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Rosa PRM, Spagnól MF, Rothlisberger L, Gelain MAS, de Brida MS, Teixeira C. Internal medicine consultation for high-risk surgical patients: reflection on hospital mortality and readmission rates in a low-income country. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2023; 69:e20230468. [PMID: 37909615 PMCID: PMC10610760 DOI: 10.1590/1806-9282.20230468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/03/2023] [Indexed: 11/03/2023]
Abstract
OBJECTIVE The objective of this study was to assess the impact of internal medicine consultation on mortality, 30-day readmission, and length of stay in surgical patients. METHODS This is a retrospective descriptive study developed in a public Brazilian teaching hospital with 850 beds. RESULTS A total of 70,245 patients were admitted from 2010 to 2018 to the surgery departments. The main outcomes measured were patients' mortality, 30-day readmission, and length of stay. Mortality of high-risk patients was lower when followed by internal medicine consultation: patients with ASA≥3 (RR 0.89 [95% confidence interval (95%CI) 0.80-0.99], p=0.02), patients with ASA≥3 plus≥65 years (RR 0.88 [95%CI 0.78-0.99], p=0.04), patients with ASA≥3 plus high-risk surgery (RR 0.86 [95%CI 0.77-0.97], p=0.01), and patients with ASA≥4 plus age ≥65 years (RR 0.83 [95%CI 0.72-0.96], p=0.01). The 30-day readmission of high-risk patients was lower when followed by internal medicine consultation: patients with ≥65 years (RR 0.57 [95%CI 0.37-0.89], p=0.01) and patients with high-risk surgery (RR 0.63 [95%CI 0.46-0.57], p=0.005). The Poisson multivariate regression with adjustment in variances showed that all the variables (namely, age, ASA, morbidity index, surgery risk, and internal medicine consultation) were associated with higher mortality of patients; however, internal medicine consultation was associated with a reduction of mortality in high-risk patients (RR 0.72 [95%CI 0.65-0.84], p=0.02) and an increase of mortality in low-risk patients (RR 1.55 [95%CI 1.31-1.67], p=0.01). CONCLUSION High-risk surgical patients may benefit from perioperative internal medicine consultations, which probably decrease hospital mortality and 30-day hospital readmission.
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Affiliation(s)
| | | | | | | | | | - Cassiano Teixeira
- Universidade Federal de Ciências da Saúde de Porto Alegre, Medical School, Internal Medicine Department – Porto Alegre (RS), Brazil
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Stevens JP. Specialty Consultation Use by Pediatric Hospitalists-A New Type of Health Care Variation. JAMA Netw Open 2023; 6:e232655. [PMID: 36912843 DOI: 10.1001/jamanetworkopen.2023.2655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2023] Open
Affiliation(s)
- Jennifer P Stevens
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Division for Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Brown CS, Osborne NH, Hider A, Kemp MT, Albright J, Scheidel C, Henke PK. Assessment of Determinants of Value in Carotid Endarterectomy. Ann Vasc Surg 2022; 88:9-17. [PMID: 36058455 DOI: 10.1016/j.avsg.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 07/12/2022] [Accepted: 08/12/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Over 150,000 carotid endarterectomies (CEA) are performed annually worldwide, accounting for $900 million in the US alone. How cost/spending and quality are related is not well understood but remains an essential component in maximizing value. We sought to identify determinants of variability in hospital 90-day episode value for CEA. METHODS Medicare and private-payer admissions for CEA from January 2nd, 2014 to August 28th, 2020 were linked to retrospective clinical registry data for hospitals in Michigan performing vascular surgery. Hospital-specific risk-adjusted 30-day composite complications (defined as reoperation, new neurologic deficit, myocardial infarction, additional procedure including CEA or carotid artery stenting, readmission, or mortality) and 30-day risk-adjusted, price standardized total episode payments were used to categorize hospitals into low or high value by defining the intersection between complications and spending. RESULTS A total of 6595 patients across 39 hospitals were identified across both datasets. Patients at low-value hospitals had a higher rate of 30-day composite complications (17.9% vs 10.1%, p<0.001) driven by a significantly higher rate of reoperation (3.0% vs 1.4%, p=0.016), readmission (10.7% vs 6.2%, p=0.012), new neurologic deficit (4.6% vs 2.3%, p=0.017), and mortality (1.6% vs 0.6%, p<0.049). Mean total episode payments were $19,635 at low-value hospitals compared to $15,709 at high-value hospitals driven by index hospitalization ($10,800 vs $9587, p= 0.002), professional ($3421 vs $2827, p < 0.001), readmission ($3011 vs $1826, p < 0.001) and post-acute care payments ($2335 vs $1486, p < 0.001). Findings were similar when only including patients who did not suffer a complication. CONCLUSIONS There is tremendous variation in both quality and payments across hospitals included for CEA. Importantly, costs were higher at low-value hospitals independent of post-operative complication. There appears to be little to no relationship between total episode spending and surgical quality, suggesting that improvements in value may be possible by decreasing total episode cost without affecting surgical outcomes.
