Average Daily Hospital Research Articles

A randomized, double-blind, placebo-controlled clinical study of traditional Chinese medicine syndrome differentiation in the treatment of acute ischemic stroke

Objectives The aim was to objectively evaluate the clinical efficacy of an experience prescription of Traditional Chinese Medicine(TCM) syndrome differentiation for stroke. Methods 102 patients with acute ischemic stroke were recruited. They were randomly assigned to the control group (n = 50) and the test group (n = 52). The control group was treated with western medicine and placebo. The test group was treated with western medicine and an experience prescription of TCM syndrome differentiation (antelope horn, sputum, Cynanchum otophyllum and turmeric) with addition according to the tongue coating. The two groups were treated for 14 days and followed up for 3 months. NIHSS, BI, mRS ≤ 2, complications, mortality, recurrence rate, safety indicators and economic indicators were oberserved. Results There was no statistical difference in NIHSS, BI, mRS ≤ 2, mortality and recurrence rate between the two groups on the fourteenth day and at 3-month follow-up (P > .05). The incidence of respiratory infection during the 14-day hospital stay in the test group was significantly lower than that in the control group (P = .015). After 14 days, PT, KPTT (P = .022) and INR (P = .013) in the test group were significantly higher than those in the control group in the normal range. The test group has a tendency to reduce the average daily hospitalization expenses (P = .053). Conlusions The experience prescription of TCM syndrome differentiation has no significant effect on the prognosis of acute ischemic stroke, but reduces the incidence of respiratory infection during hospitalization.

Early vs. late tracheostomy in intensive care settings: Impact on ICU and hospital costs

IntroductionUp to 12% of the 800,000 patients who undergo mechanical ventilation in the United States every year require tracheostomies. A recent systematic review showed that early tracheostomy was associated with better outcomes: more ventilator-free days, shorter ICU stays, less sedation and reduced long-term mortality. However, the financial impact of early tracheostomies remain unknown. ObjectivesTo conduct a cost-analysis on the timing of tracheostomy in mechanically ventilated patients. MethodsWe extracted individual length of hospital stay and length of ICU stay data from the studies included in the systematic review from Hosokawa et al. We also searched for any recent randomized control trials on the topic that were published after this review. The weighted length of stay was estimated using a random effects model. Average daily hospital and ICU costs per patients were obtained from a cost study by Kahn et al. We estimated hospital and ICU costs by multiplying LOS with respective average daily cost per patient. We calculated difference in costs by subtracting hospital costs, ICU costs and total direct variable costs from early tracheotomy to late tracheotomy. 95% confidence intervals were estimated using bootstrap re-sampling procedures with 1000 iterations. ResultsThe average weighted cost of ICU stay in patients with an early tracheostomy was $4316 less when compared to patients with late tracheostomy (95% CI: 403–8229). Subgroup analysis revealed that very early tracheostomies (<4days) cost on average $3672 USD less than late tracheostomies (95% CI: –1309, 10,294) and that early tracheostomies (<10days but >4) cost on average $6385 USD less than late tracheostomies (95% CI: –4396–17,165). ConclusionThis study shows that early tracheostomy can significantly reduce direct variable and likely total hospital costs in the intensive care unit based on length of stay alone. This is in addition to the already shown benefits of early tracheostomy in terms of ventilator dependent days, reduced length of stays, decreased pain, and improved communication. Further prospective studies on this topic are needed to prove the cost-effectiveness of early tracheostomy in the critically ill population.

Seasonal Variation of Hospital Admissions for Inflammatory Bowel Disease: An 11-Year Perspective in the U.S.

