Optimizing Hospital Resources Research Articles

Temporal trends and volume-outcome associations after traumatic brain injury: a 12-year study in Taiwan

The purpose of this study was to evaluate temporal trends in traumatic brain injury (TBI); the impact of hospital volume and surgeon volume on length of stay (LOS), hospitalization cost, and in-hospital mortality rate; and to explore predictors of these outcomes in a nationwide population in Taiwan. This population-based patient cohort study retrospectively analyzed 16,956 patients who had received surgical treatment for TBI between 1998 and 2009. Bootstrap estimation was used to derive 95% confidence intervals for differences in effect sizes. Hierarchical linear regression models were used to predict outcomes. Patients treated in very-high-volume hospitals were more responsive than those treated in low-volume hospitals in terms of LOS (-0.11; 95% CI -0.20 to -0.03) and hospitalization cost (-0.28; 95% CI -0.49 to -0.06). Patients treated by high-volume surgeons were also more responsive than those treated by low-volume surgeons in terms of LOS (-0.19; 95% CI -0.37 to -0.01) and hospitalization cost (-0.43; 95% CI -0.81 to -0.05). The mean LOS was 24.3 days and the average LOS for very-high-volume hospitals and surgeons was 61% and 64% shorter, respectively, than that for low-volume hospitals and surgeons. The mean hospitalization cost was US $7,292.10, and the average hospitalization cost for very-high-volume hospitals and surgeons was 19% and 22% lower, respectively, than that for low-volume hospitals and surgeons. Advanced age, male sex, high Charlson Comorbidity Index score, treatment in a low-volume hospital, and treatment by a low-volume surgeon were significantly associated with adverse outcomes (p < 0.001). The data suggest that annual surgical volume is the key factor in surgical outcomes in patients with TBI. The results improve the understanding of medical resource allocation for this surgical procedure, and can help to formulate public health policies for optimizing hospital resource utilization for related diseases.

Ambulatory transradial percutaneous coronary intervention: A safe, effective, and cost‐saving strategy

The aim of this prospective, multicenter study was to assess the safety, feasibility, acceptance, and cost of ambulatory transradial percutaneous coronary intervention (PCI) under the conditions of everyday practice. Major advances in PCI techniques have considerably reduced the incidence of post-procedure complications. However, overnight admission still constitutes the standard of care in most interventional cardiology centers. Eligibility for ambulatory management was assessed in 370 patients with stable angina referred to three high-volume angioplasty centers. On the basis of pre-specified clinical and PCI-linked criteria, 220 patients were selected for ambulatory PCI. The study population included a substantial proportion of patients with complex procedures: 115 (52.3%) patients with multivessel coronary artery disease, 50 (22.7%) patients with multilesion procedures, and 60 (21.5%) bifurcation lesions. After 4-6 hr observation period, 213 of the 220 patients (96.8%) were cleared for discharge. The remaining seven (3.2%) patients were kept overnight for unstable angina (n = 1), atypical chest discomfort (n = 2), puncture site hematoma (n = 1), or non-cardiovascular reasons (n = 3). Within 24 hr after discharge, no patients experienced readmission, stent occlusion, recurrent ischemia, or local complications. Furthermore, 99% of patients were satisfied with ambulatory management and 85% reported no anxiety. The average non-procedural cost was lower for ambulatory PCI than conventional PCI (1,230 ± 98 Euros vs. 2,304 ± 1814 Euros, P < 10(-6)). Ambulatory PCI in patients with stable coronary artery disease is safe, effective, and well accepted by the patients. It may both significantly reduce costs and optimize hospital resource utilization.

The Relationship between Volume and Outcome after Bariatric Surgery: A Nationwide Study in Taiwan