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Affiliation(s)
- Craig S Brown
- Department of Surgery, Section of Vascular Surgery, University of Michigan, Ann Arbor, MI.
| | - Nicholas H Osborne
- Department of Surgery, Section of Vascular Surgery, University of Michigan, Ann Arbor, MI
| | - Ahmad Hider
- Medical School, University of Michigan, Ann Arbor, MI
| | - Michael T Kemp
- Department of Surgery, Section of Vascular Surgery, University of Michigan, Ann Arbor, MI
| | - Jeremy Albright
- Department of Surgery, Section of Vascular Surgery, University of Michigan, Ann Arbor, MI
| | - Caleb Scheidel
- Department of Surgery, Section of Vascular Surgery, University of Michigan, Ann Arbor, MI
| | - Peter K Henke
- Department of Surgery, Section of Vascular Surgery, University of Michigan, Ann Arbor, MI
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Montero Ruiz E, Pérez Sánchez L, Rubal Bran D. Are there important differences in comorbidity between surgical and medical inpatients? REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2022; 69:203-207. [PMID: 35534385 DOI: 10.1016/j.redare.2021.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 05/01/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND AND OBJECTIVE Scientific and technological advances are changing medical practice and transforming hospitals, and both the age and comorbidities of hospitalized patients are rapidly increasing. The increasing complexity of these patients and the scant clinical differences between medical and surgical inpatients calls for changes in the organization and delivery of in-hospital care. Our objective has been to assess differences in age and comorbidity between surgical and medical inpatients. MATERIALS AND METHODS Retrospective, observational, descriptive study in patients aged ≥16 years discharged from all medical and surgical services during 2019, except for obstetrics and intensive care. All data were obtained from the hospital's minimum basic data set and analyzed using univariate analysis. RESULTS The study included 31,264 patients: 16,397 from the medical area and 14,867 from the surgical area. Those in the surgical area were 8 years younger (62.69 years [95% CI 62.4-62.98]), with a slightly higher proportion of women (OR 1.12 [95% CI 1.07-1.17]) compared to the medical area, and fewer non-scheduled admissions (OR 0.11 [95% CI 0.10-0.12]). There were no significant differences in comorbidity burden between study groups. CONCLUSIONS Patients in the surgical area have a high burden of medical comorbidity, similar to those in the medical area. This information is important for surgeons and anesthetists, and should compel hospitals to change the current organizational model.
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Affiliation(s)
- E Montero Ruiz
- Servicio de Medicina Interna, Hospital Universitario Ramón y Cajal, Madrid, Spain.
