Mortality following helicopter versus ground transport of injured children

INTRODUCTION

Injured children may be transported to trauma centers by helicopter air ambulance (HAA); however, a benefit in outcomes to this expensive resource has not been consistently shown in the literature and there is concern that HAA is over-utilized. A study that adequately controls for selection biases in transport mode is needed to determine which injured children benefit from HAA. The purpose of this study was to determine if HAA impacts mortality differently in minimally and severely injured children and if there are predictors of over-triage of HAA in children that can be identified.

METHODS

Children ≤18 years of age transported by HAA or ground ambulance (GA) from scene to a trauma center were identified from the 2010-2011 National Trauma Data Bank. Analysis was stratified by Injury Severity Score (ISS) into low ISS (≤15) and high ISS (>15) groups. Following propensity score matching of HAA to GA patients, conditional multivariable logistic regression was performed to determine if transport mode independently impacted mortality in each stratum. Rates and predictors of over-triage of HAA were also determined.

RESULTS

Transport by HAA occurred in 8218 children (5574 low ISS, 2644 high ISS) and by GA in 35305 (30506 low ISS, 4799 high ISS). Overall mortality was greater in HAA patients (4.0 vs 1.4%, p<0.001). After propensity score matching, mortality was equivalent between HAA and GA for low ISS patients (0.2 vs 0.2%, p=0.82) but, for high ISS patients, mortality was lower in HAA (9.0 vs 11.1% p=0.014). On multivariable analysis, HAA was associated with decreased mortality in high ISS patients (OR=0.66, p=0.017) but not in low ISS patients (OR=1.13, p=0.73). Discharge within 24h of HAA transport occurred in 36.5% of low ISS patients versus 7.4% high ISS patients (p<0.001).

CONCLUSIONS

Based on a national cohort adjusted for nonrandom assignment of transport mode, a survival benefit to HAA transport exists only for severely injured children with ISS >15. Many children with minor injuries are transported by helicopter despite frequent dismissal within 24h and no mortality benefit.

Risk Factors for Venous Thromboembolism following Thoracolumbar Surgery: Analysis of 43,777 Patients from the American College of Surgeons National Surgical Quality Improvement Program 2005 to 2012

Study Design Retrospective clinical study of a prospectively collected, national database. Objective Determine the 30-day incidence, timing, and risk factors for venous thromboembolism (VTE) following thoracolumbar spine surgery. Methods The American College of Surgeons National Surgical Quality Improvement Program Participant Use File identified 43,777 patients who underwent thoracolumbar surgery from 2005 to 2012. Multiple patient characteristics were identified. The incidence and timing (in days) of deep vein thrombosis (DVT) and pulmonary embolus (PE) were determined. Multivariable regression analysis was performed to identify significant risk factors. Results Of the 43,777 patients identified as having had thoracolumbar surgery, 202 cases of PE (0.5%) and 311 cases of DVT (0.7%) were identified. VTE rates were highest in patients undergoing corpectomy, with a 1.7% PE rate and a 3.8% DVT rate. Independent risk factors for VTE included length of stay (LOS) ≥ 6 days (odds ratio [OR] 4.07), disseminated cancer (OR 1.77), white blood cell count > 12 (OR 1.76), paraplegia (OR 1.75), albumin < 3 (OR 1.73), American Society of Anesthesiologists class 4 or greater (OR 1.54), body mass index > 40 (OR 1.49), and operative time > 193 minutes (OR 1.43). LOS < 3 days was protective (OR 0.427). Conclusions We report an overall 30-day PE rate of 0.5% and DVT rate of 0.7% following thoracolumbar spine surgery. Patients undergoing corpectomy were at highest risk for VTE. Multiple VTE risk factors were identified. Further studies are needed to develop algorithms to stratify VTE risk and direct prophylaxis accordingly.

Readability of discharge summaries: with what level of information are we dismissing our patients?

BACKGROUND

We assessed the health literacy of trauma discharge summaries and hypothesize that they are written at higher-than-recommended grade levels.

METHODS

The Flesch-Kincaid grade level (FKGL) and Flesch reading ease scores (FRES), 2 universally accepted scales for evaluating readability of medical information, were used.