Introduction: There have been speculations and conflicting data regarding seasonal variations and flares of inflammatory bowel diseases (IBD). Although the etiology of IBD has not yet been determined, environmental factors have been strongly implicated. Chronic inflammation may be triggered by bacterial or viral pathogens which could be subjected to climate or changes of biorhythm. The search for environmental causative or modulating risk factors for this disease is ongoing and some of them may be connected with public and personal hygiene. This could potentially lead to seasonal variations in the natural history of IBD. The purpose of our study was to investigate any association between seasonality and exacerbations of IBD. Methods: We analyzed the data using the National Inpatient Sample (NIS) between 2001-2011. We identified IBD related hospitalizations using the International Classification of Disease (ICD -9), 9th revision, clinical modification codes 556.0 - 557 for ulcerative colitis (UC) and 555.0 - 555.9 for Crohn's disease (CD) as the primary discharge diagnoses. The mean daily hospitalizations per month were calculated for each calendar month of the year for 11 years (2001-2011). A one-way analysis of variance (anova) was then used to determine if there was any significant variability between months. Furthermore, we looked for seasonal variations by clustering months into their respective seasons, and for variation patterns among different regions in the U.S, defined as northeast, south, mid-west and westFigure 1Results: A total of 159,241 hospitalizations with primary discharge diagnosis of IBD occurred in the US from the beginning of the calendar year 2001-2011. 107, 833 were identified as Crohn's disease and 51,408 as ulcerative colitis. Mean age of the population was 43.18 ± 19.35 (mean ± SD); 56% were females and 60% were white. The average daily hospitalization per month was highest in the months of July (1396/month), august (1396/month) and lowest in the month of December (1259/month). However we did not observe any statistically significant monthly or seasonal pattern in the number of IBD related hospitalizations. This observation remained consistent as well, among the various regions of the U.S. Conclusion: Although we observed an increase in exacerbations and hospitalization rate of both UC and CD in the months of july and august, in general, these data do not support any seasonal pattern to the natural history of inflammatory bowel disease.

Profile of Hospitalizations and Deaths from Craniofacial Fractures in Brazilian Children and Adolescents: An Ecological Study

Objective: To characterize the profile of hospitalizations and deaths related to craniofacial fractures in Brazilian children and adolescents. Material and Methods: This is an ecological cross-sectional study with inductive approach with comparative-descriptive procedure and indirect documentation technique. Data were obtained from the DATASUS / SIH-SUS website for the years 2010-2014, considering information for each state of the five Brazilian regions. Admission rates were calculated per 100,000 inhabitants, and data were analyzed by population rates, averages and absolute and relative frequencies. Results: The Northeastern region of Brazil showed the highest hospitalization rate (81.72), followed by the Northern (56.84), Southern (50.94), Midwestern (44.25) and Southeastern regions (30.28). In all regions, the years with the highest hospitalization rates were: 2010 for the Northern (13.17) and Southeastern regions (6.61), 2013 for the Northeastern (20.07) and Midwestern regions (10.17) and 2014 for the Southerner region (10.52). The highest hospitalization rates in all regions of the country in the last five years were observed for male children and adolescent. In relation to age group, higher rates were recorded from 15 to 19 years. Of the total of 27,244 hospitalizations (3.8%), 1028 patients died and 35.5% of them occurred in the Northeastern region. Considering the years under study, the average length of stay and average daily hospitalization cost were respectively 4.0 days and US$ 82.7. Conclusion: The Northeast region of Brazil had the highest hospitalization rate of children and adolescents by craniofacial fractures, and male adolescents and those aged 15-19 years were the most affected in different regions of the country. Costs of hospital admissions due to this type of injury are significant, with more deaths as a result of these injuries in Brazil in the last 5 years evaluated with the highest prevalence in the Northeastern region of Brazil.

Seasonal Variation in Peptic Ulcer Disease Hospitalization: A 10-year Perspective in the U.S.