| | - L Pérez Sánchez
- Servicio de Medicina Interna, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - D Rubal Bran
- Servicio de Medicina Interna, Hospital Universitario Lucus Augusti, Lugo, Spain
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Chhabra KR, Ghaferi AA, Yang J, Thumma JR, Dimick JB, Tsai TC. Relationship Between Health Care Spending and Clinical Outcomes in Bariatric Surgery: Implications for Medicare Bundled Payments. Ann Surg 2022; 275:356-362. [PMID: 33055585 DOI: 10.1097/sla.0000000000003979] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate sources of 90-day episode spending variation in Medicare patients undergoing bariatric surgery and whether spending variation was related to quality of care. SUMMARY OF BACKGROUND DATA Medicare's bundled payments for care improvement-advanced program includes the first large-scale episodic bundling program for bariatric surgery. This voluntary program will pay bariatric programs a bonus if 90-day spending after surgery falls below a predetermined target. It is unclear what share of bariatric episode spending may be due to unnecessary variation and thus modifiable through care improvement. METHODS Retrospective analysis of fee-for-service Medicare claims data from 761 acute care hospitals providing inpatient bariatric surgery between January 1, 2011 and September 30, 2016. We measured associations between patient and hospital factors, clinical outcomes, and total Medicare spending for the 90-day bariatric surgery episode using multivariable regression models. RESULTS Of 64,537 patients, 46% underwent sleeve gastrectomy, 22% revisited the emergency department (ED) within 90 days, and 12.5% were readmitted. Average 90-day episode payments were $14,124, ranging from $12,220 at the lowest-spending quintile of hospitals to $16,887 at the highest-spending quintile. After risk adjustment, 90-day episode spending was $11,447 at the lowest quintile versus $15,380 at the highest quintile (difference $3932, P < 0.001). The largest components of spending variation were readmissions (44% of variation, or $2043 per episode), post-acute care (19% or $871), and index professional fees (15% or $450). The lowest spending hospitals had the lowest complication, ED visit, post-acute utilization, and readmission rates (P < 0.001). CONCLUSIONS AND RELEVANCE In this retrospective analysis of Medicare patients undergoing bariatric surgery, the largest components of 90-day episode spending variation are readmissions, inpatient professional fees, and post-acute care utilization. Hospitals with lower spending were associated with lower rates of complications, ED visits, post-acute utilization, and readmissions. Incentives for improving outcomes and reducing spending seem to be well-aligned in Medicare's bundled payment initiative for bariatric surgery.
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Affiliation(s)
- Karan R Chhabra
- National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Amir A Ghaferi
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Jie Yang
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Jyothi R Thumma
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Justin B Dimick
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Thomas C Tsai
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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Jarjou'i A, Mendlovic J, Dadon Z, Sneineh MA, Tabi M, Kalak G, Jarallah YR, Yinnon AM, Munter G. Availability, timeliness, documentation and quality of consultations among hospital departments: a prospective, comparative study. Isr J Health Policy Res 2021; 10:19. [PMID: 33866967 PMCID: PMC8053423 DOI: 10.1186/s13584-021-00446-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 02/10/2021] [Indexed: 01/03/2023] Open
Abstract
Background Many in-patients require care from practitioners in various disciplines. Consultations most probably have significant implications for hospitalization outcomes. Purpose To determine key aspects of consultations provided by various departments to formulate an optimal policy. Methods This study comprised two methods: first, a questionnaire was completed in 2019 by 127 physicians interns, residents and senior doctors) from the medical and surgical departments (64 from the surgical wards, 43 from the medical wards and 22 from the emergency room and General ICU) regarding the availability, timeliness and documentation rate of the consultations they received from different disciplines. The investigators rounded through the various departments that were included in the study and they accosted a sample of interns, residents and attending physicians, who were then asked to fill the questionnaire. Overall compliance of filling the questionnaire was 95%. Residents accounted for 72% of the filled questionnaires, seniors and interns accounted for 15 and 13% respectively. Second, a convenience sample of 300 electronic records of hospitalized patients (135 from the surgical wards, 129 from the Medical wards and 36 from the emergency room and General ICU) of actually carried out consultations was reviewed for validated indicators of quality for both the consultation request and response. We used a 5-point Likert scale, ranging from poor (1) to superb (5), to grade the measured parameters. Results The availability, timeliness and documentation rate for medical consultations were 4 ± 0.9, 4.1 ± 0.9 and 4.3 ± 0.9 respectively, as compared with surgical consultations 3.2 ± 1.1, 3.4 ± 1.2 and 3.6 ± 1.2 respectively (P < 0.001). The mean time (in hours) from the consultation request till documentation (of the requested consultation) by consultants in the medical and surgical departments was 3.9 ± 5.9 and 10.0 ± 15.6, respectively (P < 0.001). The quality of requests of consultations from the medical and surgical departments was 3.4 ± 1.1 and 2.8 ± 1.2, respectively (P < 0.001). Two different models of consultations are employed: while each medical department adopts several departments for medical consultations, each day’s on-call surgeon provides all the hospital’s surgical consultations. Conclusion We detected significant differences in key aspects of consultations provided by the departments. The medical model of consultations, in which each medical department adopts several other wards to which it provides consulting services upon request, should probably be adopted as a major policy decision by hospitals directors to enhance inter-departmental consultations. Supplementary Information The online version contains supplementary material available at 10.1186/s13584-021-00446-0.
