Increase In Total Hospital Costs Research Articles

Global cost of postoperative ileus following abdominal surgery: meta-analysis.

Following abdominal surgery, postoperative ileus is a common complication significantly increasing patient morbidity and cost of hospital admission. This is the first systematic review aimed at determining the average global hospital cost per patient associated with postoperative ileus. A systematic search of electronic databases was performed from January 2000 to March 2023. Studies included compared patients undergoing abdominal surgery who developed postoperative ileus to those who did not, focusing on costing data. The primary outcome was the total cost of inpatient stay. Risk of bias was assessed using the Newcastle-Ottawa assessment tool. Summary meta-analysis was performed. Of the 2071 studies identified, 88 papers were assessed for full eligibility. The systematic review included nine studies (2005-2022), investigating 1 860 889 patients undergoing general, colorectal, gynaecological and urological surgery. These studies showed significant variations in the definition of postoperative ileus. Six studies were eligible for meta-analysis showing an increase of €8233 (95 per cent c.i. (5176 to 11 290), P < 0.0001, I2 = 95.5 per cent) per patient with postoperative ileus resulting in a 66.3 per cent increase in total hospital costs (95 per cent c.i. (34.8 to 97.9), P < 0.0001, I2 = 98.4 per cent). However, there was significant bias between studies. Five colorectal-surgery-specific studies showed an increase of €7242 (95 per cent c.i. (4502 to 9983), P < 0.0001, I2 = 86.0 per cent) per patient with postoperative ileus resulting in a 57.3 per cent increase in total hospital costs (95 per cent c.i. (36.3 to 78.3), P < 0.0001, I2 = 85.7 per cent). The global financial burden of postoperative ileus following abdominal surgery is significant. While further multicentre data using a uniform postoperative ileus definition would be useful, reducing the incidence and impact of postoperative ileus are a priority to mitigate healthcare-related costs, and improve patient outcomes.

Health Care Utilization and Cost of Allogeneic Hematopoietic Cell Transplantation in Children with Malignant and Non-Malignant Diseases

Introduction: Allogeneic hematopoietic cell transplant (alloHCT) represents a potentially life-saving treatment for patients with both malignant and non-malignant diseases. AlloHCT related costs accounted for the most rapid increase in total hospital cost, with a growth rate of 84.9%, from 2004 to 2007 according to an Agency for Health Care Research and Quality report (Stranges, HCUP Statistical Briefs, 2006). Higher cost has been associated with use of alternative donor sources and post-transplant complications. Transplant care improvements have led to better outcomes (Gooley, NEJM, 2010) but the effect on cost is not known.Methods: We obtained data for 240 patients who received an alloHCT at Columbia University Medical Center between 1/1/05 and 6/30/16 and were <21 years old at the time of alloHCT for the first year post-transplant. Patient clinical characteristics and outcomes were obtained from retrospective review of medical records. Hospitalization cost data was estimated from charges obtained from the Pediatric Health Information System (PHIS) database using hospital specific cost-to-charge ratios and adjusted for inflation. To analyze changes over time, patients were divided into three time periods 2005-08 (n=103 patients), 2009-12 (n=73 patients), 2013-16 (n=64 patients). Primary outcomes were overall survival (OS), transplant related complications (liver injury: total bilirubin >2, kidney injury (decrease in creatinine clearance by >50%), viremia, bacteremia, acute graft-versus-host-disease (aGVHD) and inpatient resource utilization. The comparisons among groups were carried out by Kruskal-Wallis test for continuous variables and Chi-square test for categorical variables.Results: There were no differences over time with respect to patient age, sex, related vs. unrelated donor, myeloablative vs. reduced intensity conditioning. The median age was 10.32 (range 0.34-20.96) years. There were significant differences in number of patients with nonmalignant disease (2005-08: 42%, 2009-12: 45%, 2013-16: 63%, p=0.027) and full HLA match (2005-08:44%, 2009-12: 56%, 2013-16: 64%, p=0.026). Liver injury in the first 30 days occurred in 2005-08: 30%, 2009-12: 32%, 2013-16: 27%, p=0.81. Kidney injury occurred in the first 30 days in 2005-08: 28%, 2009-12: 40%; 2013-16: 27%, p=0.22 and in the first year post-transplant in 2005-08: 85%, 2009-12: 78%, 2013-16: 66%, p=0.011 respectively. Viral infections were 2005-08: 27%, 2009-12: 51%, 2013-16: 41%, p=0.006, and there was a significant difference in mean days with bacteremia 2005-08: 3.4, 2009-12: 2.1, 2013-16: 1.8, p<0.001. There was also a significant difference in incidence of aGVHD 2005-08: 33%, 2009-12: 45%; 2013-16: 20%, p=0.009. There was no difference in OS 2005-08: 69%, 2009-12: 74%, 2013-16: 81%, p=0.21. There were significant differences in hospitalization lengths and costs between the three time periods with the lowest median inpatient days and costs for the 2013-16 group. The median lengths of transplant admission were 2005-08: 52 days, 2009-12: 48 days and 2013-16: 41 days (p<0.001). The median total inpatient days for the first year post-transplant were 2005-08: 98 days, 2009-12: 93 days, and 2013-16: 53 days (p<0.001). The median cost of the first transplant hospitalization was 2005-08: $184,450, 2009-12: $156,020, 2013-16: $130,244 (p<0.001), and median total one-year inpatient cost was 2005-08: $344,424, 2009-12: $308,826, 2013-16: $181,205 (p<0.001). The median cost per day survived was 2005-08: $433, 2009-12: $371, 2013-16: $202 (p<0.001). Stratifying the cohort by disease type and donor source, the median cost of alloHCT for matched related donors was 2005-08: $271,674, 2009-12: $213,546, 2013-16: $163,251 (p=0.012), for unrelated donors was 2005-08: $377,484, 2009-12: $380,211, 2013-16: $219,208 (p=0.007), for malignant diseases was 2005-08: $341,989, 2009-12: $363,676, 2013-16: $219,208 (p=0.07) and for non-malignant diseases was 2005-08: $344,424, 2009-12: $262,814, 2013-16: $184,280 (p<0.001).Conclusion: Cost of alloHCT for pediatric patients treated at our center from 2005 to 2016 appears to have decreased. This is most likely related to improved care practices stemming from various quality improvement projects, leading to decreased lengths of hospitalization as well as decreased incidence of complications most significantly kidney injury, aGVHD and bacterial infection. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