RESULTS

A total of 497 patients were included. The mean patient age was 56 ± 22 years. Average FKGL and FRES were 10 ± 1 and 44 ± 7, including 132 summaries classified as very or fairly difficult to read. A total of 204 (65%) patients had functional reading skills at grade levels below the FKGL of their dismissal note; only 74 patients (24%) had the reading skills to adequately comprehend their dismissal summary. Total 30-day readmissions were 40, 65% of whom were patients with inadequate literacy for dismissal summary comprehension.

CONCLUSIONS

Patient discharge notes are written at too advanced of an educational level. To ensure patient comprehension, dismissal notes should be rewritten to a 6th-grade level.

The Changing Landscape of Vestibular Schwannoma Management in the United States--A Shift Toward Conservatism

OBJECTIVE

To characterize the evolving management of vestibular schwannoma (VS) in the United States.

STUDY DESIGN

Retrospective analysis of the Surveillance, Epidemiology, and End Results (SEER) database.

SETTING

SEER database.

SUBJECTS AND METHODS

All patients with a diagnosis of VS were analyzed. Data were described and compared using trend analyses and univariate and multivariable logistic regression.

RESULTS

A total of 8330 patients (average age 54.7 years, 51.9% female) were analyzed. The mean incidence was approximately 1.1 per 100,000 per year and did not vary significantly across time; however, from 2004 to 2011, there was a statistically significant decrease in tumor size category at time of diagnosis (P < .01). Overall, 3982 patients (48%) received primary microsurgery, 1978 (24%) radiation therapy alone, and 2370 (29%) observation. Within the microsurgical cohort, 732 (18%) underwent subtotal resection, and of those, 98 (13.4%) received postoperative radiation therapy. Multivariable regression revealed that surgical treatment was more common in younger patients and larger tumor size categories (P < .05). Management trend analysis revealed that microsurgery was used less frequently over time (P < .0001), observation was used more frequently (P < .0001), and the pattern of radiation therapy remained unchanged. Linear regression was used to create an equation that was applied to predict future management practices. These data predict that by 2026, half of all cases of VS will be managed initially with observation.

CONCLUSION

While the incidence of VS has remained steady, tumor size at time of diagnosis has decreased over time. Within the United States there has been a clear, recent evolution in management toward observation.

Clinical Risk Score to Predict Pancreatic Fistula after Pancreatoduodenectomy: Independent External Validation for Open and Laparoscopic Approaches

BACKGROUND

A clinical risk score for pancreatic fistula (CRS-PF) was recently reported to predict postoperative pancreatic fistula (POPF) after pancreatoduodenectomy (PD). An independent external validation has not been performed. Our hypothesis was that CRS-PF predicts POPF after both laparoscopic and open PD.

STUDY DESIGN

The CRS-PF was calculated from a retrospective review of patients undergoing PD from January 2007 to February 2014. Postoperative pancreatic fistula was graded using International Study Group of Pancreatic Fistula criteria. Grade B and C leaks were defined as clinically significant. Performance was measured based on sensitivity, specificity, positive and negative predictive value, accuracy, and R(2).

RESULTS

There were 808 patients who met inclusion criteria; 539 (66.7%) had open and 269 (33.3%) had laparoscopic PD. The CRS-PF was high risk in 134 patients, intermediate in 492, low in 135, and negligible in 47. Postoperative pancreatic fistula occurred in 191 (23.6%) patients (grade A, 3.8%; B, 14.2%; and C, 5.6%), and it increased with risk category (R(2) = 0.935 all, 0.898 open, and 0.968 laparoscopic). High and intermediate risk categories were combined and classified as "test positive," and negligible and low risk categories were combined and classified "test negative," resulting in a CRS-PF with a sensitivity of 95% and a negative predictive value of 96% for predicting POPF. Contrary to previous studies, grade A POPF increased with increasing CRS-PF and POPF did not correlate with estimated blood loss (R(2) = 0.04).

CONCLUSIONS

The CRS-PF was validated independently by predicting POPF for both laparoscopic and open PD. Predictive performance was at least as good for laparoscopic PD as for open PD. Lack of correlation with estimated blood loss suggests CRS-PF might be tailored for improved performance. The CRS-PF is a clinically useful tool for POPF risk stratification after PD and allows for targeted intra- and postoperative measures to address patients at increased risk.