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Affiliation(s)
- Amir Jarjou'i
- Internal Medicine, Shaare Zedek Medical Center, Affiliated with the Hadassah-Hebrew University School of Medicine, Jerusalem, Israel. .,Division of Internal Medicine, Shaare Zedek Medical Center, Affiliated with the Hadassah-Hebrew University School of Medicine, P.O. Box 3235, 91031, Jerusalem, Israel.
| | - Joseph Mendlovic
- Deputy CEO, Shaare Zedek Medical Center, Affiliated with the Hadassah-Hebrew University School of Medicine, Jerusalem, Israel
| | - Ziv Dadon
- Division of Internal Medicine, Shaare Zedek Medical Center, Affiliated with the Hadassah-Hebrew University School of Medicine, P.O. Box 3235, 91031, Jerusalem, Israel.,Department of Cardiology, Shaare Zedek Medical Center, Affiliated with the Hadassah-Hebrew University School of Medicine, Jerusalem, Israel
| | - Marwan Abu Sneineh
- Division of Internal Medicine, Shaare Zedek Medical Center, Affiliated with the Hadassah-Hebrew University School of Medicine, P.O. Box 3235, 91031, Jerusalem, Israel
| | - Meir Tabi
- Division of Internal Medicine, Shaare Zedek Medical Center, Affiliated with the Hadassah-Hebrew University School of Medicine, P.O. Box 3235, 91031, Jerusalem, Israel.,Department of Cardiology, Shaare Zedek Medical Center, Affiliated with the Hadassah-Hebrew University School of Medicine, Jerusalem, Israel
| | - George Kalak
- Division of Internal Medicine, Shaare Zedek Medical Center, Affiliated with the Hadassah-Hebrew University School of Medicine, P.O. Box 3235, 91031, Jerusalem, Israel
| | - Yousef R Jarallah
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Affiliated with the Hadassah-Hebrew University School of Medicine, Jerusalem, Israel
| | - Amos M Yinnon
- Division of Internal Medicine, Shaare Zedek Medical Center, Affiliated with the Hadassah-Hebrew University School of Medicine, P.O. Box 3235, 91031, Jerusalem, Israel.
| | - Gabriel Munter
- Internal Medicine, Shaare Zedek Medical Center, Affiliated with the Hadassah-Hebrew University School of Medicine, Jerusalem, Israel.,Division of Internal Medicine, Shaare Zedek Medical Center, Affiliated with the Hadassah-Hebrew University School of Medicine, P.O. Box 3235, 91031, Jerusalem, Israel
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Montero Ruiz E, Rubal Bran D. Which surgical patients require shared care? Rev Clin Esp 2020; 220:578-582. [PMID: 32534805 DOI: 10.1016/j.rce.2020.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 04/27/2020] [Accepted: 05/02/2020] [Indexed: 11/18/2022]
Abstract
Most hospitalized surgical patients have significant medical comorbidity and are treated with a considerable number of drugs and/or experience significant complications. Shared care (SC) is the shared responsibility and authority in managing hospitalized patients. In this article, we discuss whether patients should be selected for SC or not. The various selection criteria are not an exact science nor are they easy to apply. Furthermore, they may leave out many patients who may be good candidates for SC. Perioperative management is essential for preventing postoperative mortality. Failure to rescue (in-hospital mortality secondary to postoperative complications) is the main factor linked to in-hospital surgical mortality and can affect any patient regardless of age, comorbidity, or type of surgery. The component that most reduces failure to rescue is the presence of internists in surgical wards. We believe that all patients hospitalized in surgery departments should receive SC.