INA-CBGs claim versus total hospital cost: A vaginal delivery investigation at Airlangga University Academic Hospital, Indonesia.

Background: Inadequate funding for vaginal delivery can be one of the barriers to reducing the maternal mortality rate. It could be therefore critical to compare the vaginal delivery cost between total hospital cost and INA-CBGs cost in national health insurance.Methods: This was a retrospective cross-sectional study conducted from October to December 2019 in Universitas Airlangga Academic Hospital. It collected data on primary diagnosis, length of stay, total hospital cost, INA-CBGs cost, and counted disparity. The data analyzed statistically using t-test independent sample (or Mann-Whitney test).Results: A total of 149 vaginal delivery claims were found, with the majority having a level II severity (79.87%) and moderate preeclampsia as a primary diagnosis (20.1%). There was a significant disparity in higher total hospital costs compared with government INA-CBGs costs (Rp. 9,238,022.09±1,265,801.88 vs 1,881,521.48±12,830.15; p<0.001). There was also an increase of LOS (p<0.001), total hospital cost (p<0.001), and cost disparity (p<0.01) in a higher severity level of vaginal delivery.Conclusion: Vaginal delivery costs in INA-CBGs scheme are underneath the actuarial value. There was also an increase in total hospital costs and a more significant disparity in the higher severity levels of vaginal delivery.Significance for public healthThe inadequate availability of funds for childbirth can be one of the administrative constraints that are directly or indirectly related to efforts to reduce maternal mortality. This study will give references to government, stakeholder, and researchers to highlight the urgency of vaginal delivery cost in a country.

Variation in hospital costs for gastroschisis closure techniques

BackgroundIn newborns with gastroschisis, both primary repair and delayed fascial closure with initial silo placement are considered safe with similar outcomes although cost differences have not been explored. MethodsA retrospective review was performed of newborns admitted with gastroschisis at a single center from 2011 to 2016. Demographic, clinical, and cost data during the initial hospitalization were collected. Differences between procedure costs and clinical endpoints were analyzed using multivariable linear regression adjusting for prematurity, complicated gastroschisis, and performance of additional operations. Results80 patients with gastroschisis met inclusion criteria. Rates of primary fascial, primary umbilical cord closure, and delayed closure were 14%, 65%, and 21%, respectively. Delayed closure was associated with an increase in total hospital costs by 57% compared to primary repair (p < 0.001). In addition, delayed closure was associated with increased total and NICU LOS (p < 0.05), parenteral nutrition duration (p = 0.02), ventilator days (p < 0.001), time to goal enteral feeds (p = 0.01), and all cost sub-categories except ward room costs (p < 0.01). ConclusionDelayed fascial closure was associated with significantly greater hospital costs during the index admission.