Introduction: Seasonal variation in peptic ulcer disease (PUD) has been previously reported, but has been poorly investigated due to the lack of large-scale studies and, thus, poorly understood. Methods: With the use of the Nationwide Inpatient Sample from 2000 through 2011, we identified PUDrelated hospitalizations using International Classification of Diseases (ICD-9), 9th Revision, Clinical Modification code 531.00 to 534.91 as the principal discharge diagnosis. The total number of hospitalizations for each calendar month of the year, added over 12 years period (2000-2011), was calculated and this number was divided by number of days in that particular month to obtain the mean hospitalizations per day for each month. Results: An estimated 351, 920 hospitalizations with the primary diagnosis of peptic ulcer disease (PUD) occurred in the US from the beginning of calendar year 2000-2011. Mean age of the study population was 66.2 ± 17.4 (mean ± SD); 47.5% were females and 73.9% were White. Depending on the average daily hospitalization for each calendar month of the year, the number of hospitalization was highest in the winter season and lowest in the fall season. There was a rising trend in PUD related hospitalizations from January to May (900/day to 920/ day). The average number of hospitalizations was highest in February (939/day); thereafter the hospitalization rate dropped to 845/day, to reach a nadir in November. Conclusion: A seasonal variation in PUD hospitalization shows higher incidence in the winter season and lowest in the fall season. When data was corrected by monthly admission proportion, winter periods are confirmed as higher risk periods.Figure 1

The burden of initial empiric antibiotic failure on healthcare resources for hospitalized patients with complicated intra-abdominal infections in Greece

Aim-Background: To estimate the impact of initial empiric antibiotic treatment failure on pharmacological and total healthcare costs in hospitalized patients with complicated intra–abdominal infections (cIAIs) in Greece. Methods: Adult patients with cIAIs hospitalized in 18 Greek surgical clinics over a 2-year period were included in this prospective observational study. Treatment failure was defined as the antibiotic addition or change (apart from intravenous to oral switch or de-escalation), the need for additional surgical procedure, or death. An average daily hospitalization cost was estimated based on the diagnosis at discharge and disease-related group mapping. Daily cost was then extrapolated for the incremental length of stay (LOS) associated with initial antibiotic failure. Costs included expenditure for additional intensive care unit (ICU) hospitalization and surgical interventions, and calculations followed a third party payer perspective (€2012). Results: A total of 201 patients with cIAIs met the inclusion criteria. Failure of the initial empiric antibiotic treatment was reported in 42.9% of subjects. The LOS was 21.9±16.4 and 8.9±4.5 days for “failed” versus “successful” patients, respectively. Total incremental per patient cost was estimated to be €3,761.56 inclusive of unsuccessful mean empiric antibiotic expenditure, the latter estimated at €220.06 per patient. Failure was related with previous antibiotic use, disease severity, antimicrobial resistance and co-morbidities, which in turn led to prolonged hospitalization, additional surgical procedures and hospitalization in the ICU. Conclusion: Subjects exhibiting failure of initial antibiotic treatment for cIAIs had a greater likelihood of requiring prolongation of hospitalization, increased use of healthcare resources and higher costs in an environment where resources are scarce.

HYPERBARIC OXYGEN FOR THE TREATMENT OF FOURNIER’S GANGRENE

Fournier's gangrene is a necrotizing fasciitis of the genitalia that is associated with high morbidity and mortality. Groups at many institutions have initiated routine adjuvant hyperbaric oxygen (HBO) therapy. We examined whether HBO has made a difference in the morbidity, mortality and costs associated with treating this disease. We also analyzed predictors of extended hospital stay and mortality. The records of patients with the hospital discharge diagnoses of Fournier's gangrene, necrotizing fasciitis, gangrene of the genitalia and scrotal gangrene from 1993 to 2002 were reviewed. Data concerning clinical presentation characteristics, hospital stay, complications, hospital charges and outcomes, including graft failure and death, were analyzed. A total of 42 patients were identified and followed a median 4.2 years. Of the patients 16 underwent surgical debridement and antibiotic therapy alone, and 26 were treated with HBO plus surgery and antibiotics. Overall disease specific mortality was 21.4%, that is 12.5% in the nonHBO group and 26.9% in the HBO group. Three or more complications occurred in 13% of nonHBO and in 19% of HBO cases, of which the most common was myocardial infarction. The skin graft failure rate was 6% (nonHBO) and 8% (HBO). Physical disability was a statistically significant predictor of extended hospital stay (p <0.01). There was a trend toward a correlation between known coronary artery disease and death (p = 0.2). A statistically significant difference was noted in average daily hospital charges in nonHBO vs HBO cases ($2,552 vs $3,384 daily, p <0.01). These data do not support routine HBO in the treatment of Fournier's gangrene. There was a trend toward higher morbidity and mortality in the HBO group, suggesting that treatment may have been given to patients who were more ill.