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Affiliation(s)
- E Montero Ruiz
- Servicio de Medicina Interna, Hospital Universitario Ramón y Cajal, Madrid, España.
| | - D Rubal Bran
- Servicio de Medicina Interna, Hospital Universitario Lucus Augusti, Lugo, España
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Montero Ruiz E, Rubal Bran D. Which surgical patients require shared care? Rev Clin Esp 2020. [DOI: 10.1016/j.rceng.2020.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ten-year Trends in Surgical Mortality, Complications, and Failure to Rescue in Medicare Beneficiaries. Ann Surg 2020; 271:855-861. [DOI: 10.1097/sla.0000000000003193] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Hospital interconsultations: A puzzle to put together. Rev Clin Esp 2018. [DOI: 10.1016/j.rceng.2018.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Casariego-Vales E, Cámera LA. Hospital interconsultations: A puzzle to put together. Rev Clin Esp 2018; 218:293-295. [PMID: 29861075 DOI: 10.1016/j.rce.2018.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 04/16/2018] [Indexed: 10/14/2022]
Affiliation(s)
- E Casariego-Vales
- Servicio de Medicina Interna, Hospital Universitario Lucus Augusti, Lugo, España.
| | - L A Cámera
- Programa de Medicina Geriátrica, Servicio de Clínica y Medicina Interna, Hospital Italiano, Buenos Aires, Argentina
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O'Connor KM, Zipes DG, Schaffzin JK, Rosenberg R. Pediatric Hospitalist Comanagement Survey of Clinical and Billing Practices. Hosp Pediatr 2017; 7:615-620. [PMID: 28882849 DOI: 10.1542/hpeds.2017-0024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Surgical comanagement is an increasingly common practice in pediatric hospital medicine. Information about the structure and financing of such care is limited. The aim of the researchers for this study was to investigate pediatric hospitalist surgical comanagement models and to assess pediatric hospitalist familiarity with and patterns of billing for surgical patients. We conducted a cross-sectional cohort web-based survey of pediatric hospitalists using the American Academy of Pediatrics' Section on Hospital Medicine listserv. In our study (N = 133), we found wide variation in our cohort in surgical patient practice management, including program structure, individual billing practices, and knowledge regarding billing practices. Even for pediatric hospitalists with comanagement service agreements between surgeons and pediatric hospitalists, there was no increased awareness or knowledge about reimbursement or billing for surgical patients. This global lack of knowledge in our small but diverse sample suggests that billing resources and training for pediatric hospitalists practicing comanagement of surgical patients are needed.
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Affiliation(s)
- Katherine M O'Connor
- Division of Pediatric Hospital Medicine, Children's Hospital at Montefiore, Bronx, New York;
| | - David G Zipes
- Peyton Manning Children's Hospital, Indianapolis, Indiana; Henry Community Health Center, New Castle, Indiana
| | - Joshua K Schaffzin
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; and
| | - Rebecca Rosenberg
- Department of Pediatrics, NYU School of Medicine and Hassenfeld Children's Hospital at NYU Langone Medical Center, New York, New York
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Pitter FT, Jørgensen CC, Lindberg-Larsen M, Kehlet H. Postoperative Morbidity and Discharge Destinations After Fast-Track Hip and Knee Arthroplasty in Patients Older Than 85 Years. Anesth Analg 2017; 122:1807-15. [PMID: 27195631 DOI: 10.1213/ane.0000000000001190] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Elderly patients are at risk of increased length of hospital stay (LOS), postoperative complications, readmission, and discharge to destinations other than home after elective total hip arthroplasty (THA) and total knee arthroplasty (TKA). Recent studies have found that enhanced recovery protocols or fast-track surgery can be safe for elderly patients undergoing these procedures and may result in reduced LOS. However, detailed studies on preoperative comorbidity and differentiation between medical and surgical postoperative morbidity in elderly patients are scarce. The aim of this study was to provide detailed information on postoperative morbidity resulting in LOS >4 days or readmissions <90 days after fast-track THA and TKA in patients ≥85 years. METHODS This is a descriptive, observational study in consecutive unselected