A comparison of two quality measurement tools in pediatric surgery--the American College of Surgeons National Surgical Quality Improvement Program-Pediatric versus the Agency for Healthcare Research and Quality Pediatric Quality Indicators

BACKGROUND/PURPOSE

Identifying quality in pediatric surgery can be difficult given the low frequency of postoperative complications. We compared postoperative events following pediatric surgical procedures at a single institution identified by ACS-NSQIP Pediatric (ACS NSQIP-P) methodology and AHRQ Pediatric Quality Indicators (AHRQ PDIs), an administrative tool.

METHODS

AHRQ PDI algorithms were run on inpatient hospital discharge abstracts for 1257 children in the 2010 to 2013 ACS NSQIP-P at our institution. Four events-pulmonary complications, postoperative sepsis, wound dehiscence and bleeding-were matched between ACS NSQIP-P and AHRQ PDI.

RESULTS

Events were identified by ACS NSQIP-P in 7.9% of children and by AHRQ PDI in 8.0%. The four matched events were identified in 5.5% and 3.7%, respectively. Specificities of AHRQ PDI ranged from 97% to 100% and sensitivities from 0 to 2%. The largest discrepancy was in bleeding, where AHRQ PDI captured 1 of the 54 events identified by ACS NSQIP-P. None of the 41 pulmonary, sepsis, and wound dehiscence events identified by AHRQ PDI were clinically relevant according to ACS NSQIP-P.

CONCLUSIONS

Adverse events following pediatric surgery are infrequent; thus, additional measures of quality to supplement postoperative adverse events are needed. AHRQ PDIs are inadequate for assessing quality in pediatric surgery.

Surgical site infections (SSIs) after stoma reversal (SR): risk factors, implications, and protective strategies

BACKGROUND

Stoma reversals (SRs) are commonly performed with potentially significant postoperative complications including surgical site infections (SSIs). Our aim was to determine the incidence and risk factors for SSIs in a large cohort of SR patients.

DESIGN

We reviewed our institutional 2006-2011 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database for 30-day SSIs in patients undergoing SR. Records were additionally reviewed for 10 non-ACS-NSQIP variables. The primary outcome was SSI after SR. Secondary outcomes were additional 30-day postoperative complications and length-of-stay. Predictors of SSIs were identified using multivariable logistic regression.

RESULTS

From 528 SR patients, 36 patients developed a SSI (6.8 %). Most patients underwent SR for loop ileostomies (76.5 %) after index operations for ulcerative colitis (38.6 %) and colorectal cancer (27.8 %). SSI patients had fewer subcutaneous drains compared to patients with no SSI and had significantly higher rates of smoking, ASA 3-4 classification and laparotomies at SR (p < 0.05). Patients with SSI had increased length-of-stay and 30-day morbidities including sepsis and returns to the operating room (p < 0.05) compared to no-SSI patients. On multivariable analysis, subcutaneous drain placement was suggestive of SSI protection (odds ratio [OR] 0.52, 95 % confidence interval [CI] 0.2-1.1), but only smoking was significantly associated with an increased risk for SSI (OR 2.4, 95 % CI 1.1-5.4).

CONCLUSIONS

Smoking increased the risk of SR SSIs in patients by over twofold, and SR SSIs are associated with additional significant morbidities. Smoking cessation should be an important part of any SSI risk-reduction strategy.

Benchmarks for splenectomy in pediatric trauma: how are we doing?

BACKGROUND/PURPOSE

Following publication of American Pediatric Surgical Association (APSA) hospital benchmarks for the operative management of blunt splenic trauma in specialized centers, it was found that most hospitals exceeded these benchmarks. We sought to determine if benchmarks were being met a decade later and to identify factors associated with splenectomy in injured children.

METHODS

Rates of splenic procedures were calculated for children≤19 with a blunt splenic injury (ICD-9 865) using the 2010-2011 National Trauma Data Bank. Multivariable analysis was performed to determine independent predictors of splenectomy.

RESULTS

Of 8597 children, 24.3% received care at pediatric trauma centers (PTC), 34.6% at adult trauma centers (ATC), and the remaining 41.2% at other centers (OTC). The overall operative rate was 9.2% (3.9% if age≤14, 6.7% if ≤17). Operative rates were higher in children treated at ATC and OTC when compared to PTC. On multivariable analysis, age>14, coexisting injuries, severity of splenic injury, and care at ATC or OTC were predictive of undergoing operative treatment.