Effects of left ventricular assist devices on outcomes in patients undergoing heart transplantation

Background. Left ventricular assist devices (LVADs) are increasingly being used to “bridge” patients to heart transplantation.Methods. Data from 40 consecutive status 1 heart transplantation patients treated with intravenous inotrope therapy (n = 20) or the HeartMate LVAD (n = 20) were retrospectively analyzed.Results. Baseline clinical characteristics were similar in the two groups. At the time of transplantation, LVAD patients had significantly higher blood pressure and sodium with significantly lower blood urea nitrogen and creatinine. After transplantation, renal failure (52.6% versus 16.7%) and right heart failure (31.6% versus 5.6%) occurred more frequently (p < 0.05) in the inotrope group. Six-month survival after transplantation did not significantly differ in the inotrope or LVAD groups (73.7% versus 88.9%) but event-free survival was significantly (p < 0.05) lower in the inotrope group (15.8% versus 55.6%). Total hospital charges were significantly lower in the inotrope group ($213,860 ± $107,560 versus $342,620 ± $104,420), but average daily hospital charges were not different ($3,990 ± $1,300 versus $4,130 ± $2,050).Conclusions. Status 1 heart transplant patients treated with an LVAD as opposed to inotrope therapy have improved clinical and metabolic function at the time of transplant and improved survival to 6 months after transplant without major complications. Total costs are higher in the LVAD patients but average daily costs are similar.

Health and economic outcomes of antibiotic resistance in Pseudomonas aeruginosa.

Antimicrobial resistance is an increasing problem. To examine the clinical and economic impact of antibiotic resistance in Pseudomonas aeruginosa. In-hospital mortality, secondary bacteremia, length of stay, and hospital charges were examined in a cohort of 489 inpatients with positive clinical cultures for P aeruginosa. One hundred forty-four had a resistant baseline P aeruginosa isolate and 30 had resistance emerge during follow-up. Multivariable and survival analytic methods were used to adjust for confounding and effects of time. The overall in-hospital mortality rate was 7.6%, 7.7% in patients with a resistant isolate at baseline (relative risk [RR], 1.3; 95% confidence interval [CI], 0.6-2.8) and 27% in patients in whom resistance emerged (RR, 3.0; 95% CI, 1.2-7.8). Secondary bacteremia developed in 1.4% of patients in whom resistance did not emerge and in 14% of those in whom resistance emerged (RR, 9.0; 95% CI, 2.7-30). The median duration of hospital stay following the initial P aeruginosa isolate was 7 days. Emergence of resistance, but not baseline resistance, was significantly associated with a longer hospital stay (P<.001 and P=.71, respectively). The average daily hospital charge was $2059. Neither baseline resistance nor emergence of resistance had a significant effect on the daily hospital charge. In a matched cohort analysis, a trend was seen toward increased total charges in patients demonstrating emergence of resistance (difference, $7340; P=.14). Emergence of antibiotic resistance in P aeruginosa results in severe adverse outcomes. Efforts should be directed toward early detection and prevention of emergence of antibiotic resistance.

The impact of gunshot wounds on an orthopaedic surgical service in an urban trauma center.