patients ≥85 years undergoing fast-track THA/TKA. The primary outcome was the causes of postoperative morbidity leading to an LOS of >4 days. Secondary outcomes were 90-day surgically related readmissions, discharge destination, 90-day mortality, and role of disposing factors for LOS >4 days and 90-day readmissions. Data on preoperative characteristics were prospectively gathered using patient-reported questionnaires. Data on all admissions were collected using the Danish National Health Registry, ensuring complete follow-up. Any cases of LOS >4 days or readmissions were investigated through review of discharge forms or medical records. Backward stepwise logistic regression was used for analysis of association between disposing factors and LOS >4 days and 90-day readmission. RESULTS Of 13,775 procedures, 549 were performed in 522 patients ≥85 years. Median age was 87 years (interquartile range, 85-88) and median LOS of 3 days (interquartile range, 2-5). In 27.3% procedures, LOS was >4 days, with 82.7% due to medical causes, most often related to anemia requiring blood transfusion and mobilization issues. Use of walking aids was associated with LOS >4 days (odds ratio [OR], 1.99; 95% confidence interval [CI], 1.26-3.15; P = 0.003), whereas preoperative anemia showed borderline significance (OR, 1.52; 95% CI, 0.99-2.32; P = 0.057). Thirty-eight patients (6.9%) were not discharged directly home, of which 68.4% had LOS >4 days. Readmission rates were 14.2% and 17.9% within 30 and 90 days, respectively, and 75.5% of readmissions within 90 days were medical, mainly due to falls and suspected but disproved venous thromboembolic events. Preoperative anemia was associated with increased (OR, 1.81; 95% CI, 1.13-2.91; P = 0.014) and living alone with decreased (OR, 0.50; 95% CI, 0.31-0.80; P = 0.004) risk of 90-day readmissions. Ninety-day mortality was 2.0%, with 1.0% occurring during primary admission. CONCLUSIONS Fast-track THA and TKA with an LOS of median 3 days and discharge to home are feasible in most patients ≥85 years. However, further attention to pre- and postoperative anemia and the pathogenesis of medical complications is needed to improve postoperative outcomes and reduce readmissions.
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Affiliation(s)
- Frederik T Pitter
- From the *Section for Surgical Pathophysiology 4074, Rigshospitalet, Copenhagen University, Copenhagen, Denmark; †The Lundbeck Foundation Centre for Fast-track Hip and Knee Replacement, Copenhagen, Denmark; and ‡Department of Orthopedic Surgery, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
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Short MN, Ho V, Aloia TA. Impact of processes of care aimed at complication reduction on the cost of complex cancer surgery. J Surg Oncol 2015; 112:610-5. [PMID: 26391328 PMCID: PMC5396380 DOI: 10.1002/jso.24053] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 09/13/2015] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND OBJECTIVES Health care providers add multiple processes to the care of complex cancer patients, believing they prevent and/or ameliorate complications. However, the relationship between these processes, complication remediation, and expenditures is unknown. METHODS Data for patients with cancer diagnoses undergoing colectomy, rectal resection, pulmonary lobectomy, pneumonectomy, esophagectomy, and pancreatic resection were obtained from hospital and inpatient physician Medicare claims for the years 2005-2009. Risk-adjusted regression analyses measured the association between hospitalization costs and processes presumed to prevent and/or remedy complications common to high-risk procedures. RESULTS After controlling for comorbidities, analysis identified associations between increased costs and use of multiple processes, including arterial lines (4-12% higher; P < 0.001) and pulmonary artery catheters (23-33% higher; P < 0.001). Epidural analgesia was not associated with higher costs. Consultations were associated with 24-44% (P < 0.001) higher costs, and total parenteral nutrition was associated with 13-31% higher costs (P < 0.001). CONCLUSIONS Many frequently utilized processes and services presumed to avoid and/or ameliorate complications are associated with increased surgical oncology costs. This suggests that the patient-centered value of each process should be measured on a procedure-specific basis. Likewise, further attention should be focused on defining the efficacy of each of these costly, but frequently unproven, additions to perioperative care.