CONCLUSIONS

Operative rates for splenic injuries meet APSA benchmarks at PTC yet remain high at other centers. Care at an ATC or OTC is associated with greater odds of operative management after adjustment for age and injury severity.

Effect of multiple chronic diseases on health care expenditures in childhood

OBJECTIVES

To examine multiple chronic conditions and related health care expenditures in children.

METHODS

Retrospective cohort study of all dependents of Mayo Clinic employees aged 0-17 on Jan 1, 2004 with continuous health benefits coverage for 4 years (N=14,727). Chronic conditions, health care utilization, and associated expenditures were obtained from medical and pharmacy claims.

RESULTS

The most prevalent chronic conditions were asthma/chronic obstructive pulmonary disease (12%), allergic rhinitis (11%), and behavior problems (9%). The most costly conditions were congenital anomalies, asthma/chronic obstructive pulmonary disease, and behavior problems ($9602, $4335, and $5378 annual cost per child, respectively). Annual health care expenditures increased substantially with the number of chronic conditions, and a small proportion of children with multiple chronic conditions accounted for a large proportion of health care costs. In addition, those with multiple chronic conditions were more likely to persist in the top 10th percentile spender group in year-to-year spending.

CONCLUSION

Children with multiple chronic conditions accounted for a large proportion of health care expenditures. These children were also likely to persist as high spenders in the 4-year time frame. Further research into effective ways to manage the health care delivery for children with multiple chronic conditions is needed.

Decline in ACEI/ARB Prescribing as Heart Failure Core Metrics Improve During Computer-Based Clinical Decision Support

Computer-based clinical decision-support systems are effective interventions to improve compliance with guidelines and quality measures. However, understanding of their long-term impact, including unintended consequences, is limited. The authors assessed the clinical impact of the sequential implementation of 2 such systems to improve the use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEIs/ARBs) in inpatients with heart failure. Compliance with the core measure improved from 91.0% at baseline to 93.6% with the Pharmacy Care (P-Care) Rule and to 96.4% with the Centricity-Blaze (CE-Blaze) Rule. At the same time, prescriptions for ACEIs/ARBs documented in the hospital discharge summary decreased from 83.2% at baseline to 75.8% with the P-Care rule and to 64.1% with the CE-Blaze Rule. The inpatient mortality rate and the 30-day readmission rate did not change significantly. Better documentation of contraindications in the electronic medical record seems to account for the core measure improvement, even as ACEI/ARB therapy has unexpectedly declined.

Episode-based payment: evaluating the impact on chronic conditions

BACKGROUND

Policy makers are interested in aggregating fee-for-service reimbursement into episode-based bundle payments, hoping it will lead to greater efficiency in the provision of care. The focus of bundled payment initiatives has been upon surgical or discrete procedures. Relatively little is known about calculating and implementing episode-based payments for chronic conditions.

OBJECTIVE

Compare the differences in two different episode-creation algorithms for two common chronic conditions: diabetes and coronary artery disease (CAD).

STUDY DESIGN

We conducted a retrospective evaluation using enrollees with continuous coverage in a self-funded plan from 2003 to 2006, meeting Healthcare Effectiveness Data and Information Set (HEDIS) criteria for diabetes or CAD. For each condition, an annual episode-based payment was assessed using two algorithms: Episode Treatment Groups (ETGs) and the Prometheus model.

PRINCIPAL FINDINGS

We began with 1,580 diabetes patients with a 4-year total payment mean of $67,280. ETGs identified 1,447 (92%) as having diabetes with 4-year episode-based mean payments of $12,731; while the Prometheus model identified 1,512 (96%) as having diabetes, but included only 1,195 of them in the Prometheus model with mean diabetes payments of $23,250. Beginning with 1,644 CAD patients with a 4-year total payment mean of $65,661, ETGs identified 983 patients (60%) with a 4-year episode-based mean of $24,362. The Prometheus model identified 1,135 (69%) as CAD patients with 948 CAD patients having a mean of $26,536.