Clinical and economic impact of meropenem resistance in Pseudomonas aeruginosa-infected patients.

The emergence of carbapenem resistance has had a significant impact on both clinical and economic outcomes. A retrospective, observational cohort study was performed in a 433-bed tertiary care medical center. The cohort was established from all inpatients with Pseudomonas aeruginosa-positive cultures over a 3-year period. Two multivariate models were developed: a logistic regression model to evaluate the primary outcome of in-hospital mortality and a linear regression model to evaluate the secondary outcome of total hospital cost. The adjusted odds ratio for in-hospital mortality among patients with meropenem-resistant isolates was 2.89 (95% confidence interval [CI], 1.15-7.28). There were significantly more deaths in the meropenem-resistant group (28.1% vs 8.9%, P = .003). Patients with meropenem-resistant P aeruginosa experienced a 4-day increase in median length of stay versus those in the meropenem-susceptible group (14 vs 9 days, P = .004). Likewise, the percentage of patients who required intensive care unit (ICU) admission increased from 42% to 81.3% (P <.001). Meropenem resistance was also associated with a significant increase in total hospital cost by a factor of 1.42 among patients who were not admitted to the ICU (95% CI, 1.03-1.95). Our results demonstrate that meropenem resistance was a significant predictor of in-hospital mortality. Carbapenem resistance also resulted in a significant increase in hospital cost, but only among patients who were not admitted to the ICU.

Bariatric Surgery-Induced Weight Loss Is Associated With Improved Colorectal Cancer Surgical Outcomes in Morbidly Obese Patients

Introduction: We have shown previously that morbid obesity leads to worse post-operative colorectal cancer (CRC) surgical outcomes. However, no literature exists on whether these outcomes are ameliorated after bariatric surgery. Aim was to evaluate the impact of bariatric surgery-induced weight loss on post-operative outcomes of CRC surgery. Methods: Retrospective cohort study of 20,288 patients who underwent CRC surgery between the years of 2008-2012. Patients were identified using the Nationwide Inpatient Sample, a 20% sample of United States of America hospitals. We compared patients who lost weight due to bariatric surgery [body mass index (BMI) < 35 kg/mr2] to morbidly obese patients (BMI ≥ 40 kg/mr2). Results: During the five year study period, there were 1,235 patients in the bariatric surgery group and 19,053 morbidly obese patients who underwent CRC surgery. Significant demographic and clinical characteristics are shown in Table 1. Bariatric surgery-induced weight loss was associated with younger age, female gender and White race in patients undergoing CRC surgery (p < 0.05). Furthermore, bariatric surgery patients were less likely to have congestive heart failure, Diabetes Mellitus, hypertension and renal failure (p < 0.05). On multivariate linear regression, after adjusting for significant covariates and comorbidities, morbidly obese patients had a prolonged length of hospital stay 1.81 days [95% confidence interval (CI):1.81-1.82, P < 0.001], a $5,967 increase in total hospital costs $5,967 (95% CI: 5,965-5,968, P < 0.001) and a twofold increase in disposition to short term rehab facilities, odds ratio (OR) 2.1 (95% CI: 1.2-3.6, p < 0.006) as opposed to bariatric surgery patients. There was also a trend towards increased mortality in the morbidly obese patients, although not significant OR 3.9 (95% CI: 0.5, 29.3). Finally, trend analysis (Figure 1) showed increasing volume of CRC surgeries performed in morbidly obese patients over time as opposed to patients with history of bariatric surgery.Figure 1Table 1: Univariate analysis of patients with and without obesity undergoing CRC surgery.Conclusion: With the increasing volume of morbidly obese patients undergoing CRC surgery, bariatric surgery-induced weight loss seems to improve health care utilization in these patients, with a trend towards lower mortality, possibly due to improved obesity- induced comorbidities.