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Affiliation(s)
- Marah N. Short
- Baker Institute for Public Policy at Rice UniversityHoustonTexas
| | - Vivian Ho
- Baker Institute for Public Policy and Department of EconomicsRice UniversityHoustonTexas
- Department of MedicineBaylor College of MedicineHoustonTexas
| | - Thomas A. Aloia
- Department of Surgical OncologyUniversity of Texas MD Anderson Cancer CenterHoustonTexas
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Stevens JP, Nyweide D, Maresh S, Zaslavsky A, Shrank W, MD MDH, Landon BE. Variation in Inpatient Consultation Among Older Adults in the United States. J Gen Intern Med 2015; 30:992-9. [PMID: 25693650 PMCID: PMC4471009 DOI: 10.1007/s11606-015-3216-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Revised: 01/08/2015] [Accepted: 01/16/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND Differences among hospitals in the use of inpatient consultation may contribute to variation in outcomes and costs for hospitalized patients, but basic epidemiologic data on consultations nationally are lacking. OBJECTIVE The purpose of the study was to identify physician, hospital, and geographic factors that explain variation in rates of inpatient consultation. DESIGN This was a retrospective observational study. SETTING AND PARTICIPANTS This work included 3,118,080 admissions of Medicare patients to 4,501 U.S. hospitals in 2009 and 2010. MAIN MEASURES The primary outcome measured was number of consultations conducted during the hospitalization, summarized at the hospital level as the number of consultations per 1,000 Medicare admissions, or "consultation density." KEY RESULTS Consultations occurred 2.6 times per admission on average. Among non-critical access hospitals, use of consultation varied 3.6-fold across quintiles of hospitals (933 versus 3,390 consultations per 1,000 admissions, lowest versus highest quintiles, p < 0.001). Sicker patients received greater intensity of consultation (rate ratio [RR] 1.18, 95% CI 1.17-1.18 for patients admitted to ICU; and RR 1.19, 95% CI 1.18-1.20 for patients who died). However, even after controlling for patient-level factors, hospital characteristics also predicted differences in rates of consultation. For example, hospital size (large versus small, RR 1.31, 95% CI 1.25-1.37), rural location (rural versus urban, RR 0.78, CI 95% 0.76-0.80), ownership status (public versus not-for-profit, RR 0.94, 95% CI 0.91-0.97), and geographic quadrant (Northeast versus West, RR 1.17, 95% CI 1.12-1.21) all influenced the intensity of consultation use. CONCLUSIONS Hospitals exhibit marked variation in the number of consultations per admission in ways not fully explained by patient characteristics. Hospital "consultation density" may constitute an important focus for monitoring resource use for hospitals or health systems.
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Affiliation(s)
- Jennifer P. Stevens
- />Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, MA USA
- />Division for Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA USA
| | - David Nyweide
- />Center for Medicare and Medicaid Innovation, Centers for Medicare and Medicaid Services, Department of Health and Human Services, Baltimore, MD USA
| | - Sha Maresh
- />Center for Medicare and Medicaid Innovation, Centers for Medicare and Medicaid Services, Department of Health and Human Services, Baltimore, MD USA
| | - Alan Zaslavsky
- />Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave, Boston, MA 02115 USA
| | - William Shrank
- />Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - Michael D. Howell MD
- />Center for Quality, University of Chicago, Chicago, IL USA
- />Section of Pulmonary and Critical Care, University of Chicago, Chicago, IL USA
| | - Bruce E. Landon
- />Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, MA USA
- />Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave, Boston, MA 02115 USA
- />Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, MA USA
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Lamo-Espinosa J, Pascual-Roquet Jalmar E. Hospital readmission rates following primary total hip arthroplasty: present and future in sight. ANNALS OF TRANSLATIONAL MEDICINE 2015; 3:S38. [PMID: 26046085 PMCID: PMC4437938 DOI: 10.3978/j.issn.2305-5839.2015.03.33] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Accepted: 03/04/2015] [Indexed: 11/14/2022]
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