To determine the prevalence of gunshot wound related orthopaedic injuries in an urban trauma center and outline the socioeconomic background of this patient population. Retrospective study conducted from January 1, 1994, through December 30, 1994. University-affiliated level 1 trauma center. Strict inclusion and exclusion criteria were established. All patients were admitted through the emergency room with a gunshot wound for which the orthopaedic surgery service was consulted. The study group consisted of 284 patients. Those individuals excluded from the study were patients with an orthopaedic injury who died during or before attempts at resuscitation in the emergency room and patients treated on an outpatient basis. Orthopaedic and nonorthopaedic diagnoses, etiology, procedures performed, number of hours from admission to the first surgical procedure, average daily hospital census, drug and alcohol screen results, and patient financial status. The orthopaedic service was consulted on 284 patients admitted with gunshot wounds. This group comprised 24% of all orthopaedic admissions, 33% of the average daily orthopaedic census, and 14% of all orthopaedic surgery cases performed. Ninety-four percent were African American and 87% were male, with a mean age of 27 years. Approximately half were tested for alcohol and/or drugs, 45% of whom were positive for alcohol and 65% for drugs. Only 4% of the patients were privately insured. During the period of this study, gunshot wound injuries required more orthopaedic trauma resources than any other single diagnosis.

Decision analysis of hematopoietic growth factor use in patients receiving cancer chemotherapy.

Hematopoietic growth factors (HGFs) have been shown to reduce the incidence of neutropenia and fever in patients receiving cancer chemotherapy. This cost analysis was designed to determine the conditions in which use of HGFs in patients receiving cancer chemotherapy is cost-effective. We used a standard model based on decision theory; the model assumes that all patients experiencing neutropenia and fever will be hospitalized and treated with intravenous antibiotics. Data from a prospective, randomized clinical trial of granulocyte colony-stimulating factor in small-cell lung cancer treated with combination chemotherapy were used to determine baseline probabilities for control hospitalization risk and survival; proportional hospitalization risk with prophylactic HGF; and median durations of hospitalization and prophylactic HGF use. The model was analyzed by one-way and multivariate sensitivity analyses, with estimation of threshold values at which the expected cost is the same for either of two treatment options. One or more of the specific costs and durations and the probability for each group of threshold curves were varied in a sensitivity analysis that generated variable thresholds. Use of Monte Carlo analysis based on the available distributions of the main variables provided 90% confidence limits and an inference method for comparing decision options. The expected excess cost per treatment cycle, based on hospitalization for neutropenic fever and/or HGF administration, was $5500 for no HGF, $4750 for prophylactic HGF, and $6875 for therapeutic HGF. Sensitivity analysis provided the following thresholds for no HGF versus prophylactic HGF: control risk of hospitalization, 0.40; risk of hospitalization with HGF as a proportion of control, 0.64; total daily cost of hospitalization, $727; total daily cost of HGF, $344; duration of hospitalization, 7.3 days; and duration of HGF use, 11.0 days. Multivariate analysis revealed that conditions favoring the use of HGF on a cost basis become greater (a) as risk of hospitalization, total daily hospital cost, and duration of hospitalization increase and (b) as the proportional risk of hospitalization with HGF, daily cost of HGF, and duration of HGF treatment decrease. The major determinants of total excess cost were the control risk of hospitalization, the proportional reduction in risk with HGF, and the average daily hospital cost. Use of HGFs should be based on the risk of hospitalization for neutropenic fever and consideration of the patient population and institutional costs.

Die früh-funktionelle konservative Therapie der frischen fibularen Kapsel-Band-Ruptur aus sozial-ökonomischer Sicht

The expected direct and indirect costs following a fresh fibular rupture of the capsular ligament, and hence the socioeconomic burden on the patient, was investigated by a prospective randomised study comprising 120 males and females between 18 and 45 years of age. A comparison of three different conservative treatment methods A (immobilisation in a plaster cast for three weeks, followed by mobilisation with the aircast splint), B (mobilisation with the aircast splint) and C (Unna's paste dressing for two weeks with subsequent tape dressings and in each case immediate mobilisation) showed a significantly better stability after 6 months in the groups B (2.6 +/- 2.3) and C (3.6 +/- 3.8) than in A (4.8 +/- 3.5). The direct subsequent costs were also significantly lower in the groups B (DM 175.-) and C (DM 206.-) than in A (DM 340,-). Taking an average daily hospital care fee of DM 319.- (1991 in West Germany) as basis, the direct costs sequential to early functional treatment are the lowest also in comparison with surgical treatment in a hospital. The indirect sequential costs due to loss of working hours are mainly dependent on professionally conditioned physical stress but increase with the period of immobilisation after a fresh fibular rupture of the capsular ligament.