Hospital costs of complications after a pancreatoduodenectomy

BackgroundA pancreatoduodenectomy (PD) is a highly advanced procedure associated with considerable post-operative complications and substantial costs. In this study the hospital costs associated with complications after PD were assessed. MethodsA retrospective cohort study was conducted on 100 consecutive patients who underwent a pylorus-preserving (PP)PD between January 2012 and July 2013. Per patient, all complications occurring during admission or in the 30-day period after discharge were documented. All hospital costs related to the (PP)PD were defined as the costs of all medical interventions and resources during the hospitalisation period as recorded by the electronic supply tracking system. ResultsThe median hospital costs ranged from €17 482 for a patient without complications to €55 623 for a patient with a post-operative haemorrhage. A post-operative haemorrhage was associated with a 39.6% increase in total hospital costs after adjusting for patient characteristics. Other factors significantly associated with an increase in total hospital costs were: the presence of a malignancy other than a pancreatic adenocarcinoma (29.4% cost increase), the severity grade of a complication (34.3–70.6% increase) and the presence of a post-operative infection (32.4% increase). ConclusionsThis study provides an in-depth analysis of hospital costs and identifies factors that are associated with substantial cost consequences of specific complications occurring after a PD.

Trends in Incidence, Management, and Outcomes of Cardiogenic Shock Complicating ST‐Elevation Myocardial Infarction in the United States

BackgroundLimited information is available on the contemporary and potentially changing trends in the incidence, management, and outcomes of cardiogenic shock complicating ST‐elevation myocardial infarction (STEMI).Methods and ResultsWe queried the 2003–2010 Nationwide Inpatient Sample databases to identify all patients ≥40 years of age with STEMI and cardiogenic shock. Overall and age‐, sex‐, and race/ethnicity‐specific trends in incidence of cardiogenic shock, early mechanical revascularization, and intra‐aortic balloon pump use, and inhospital mortality were analyzed. From 2003 to 2010, among 1 990 486 patients aged ≥40 years with STEMI, 157 892 (7.9%) had cardiogenic shock. The overall incidence rate of cardiogenic shock in patients with STEMI increased from 6.5% in 2003 to 10.1% in 2010 (Ptrend<0.001). There was an increase in early mechanical revascularization (30.4% to 50.7%, Ptrend<0.001) and intra‐aortic balloon pump use (44.8% to 53.7%, Ptrend<0.001) in these patients over the 8‐year period. Inhospital mortality decreased significantly, from 44.6% to 33.8% (Ptrend<0.001; adjusted OR, 0.71; 95% CI, 0.68 to 0.75), whereas the average total hospital cost increased from $35 892 to $45 625 (Ptrend<0.001) during the study period. There was no change in the average length of stay (Ptrend=0.394). These temporal trends were similar in patients <75 and ≥75 years of age, men and women, and across each racial/ethnic group.ConclusionsThe incidence of cardiogenic shock complicating STEMI has increased during the past 8 years together with increased use of early mechanical revascularization and intra‐aortic balloon pumps. There has been a concomitant decrease in risk‐adjusted inhospital mortality, but an increase in total hospital costs during this period.

Epidemiology and outcomes of acute respiratory failure in the United States, 2001 to 2009: A national survey

The objective of this study was to evaluate trends in hospitalization, cost, and short-term outcomes in acute respiratory failure (ARF) between 2001 and 2009 in the United States. Using the Nationwide Inpatient Sample we identified cases of ARF based on International Classification for Diseases, Ninth Revision, Clinical Modification codes. We calculated weighted frequencies of ARF hospitalizations by year and estimated population-adjusted incidence and mortality rates. We used logistic regression to examine hospital mortality rates over time while adjusting for changes in demographic characteristics and comorbidities of patients. The number of hospitalizations with a diagnosis of ARF rose from 1,007,549 in 2001 to 1,917,910 in 2009, with an associated increase in total hospital costs from $30.1 billion to $54.3 billion. During the same period we observed a decrease in hospital mortality from 27.6% in 2001 to 20.6% in 2009, a slight decline in average length of stay from 7.8 days to 7.1 days, and no significant change in the mean cost per case ($15,900). Rates of mechanical ventilation (noninvasive [NIV] or invasive mechanical ventilation [IMV]) remained stable over the 9-year period, and the use of NIV increased from 4% in 2001 to 10% in 2009. Over the period of 2001 to 2009, there was a steady increase in the number of hospitalizations with a discharge diagnosis of ARF, with a decrease in inpatient mortality. There was a significant shift during this time toward the use of NIV, with a decrease in the rates of IMVuse.