CONCLUSIONS

The two episode-based methods identify different patients with these two chronic conditions. In addition, there are significant differences in the episode-based payment estimates for diabetes, but similar estimates for CAD. Implementing episode-based payments for chronic conditions is challenging, and thoughtful discussions are needed to determine appropriate payments.

The asthma ePrompt: a novel electronic solution for chronic disease management

OBJECTIVE

This study tested the ability of an electronic prompt to promote an asthma assessment during primary care visits.

METHODS

We performed a prospective study of all eligible adult patients with previously diagnosed asthma in three geographically distinct ambulatory family medicine clinics within a 4-month period. The usual clinic visit process was performed at two geographically distinct control sites (n = 75 and n = 55 patients, respectively). The intervention group site (n = 64) had an electronic flag embedded in the Patient Check-in Locator field which prompted the distribution of a self-administered Asthma Management Questionnaire (AMQ) in the waiting room. The primary outcome measure was a documented asthma severity assessment.

RESULTS

The front desk distributed the AMQ successfully in 100% of possible opportunities and the AMQ was completed by 84% of patients. Providers in the intervention group were significantly more likely than providers in the two non-intervention groups to document asthma severity in the medical record during a non-asthma ambulatory clinic visit (63.3% vs. 18.7% vs. 3.6%; p < .001).

CONCLUSION

The provision of standardized asthma information triggered by an electronic prompt at the time of check-in effectively initiates an asthma assessment during the primary care visits.

Direct costs of bipolar disorder versus other chronic conditions: an employer-based health plan analysis

OBJECTIVE

This study was a retrospective data-based analysis of health care utilization and costs for patients diagnosed as having bipolar disorder compared with patients with diagnoses of depression, diabetes, coronary artery disease, or asthma.

METHODS

Data were from an employer-based health plan. Consistent diagnosis and continuous enrollment from 2004 to 2007 were used to identify the study population (total N = 7,511), including those with bipolar disorder (N = 122), depression (N = 1,290), asthma (N = 2,770), coronary artery disease (N = 1,759), diabetes (N = 1,418), and diabetes with coronary artery disease (N = 455). Resource utilization quantified as cost (total, specialty care, psychiatric outpatient) and number of visits (specialty care and outpatient psychiatric care) was compared across groups.

RESULTS

Patients with bipolar disorder had higher adjusted mean per member per month (PMPM) costs than any other comparison group except for those with both diabetes and coronary artery disease. The cost was predominantly related to pharmacy costs and both inpatient and outpatient psychiatric care. A subset of 20% of patients with bipolar disorder accounted for 64% of the total costs. This subgroup of patients was more likely to be female, to have frequent hospital stays, and to have a higher number of comorbidities. Depressed patients, in contrast to bipolar disorder patients, had higher adjusted mean PMPM costs in primary care and nonpsychiatric inpatient costs.

CONCLUSIONS

Health care costs for bipolar disorder exceeded those for several common chronic illnesses. These data provide further evidence for employers, insurers, and providers to seek innovative models to deliver effective and efficient care to individuals with bipolar illness.

Direct costs of bipolar disorder versus other chronic conditions: an employer-based health plan analysis

OBJECTIVE

This study was a retrospective data-based analysis of health care utilization and costs for patients diagnosed as having bipolar disorder compared with patients with diagnoses of depression, diabetes, coronary artery disease, or asthma.

METHODS

Data were from an employer-based health plan. Consistent diagnosis and continuous enrollment from 2004 to 2007 were used to identify the study population (total N = 7,511), including those with bipolar disorder (N = 122), depression (N = 1,290), asthma (N = 2,770), coronary artery disease (N = 1,759), diabetes (N = 1,418), and diabetes with coronary artery disease (N = 455). Resource utilization quantified as cost (total, specialty care, psychiatric outpatient) and number of visits (specialty care and outpatient psychiatric care) was compared across groups.

RESULTS

Patients with bipolar disorder had higher adjusted mean per member per month (PMPM) costs than any other comparison group except for those with both diabetes and coronary artery disease. The cost was predominantly related to pharmacy costs and both inpatient and outpatient psychiatric care. A subset of 20% of patients with bipolar disorder accounted for 64% of the total costs. This subgroup of patients was more likely to be female, to have frequent hospital stays, and to have a higher number of comorbidities. Depressed patients, in contrast to bipolar disorder patients, had higher adjusted mean PMPM costs in primary care and nonpsychiatric inpatient costs.