Surfactant Replacement Therapy: Impact on Hospital Charges for Premature Infants With Respiratory Distress Syndrome

Surfactant replacement therapy for neonatal respiratory distress syndrome has the potential to reduce morbidity and mortality of very premature infants. To investigate whether surfactant replacement therapy will also reduce hospital charges for these infants, we compared the hospital charges incurred by a group of patients treated with surfactant with charges of control patients. Mortality in the surfactant-treated group (8%) was significantly decreased compared with the control patients (29%). Average daily hospital charges in the surfactant-treated patients were 25% less than for the control patients. Most of the savings in daily hospital charges were due to a 52% reduction in daily charges for laboratory, x-ray, respiratory therapy, and other ancillary services. Similarly, ancillary charges for the first full week of hospitalization were significantly reduced by $1,883 for patients who received surfactant therapy. Analysis of the charges for the entire hospitalization revealed that surfactant-treated patients had a significantly smaller proportion of their charges that resulted from ancillary services and an increased proportion due to room charges. The average total hospital charges for the two groups were similar, but the total hospital charges to produce a surviving infant were $18,500 less in the surfactant-treated group than the charges to produce a survivor from the control group. It is likely that, in addition to a reduction in neonatal mortality and morbidity from respiratory distress syndrome, surfactant replacement therapy may also significantly reduce charges for ancillary services for these patients. In this way, surfactant therapy may be cost-effective by improving survival without increasing overall hospital costs.

A psychiatric unit becomes a psychiatric-medical unit: Administrative and clinical implications

Increasing awareness of the frequent concurrence of medical and psychiatric illness has led to a resurgence of interest in psychiatric-medical units. This paper describes the conversion of a 19-bed general hospital psychiatric unit to a psychiatric-medical model. The conversion involved hiring a full-time chief and changing priorities for elective admission, but did not involve major changes in staffing; community-based psychiatrists continued to admit the majority of patients. Arrangements were made for medical house staff coverage of emergent medical problems, while daily medical care remained in the hands of the psychiatrists and their private medical consultants. In the year following the transition numerous patients with combined acute medical and psychiatric illness not treatable in the previous model were accepted and successfully treated. Quantitative study of annual statistics from the pre- and posttransition years revealed the following: 1) The average age of patients increased from 46 to 54 years. 2) The proportion of patients over 65 increased from 19% to 34.9%. 3) The proportion of patients with identified concurrent medical diagnoses increased from 54.7% to 69.1%. 4) Dispositions to nursing homes and chronic care facilities decreased from 10.5% to 8.9%. 5) Length of stay increased from 19.3 to 23.1 days. 6) The average daily hospital bill for psychiatric inpatients rose by 24.6%, compared with a hospital-wide average increase of 16.3%. Although the change in model appeared to offer effective treatment to previously underserved patients, it implied a significant shifting of patients and of costs. Administrative implications are discussed, and a list of preconditions for a successful conversion are suggested.

Pulmonary abscesses in a mental hospital.

THE DISCOVERY of a pulmonary abscess in a patient in one of our services led us to begin an investigation of the total population and to review the available records to determine the relative incidence of this disorder in the Agnews State Hospital, to ascertain whether it were commoner here than in the general population, and, if so, to investigate those factors which might be involved in the production of this increased incidence. In a survey of all patients in the hospital on or hospitalized since October, 1952, we discovered 15 nontuberculous, pyogenic lung abscesses. With an average daily hospital population of about 4,500, this figure represents an incidence rate of 0.24% for this hospital population. Although no recent statistics are available, a comprehensive survey of hospital discharges in the City of New York in 1933 showed the incidence rate for that population to be 0.00145%, which is, perhaps, slightly