Hospital costs of nosocomial multi-drug resistant Pseudomonas aeruginosa acquisition

BackgroundWe aimed to assess the hospital economic costs of nosocomial multi-drug resistant Pseudomonas aeruginosa acquisition.MethodsA retrospective study of all hospital admissions between January 1, 2005, and December 31, 2006 was carried out in a 420-bed, urban, tertiary-care teaching hospital in Barcelona (Spain). All patients with a first positive clinical culture for P. aeruginosa more than 48 h after admission were included. Patient and hospitalization characteristics were collected from hospital and microbiology laboratory computerized records. According to antibiotic susceptibility, isolates were classified as non-resistant, resistant and multi-drug resistant. Cost estimation was based on a full-costing cost accounting system and on the criteria of clinical Activity-Based Costing methods. Multivariate analyses were performed using generalized linear models of log-transformed costs.ResultsCost estimations were available for 402 nosocomial incident P. aeruginosa positive cultures. Their distribution by antibiotic susceptibility pattern was 37.1% non-resistant, 29.6% resistant and 33.3% multi-drug resistant. The total mean economic cost per admission of patients with multi-drug resistant P. aeruginosa strains was higher than that for non-resistant strains (15,265 vs. 4,933 Euros). In multivariate analysis, resistant and multi-drug resistant strains were independently predictive of an increased hospital total cost in compared with non-resistant strains (the incremental increase in total hospital cost was more than 1.37-fold and 1.77-fold that for non-resistant strains, respectively).ConclusionsP. aeruginosa multi-drug resistance independently predicted higher hospital costs with a more than 70% increase per admission compared with non-resistant strains. Prevention of the nosocomial emergence and spread of antimicrobial resistant microorganisms is essential to limit the strong economic impact.

Excess Costs of Hospital Care Associated With Neonatal Candidemia

Nosocomial bloodstream infections are associated with increased hospital costs in adult and pediatric patients. Candida is an increasingly important nosocomial pathogen within intensive care nurseries. The purpose of this study was to determine the attributable cost of candidemia in neonates. This case-control study included all neonates with candidemia receiving care in hospitals in Connecticut and in Baltimore County and the city of Baltimore, MD. We identified 47 cases and 130 control patients. Multivariable linear regression was used to control for state, birth weight and mortality to determine the effect of candidemia on length of stay, cost per day and total hospital costs. Candidemia was associated with a $28,000 increase in total hospital costs in multivariable analysis. This increase in total cost was the result of both an increase in costs per day and length of hospital stay. Other cost-increasing variables included in the analysis were: state of origin (Connecticut), survival and decreasing birth weight. This represents the first study of the adjusted costs of candidemia in neonates. In addition to high mortality, candidemia was associated with increased hospital costs. This cost analysis could be helpful in determining the financial benefits of preventing candidemia in high risk neonates.

Follow-up costs increase the cost disparity between endovascular and open abdominal aortic aneurysm repair

This study compared the hospital and follow-up costs of patients who have undergone endovascular (EVAR) or open (OR) elective abdominal aortic aneurysm repair. The records of 195 patients (EVAR, n = 55; OR, n = 140) who underwent elective aortic aneurysm repair between 1995 and 2004 were reviewed. Primary costing data were analyzed for 54 EVAR and 135 OR patients. Hospital costs were divided into preoperative, operative, and postoperative costs. Follow-up costs for EVAR patients were recorded, with a median follow-up time of 12 months. Mean preoperative costs were slightly higher in the EVAR group (AU $961/US $733 vs AU $869/US $663; not significant). Operative costs were significantly higher in the EVAR group (AU $16,124/US $12,297 vs AU $6077/US $4635; P < .001); this was entirely due to the increased cost of the endograft (AU $10,181/US $7,765 for EVAR vs AU $476/US $363 for OR). Postoperative costs were significantly reduced in the EVAR group (AU $4719/US $3599 vs AU $11,491/US $8,764; P < .001). Total hospital costs were significantly greater in the EVAR group (AU $21,804/US $16,631 vs AU $18,437/US $14,063; P < .001). The increase in total hospital costs was due to a significant difference in graft costs, which was not offset by reduced postoperative costs. The average follow-up cost per year after EVAR was AU $1316/US $999. At 1 year of follow-up, EVAR remained significantly more expensive than OR (AU $23,120/US $17,640 vs AU $18,510/US $14,122; P < .001); this cost discrepancy increased with a longer follow-up. EVAR results in significantly greater hospital costs compared with OR, despite reduced hospital and intensive care unit stays. The inclusion of follow-up costs further increases the cost disparity between EVAR and OR. Because EVAR requires lifelong surveillance and has a high rate of reintervention, follow-up costs must be included in any cost comparison of EVAR and OR. The economic cost, as well as the efficacy, of new technologies such as EVAR must be addressed before their widespread use is advocated.