CONCLUSIONS

Health care costs for bipolar disorder exceeded those for several common chronic illnesses. These data provide further evidence for employers, insurers, and providers to seek innovative models to deliver effective and efficient care to individuals with bipolar illness.

Effect of multiple chronic conditions among working-age adults

OBJECTIVE

To determine the longitudinal effect on healthcare costs of multiple chronic conditions among adults aged 18 to 64 years.

STUDY DESIGN

Retrospective cohort assessment of working-age employees and their dependents with continuous coverage in a self-funded health plan from January 1, 2004, to December 31, 2007. Data were obtained from health benefit enrollment files and from medical and pharmacy claims.

METHODS

Individuals were defined as having chronic conditions based on modification of a published method. The mean annual healthcare costs were estimated for individuals with 0, 1, 2, 3, 4, or 5 or more chronic conditions. The probability of persistence in high-cost categories across years was estimated for individuals in each group.

RESULTS

Overall, 75.3% of working-age adult enrollees had at least 1 chronic condition, 54.3% had multiple chronic conditions, and 16.5% had 5 or more chronic conditions. The cost of healthcare was higher among individuals with more chronic conditions for all ages. The mean medical cost per year for an individual with no chronic conditions was $2137, while that for an individual with 5 or more chronic conditions was $21,183. Enrollees with more chronic conditions had higher persistence in high-cost categories between years and persisted at these high costs for more years.

CONCLUSIONS

While multiple chronic conditions are common in the population 65 years and older, they are also of great concern for the working-age population. Understanding how to effectively manage individuals with multiple chronic conditions is an important challenge. Effective care management focused on managing the patient as opposed to a condition has the potential to significantly affect healthcare costs.

Body mass index and the impact on hospital resource use in patients undergoing total knee arthroplasty

We identified all total knee arthroplasty patients between 1996 and 2004 and classified them by preoperative body mass index (BMI) as normal (BMI, 18.5-24.9 kg/m(2)), overweight (BMI, 25.0-29.9 kg/m(2)), obese (30-34.9 kg/m(2)), or morbidly obese (≥ 35.0 kg/m(2)). Of 5521 patients, 769 had a normal BMI, 1938 were overweight, 1539 were obese, and 1275 were morbidly obese. Adjusted length of stay was no different between normal (4.85 days), overweight (4.84 days), obese (4.86 days), or morbidly obese patients (4.93 days) (P = .30). Overall costs were similar among normal ($15,386), overweight ($15,430), obese ($15,646), or morbidly obese patients ($15,752) (P = .24). Postsurgical costs were no different among normal ($9860), overweight ($9889), obese ($10,063), or morbidly obese patients ($10,136) (P = .44). Our results suggest that increased BMI does not lead to increased hospital resource use for total knee arthroplasty.

Long-term medication adherence after myocardial infarction: experience of a community

BACKGROUND

Adherence to evidence-based medications after myocardial infarction is associated with improved outcomes. However, long-term data on factors affecting medication adherence after myocardial infarction are lacking.

METHODS

Olmsted County residents hospitalized with myocardial infarction from 1997-2006 were identified. Adherence to HMG-CoA reductase inhibitors (statins), beta blockers, angiotensin-converting enzyme inhibitors, and angiotensin II receptor blockers, were examined. Cox proportional hazard regression was used to determine the factors associated with medication adherence over time.

RESULTS

Among 292 subjects with incident myocardial infarction (63% men, mean age 65 years), patients were followed for an average of 52+/-31 months. Adherence to guideline-recommended medications decreased over time, with 3-year medication continuation rates of 44%, 48%, and 43% for statins, beta-blockers, and angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, respectively. Enrollment in a cardiac rehabilitation program was associated with an improved likelihood of continuing medications, with adjusted hazard ratio (95% confidence interval) for discontinuation of statins and beta-blockers among cardiac rehabilitation participants of 0.66 (0.45-0.92) and 0.70 (0.49-0.98), respectively. Smoking at the time of myocardial infarction was associated with a decreased likelihood of continuing medications, although results did not reach statistical significance. There were no observed associations between demographic characteristics, clinical characteristics of the myocardial infarction, and medication adherence.

