulmonary vasculature, visibility of the mediastinum, definition of the diaphragm, and degree of lung inflation. Radiologists were also asked to choose which films they preferred. A majority of board certified radiologists preferred CXRs taken with the interface in 21 of 25 patients (p < 0.0001). Furthermore, four of the five criteria evaluated were improved (p < 0.05) on synchronized CXRs. Synchronization of the bedside CXR with the end of inspiration ensures that they are always obtained at maximal inflation, which improves the appearance of a majority of radiographs by at least one of five criteria.

Financial impact of elimination of routine chest radiographs in a pediatric intensive care unit

OBJECTIVE

To determine the change in chest radiograph use if each chest radiograph requires a separate order and clinical indication.

DESIGN

Prospective, nonrandomized, controlled design with an intervention.

SETTING

The pediatric intensive care unit (PICU) at Primary Children's Medical Center, Salt Lake City, UT.

PATIENTS

The study comprised 3,727 PICU patients treated between 1992 and 1996.

INTERVENTIONS

A change in ordering practice: There will be no standing orders for routine daily morning chest radiographs. Each radiograph requires a written order and a clinical indication.

MEASUREMENTS AND MAIN RESULTS

During a 29-month control phase when routine daily chest radiographs were obtained for all intubated patients, 1.026 chest radiographs per patient day were performed. After the intervention, the ratio dropped to 0.653 chest radiographs per patient day, a decrease of 36.4%. This resulted in a (projected) variable cost savings of $45,476. Data were also collected for quality assurance purposes.

CONCLUSIONS

These results demonstrate the impact of an evaluation and subsequent change in radiology ordering practice in our PICU. The change resulted in decreased variability in ordering practice, fewer chest radiographs per patient, and an accompanying cost savings to our patients and payors.

Trauma service cost: the real story

OBJECTIVE

The objective was to define and characterize the costs associated with trauma care at a level I trauma center. Once the costs were identified, attending physician-led teams were designed to reduce costs within each cost center.

SUMMARY BACKGROUND DATA

The location and magnitude of the costs on a trauma service remain largely unknown. Focused cost-containment strategies remain difficult to implement because the expected return on these interventions is unknown.

METHODS

Cost center data were reviewed for the 40 major DRGs admitted for the first 6 months of the fiscal years 1996 and 1997. Data were obtained from the hospital finance department using the Transition Systems Inc. accounting system. We focused on variable direct costs, those that vary with patient volume (e.g., staff nursing expense and medical/surgical supplies). To address issues of inflation, pay raises, and changing costs, a proxy value was created for 1996 and costs were held constant for the 1997 calculation. The major services that constitute cost centers identified in the system were nursing, surgical, pharmacy, laboratory, radiology, and emergency services. Attendings were assigned to develop and oversee customized cost-reduction modalities specific to each cost center. The cost-reduction modalities used to achieve significant savings were as follows: nursing, case management approach focusing on early discharge; surgical, meeting with operating room (OR) purchasing to modify expensive behavior patterns; pharmacy, integrating clinical pharmacist with direct attending support; laboratory, enforcing protocol for lab draws; radiology, increasing the use of emergency room ultrasound and accepting outside x-rays; and emergency services, 24-hour in-house attending staff to reduce emergency room time. The surgical and emergency services cost centers predominately generate costs by the length of time care is delivered in that area.

RESULTS

For each period, data from 363 patients were compared. Mean length of stay decreased between the study periods from 8.72 to 7.06 days, while the average injury severity score was unchanged. Together, these cost centers constituted 87.4% of the total cost of care delivered. Significant cost reduction was achieved in all six variable cost centers: nursing (24%), surgical (5%), pharmacy (57%), laboratory (27), radiology (7%), and emergency (36). The mean cost per case was reduced by 25%.

CONCLUSIONS

Identification of the true cost centers and directed attending surgeon involvement are essential to the development and implementation of a successful cost-reduction process.