Clinical and Economic Outcomes in Critically Ill Patients with Nosocomial Catheter-Related Bloodstream Infections

Central venous catheters are universally used during the treatment of critically ill patients. Their use, however, is associated with a substantial infection risk, potentially leading to increased mortality and costs. We evaluate clinical and economic outcomes associated with nosocomial central venous catheter-related bloodstream infection (CR-BSI) in intensive care unit (ICU) patients. A retrospective (1992-2002), pairwise-matched (ratio of case patients to control subjects, 1:2 or 1:1), risk-adjusted cohort study was performed at a 54-bed general ICU at a university hospital. ICU patients with microbiologically documented CR-BSI (n = 176) were matched with control subjects (n = 315) on the basis of disease severity, diagnostic category, and length of ICU stay (equivalent or longer) before the onset of CR-BSI in the index case patient. Clinical outcome was principally evaluated by in-hospital mortality. Economic outcome was evaluated on the basis of duration of mechanical ventilation, length of ICU and hospital stays, and total hospital costs, as derived from the patient's hospital invoices. The attributable mortality rate for CR-BSI was estimated to be 1.8% (95% confidence interval, -6.4% to 10.0%); in-hospital mortality rates for patients with CR-BSI and matched control subjects were 27.8% and 26.0%, respectively. CR-BSI was associated with significant excesses in duration of mechanical ventilation, duration of ICU and hospital stays, and a significant increase in total hospital cost. Linear regression analysis with adjustment for duration of hospitalization and clinical covariates, revealed that CR-BSI is independently associated with higher costs. In ICU patients, CR-BSI does not result in increased mortality. It is, however, associated with a significant economic burden, emphasizing the importance of continuous efforts in prevention.

Intensive care unit physician staffing is associated with decreased length of stay, hospital cost, and complications after esophageal resection.

To determine whether having daily rounds by an intensive care unit (ICU) physician is associated with clinical and economic outcomes after esophageal resection. ICU information was obtained from a prospective survey and linked to retrospective patient data from the Maryland Health Services Cost Review Commission. The main outcome variables were in-hospital mortality rate, length of stay, hospital cost, and complications after esophageal resection. Nonfederal acute care hospitals in Maryland that performed esophageal resection (n = 35 hospitals) during the study period, 1994-1998. Adult patients who underwent esophageal resection in Maryland (n = 366 patients) from 1994 to 1998. Presence vs. absence of daily rounds by an ICU physician. After adjusting for patient case-mix and other hospital characteristics, lack of daily rounds by an ICU physician was independently associated with a 73% increase in hospital length of stay (7 days; 95% confidence interval [CI], 1-15; p =.012) and a 61% increase in total hospital cost ($8,839; 95% CI, $ 1,674-$19,192; p =.013), but there was no association with in-hospital mortality rate. In addition, the following postoperative complications were independently associated with lack of daily rounds by an ICU physician: pulmonary insufficiency (odds ratio [OR], 4.0; CI, 1.4-11.0), renal failure (OR, 6.3; CI, 1.4-28.7), aspiration (OR, 1.7; CI, 1.0-2.8), and reintubation (OR, 2.8; CI, 1.5-5.2). Having daily rounds by an ICU physician is associated with shorter lengths of stay, lower hospital cost, and decreased frequency of postoperative complications after esophageal resection. Healthcare providers and policymakers should use this information to help improve quality of care and reduce costs for patients undergoing high-risk surgical procedures.

Phenytoin and fosphenytoin: a model of cost and clinical outcomes.

We developed a pharmacoeconomic model to compare costs and clinical outcomes of administering phenytoin and fosphenytoin alone and in combination in hospitalized patients. Effectiveness data were obtained by distributing a questionnaire to 33 registered nurses at three acute care hospitals who worked in critical care, neurology services, or emergency department. The questionnaire addressed methods of phenytoin and fosphenytoin administration, frequency of adverse reactions, methods of treating adverse reactions, and demographic information. The model estimated that if 50% of phenytoin loading doses were substituted with fosphenytoin, a reduction in adverse events resulted in an estimated increase of $36/patient cost to the hospital. If phenytoin maintenance dosages were substituted with fosphenytoin, the model predicted essentially no change in cost to the hospital. It appears that fosphenytoin reduces adverse events at a reasonable increase in total hospital costs.