CONCLUSIONS

After myocardial infarction, a large proportion of patients discontinue use of medications over time. Enrollment in cardiac rehabilitation after myocardial infarction is associated with improved medication adherence.

The net value of health care for patients with type 2 diabetes, 1997 to 2005

BACKGROUND

The net economic value of increased health care spending remains unclear, especially for chronic diseases.

OBJECTIVE

To assess the net value of health care for patients with type 2 diabetes.

DESIGN

Economic analysis of observational cohort data.

SETTING

Mayo Clinic, Rochester, Minnesota, a not-for-profit integrated health care delivery system.

PATIENTS

613 patients with type 2 diabetes.

MEASUREMENTS

Changes in inflation-adjusted annual health care spending and in health status between 1997 and 2005 (with health status defined as 10-year cardiovascular risk), holding age and diabetes duration constant across the observation period ("modifiable risk"), and simulated outcomes for all diabetes complications based on the UKPDS (United Kingdom Perspective Diabetes Study) Outcomes Model. Net value was estimated as the present discounted monetary value of improved survival and avoided treatment spending for coronary heart disease minus the increase in annual spending per patient.

RESULTS

Assuming that 1 life-year is worth $200,000 and accounting for changes in modifiable cardiovascular risk, the net value of changes in health care for patients with type 2 diabetes was $10,911 per patient (95% CI, -$8480 to $33,402) between 1997 and 2005, a positive dollar value that suggests the value of health care has improved despite increased spending. A second approach based on diabetes complications yielded a net value of $6931 per patient (CI, -$186,901 to $211,980).

LIMITATION

The patient population was homogeneous and small, and the wide CIs of the estimates are compatible with a decrease as well as an increase in value.

CONCLUSION

The economic value of improvements in health status for patients with type 2 diabetes seems to exceed or equal increases in health care spending, suggesting that those increases were worth the extra cost. However, the possibility that society is getting less value for its money could not be statistically excluded, and there is opportunity to improve the value of diabetes-related health care.

PRIMARY FUNDING SOURCE

None.

Cost savings of hip arthroplasty patients on specialized orthopedic surgery units

We retrospectively compared resource use of 2 groups of patients who underwent total hip arthroplasty between 1996 and 2004: those cared for on specialized orthopedic surgery (SOS) units and those cared for on nonorthopedic nursing (NON) units. Of 5546 patients, 5275 (95.1%) were admitted to SOS units and 271 (4.9%) to NON units. Mean overall adjusted cost saving for SOS patients was $622 (SD, $315; 95% CI, $3, $1241). Mean blood bank and room-and-board costs were lower on SOS units: $110 (SD, $36; 95% CI, $40, $181) and $298 (SD, $118; 95% CI, $66, $530), respectively. Difference in length of stay was not significant: mean, 0.19 day; SD, 0.11 day; 95% CI, -0.02 day, 0.40 day. Our results suggest that SOS units, as one way of optimizing patient flow in the postoperative period, may reduce unnecessary inpatients costs.

Flunking asthma? When HEDIS takes the ACT

OBJECTIVE

To test several patient-oriented asthma outcome measures and the Healthcare Effectiveness Data and Information Set (HEDIS) measure of appropriate medication for persistent asthma to determine the most useful quality indicator of asthma care.

DESIGN

Prospective mail survey of adult employees and dependents with asthma.

METHODS

The medical and pharmacy claims of all subjects from 12 months before and after the survey were abstracted. Outcomes measures included the Asthma Control Test (ACT), workday loss, unscheduled healthcare utilization (emergency department and inpatient care), and satisfaction with care.

RESULTS

Although 81% of all responders had wellcontrolled asthma, persistent asthma was uncontrolled in 28%. Only 64.5% received appropriate controller medication. Well-controlled asthma is associated with a high degree of satisfaction, less workday loss, fewer prednisone bursts, and minimal unscheduled healthcare utilization. Except for a reduced incidence of more than 2 oral corticosteroid dispensings (6.4% vs 13.6%, P = .012), compliance with the HEDIS appropriate medication for asthma was not positively associated with any of the patient-centered outcomes studied.

CONCLUSIONS

Asthma control was the most useful patient outcome quality indicator in this study. Compliance with the HEDIS asthma measure in this population was not associated with a better patient-oriented outcome. This finding may be different with different levels of asthma control. The positive association between well-controlled asthma and patient satisfaction, minimal unscheduled healthcare utilization, and low workday loss suggests that asthma control as measured by ACT may be a better performance measure in asthma.

Resource utilization of total knee arthroplasty patients cared for on specialty orthopedic surgery units

BACKGROUND

The use of specialized orthopedic surgery (SOS) units in total knee arthroplasty (TKA) patients is well established. The number and costs of arthoplasty surgeries continue to increase, requiring institutions to reexamine their existing practices for financial sustainability.

OBJECTIVE

The objective of this study was to determine whether having elective TKA patients in SOS units affects resource utilization and outcomes.

DESIGN

The study was designed to retrospectively compare elective TKA patients from 1996 to 2004 admitted directly to SOS units with those admitted to nonorthopedic nursing (NON) units.

SETTING

The setting was an academic teaching hospital.

PATIENTS

Five thousand five hundred and thirty-four patients met inclusion criteria. Of these, 5082 (patients 91.8%) were admitted to SOS units and 452 (8.2%) to NON units.

MEASUREMENTS

The primary outcomes measured were length of stay (LOS) and costs, adjusted for age, sex, surgical year, comorbidities, and American Society of Anesthesiologists status. Secondary outcomes were 30-day mortality, readmissions, reoperations, and discharge disposition.

RESULTS

Mean age of the patients in SOS and NON units was 68.3 and 67.9 years, respectively (P = .50). Adjusted LOS was 0.234 days shorter in SOS units (95% CI: 0.083, 0.385). Adjusted total and hospital cost savings in the SOS unit group were $600 (95% CI: $122, $1079) and $594 (95% CI: $141, $1047), respectively. More NON-unit patients required unanticipated transfers to the intensive care unit (ICU) from the general postoperative nursing unit (3.1% vs. 1.63%; P = .023); however, the mean number of ICU days did not differ between groups. NON-unit patients were more likely to be discharged with home health care (P < .001). There were no differences in 30-day outcomes.

CONCLUSIONS

Patients on SOS units following elective TKA have a reduced LOS and decreased total and hospital costs. Our results should encourage hospitals to reevaluate postoperative patient flow to optimize resource utilization.

Retrospective cost analysis comparing Essure hysteroscopic sterilization and laparoscopic bilateral tubal coagulation

STUDY OBJECTIVE

To compare the institutional cost of permanent female sterilization by Essure hysteroscopic sterilization and laparoscopic bilateral coagulation.

DESIGN

Retrospective cohort study (Canadian Task Force classification II-2).

SETTING

Midwestern academic medical center.

PATIENTS

Women of reproductive age who elected for permanent contraception by the Essure method (n = 43) or by laparoscopic tubal coagulation (n = 44) during the time frame studied.

INTERVENTIONS

Placement of the Essure inserts according to the manufacturer's instructions or laparoscopic tubal sterilization using bipolar forceps according to standard techniques of open or closed laparoscopy.

MEASUREMENTS AND MAIN RESULTS

Cost-center data for the institutional cost of the procedure was abstracted for each patient included in the study. In addition, demographic data and procedural information were obtained and compared for the patient populations. The Essure system of hysteroscopic sterilization had a significantly decreased cost compared with laparoscopic tubal sterilization when both procedures were performed in an operating room setting. The decrease per patient in institutional cost was 180 dollars (p = .038). This included the cost of the confirmatory hysterosalpingogram 3 months after Essure placement and the cost of laparoscopic tubal occlusion by Filshie clip if the Essure micro-inserts could not be placed. The majority of the cost was related to hospital costs as opposed to physician costs. The Essure procedure had higher costs for disposable equipment (p <.0001), but this was offset by higher charges for operating room costs, which included the recovery room (p <.0001) and pharmacy costs (p <.0001) in the patients in the laparoscopy group.

CONCLUSION

In our setting, the Essure hysteroscopic sterilization had significant cost savings compared with laparoscopic tubal sterilization (p = .038). We believe that our data represent the minimum of potential savings using this approach, and future developments will only increase the cost difference found in our study.