This study purposed to explore the impact of hospital volume and surgeon volume on hospital resource utilization after bariatric surgery and to identify the predictors of length of stay (LOS) and hospital treatment cost in a nationwide population in Taiwan. This population-based cohort study retrospectively analyzed 2,674 bariatric surgery procedures performed from 1997 to 2008. Hospitals were classified as low- and high-volume hospitals if their annual number of bariatric surgeries were <35 and ≥ 35, respectively. Surgeons were classified as low- and high-volume surgeons if their annual number of bariatric surgeries were <15 and ≥ 15, respectively. Hierarchical linear regression models were used to predict LOS and hospital treatment cost. The mean LOS was 7.67 days and the LOS for high-volume hospitals/surgeons was, on average, 28%/31% shorter than that for low-volume hospitals/surgeons. The mean hospital treatment cost was US$2,344.08, and the average hospital costs for high-volume hospitals/surgeons were 10%/13% lower than those for low-volume hospitals/surgeons. Advanced age, male gender, high Charlson co-morbidity index, and current treatment in a low-volume hospital, by a low-volume surgeon, and via open gastric bypass were significantly associated with long LOS and high hospital treatment cost (P < 0.001). The data suggest that annual surgical volume is the key factor in hospital resource utilization. The results improve the understanding of medical resource allocation for this surgical procedure and can help to formulate public health policies for optimizing hospital resource utilization for related diseases.

Efficacy of emergency room approach versus emergency medical services approach for STEMI activation strategy: optimizing hospital resource utilization while maintaining door-to-balloon time and mortality

Background: Patients with severe aortic stenosis (AS) and prior cardiac surgery undergoing aortic valve replacement (AVR) are at high risk. We aimed to describe the fluoroscopy and left anterior descending (LAD) artery angiography guidance technique for transapical AVR access and the related procedural results. Methods: Patients with severe AS and prior cardiac surgery undergoing transapical AVR using LAD-angiographic guided apical puncture were analyzed (n=9). Additional guidance was added to the standard technique as follows. Mini-thoracotomy was performed at the level of the intercostal space in closer relationship to the apex identified by fluoroscopy. LAD angiography was performed at the time that the area of interest was recognized by radiopaque mark to ensure puncture lateral to the LAD (Fig. 1). Apical needle puncture was performed under fluoroscopy guidance directed towards the aortic root. Results: The population had a mean age of 83 years and were more frequently male (89%) with a high-risk profile (mean STS score of 11%). Two patients received the 23-mm Sapien valve, and seven patients received the 26-mm Sapien device. All nine patients underwent successful implantation of transcatheter aortic valves with virtual abolishment of transaortic gradient, without procedural complications. Conclusion: Fluoroscopy and angiography for guidance of transapical approach facilitate a safe and rapid access to the apex, ensuring no risk of damage to the LAD or large diagonals.

A Simplified Score for Transfer of Patients Requiring Mechanical Ventilation to a Long-Term Care Hospital

Long-term care hospitals are Medicare providers of postacute care that have a mean length of stay of 25 days or more. Early identification and timely transfer of patients requiring mechanical ventilation to such hospitals may improve the efficiency of inpatient care. To develop a predictive model and a simplified score for use on day 7 of hospitalization to assess whether a patient receiving mechanical ventilation is likely to require an additional 25 days of hospitalization (ie, would qualify for transfer to a long-term care hospital). A retrospective, cross-sectional study using hospital discharge and billing data from the 2005 Nationwide Inpatient Sample for 54 686 Medicare beneficiaries admitted to US community hospitals who met the study's eligibility criteria. The outcome was overall length of stay (≥32 vs <32 days). Split-sample validation was used. Multivariable survey-logistic regression analyses were performed to assess predictors and probability of the outcome. A simplified score was derived from the final predictive model. The discriminatory power of the predictive model was 0.75 and that of the simplified score was 0.72. The model calibrated well. All predictors were significantly (P < .01) associated with a hospitalization of 32 days or longer; having a tracheostomy was the strongest predictor (odds ratio, 4.74). The simplified scores ranged from -5 to 110 points and were categorized into 3 classes of risk. Efforts to aid discharge decision making and optimize hospital resource planning could take advantage of our predictive model and the simplified scoring tool.

Delayed operating room availability significantly impacts the total hospital costs of an urgent surgical procedure

Financial pressures drive efforts to optimize hospital resource use, but inefficiencies occur in systems as volume nears total capacity. We examined how operating room use impacts efficiency and costs of treating an urgent surgical condition. A retrospective review of patients who underwent appendectomy for appendicitis at a single hospital from 2004 to 2009 was performed. Patient demographics, operative characteristics, pathologic diagnoses, hospital time intervals, and costs were analyzed. Gap time (time from case booking to surgery start) was used to measure operating room availability. In all, 453 patients met inclusion criteria. Longer gap times were associated with increased hospital-based costs. A gap time of greater than 2 h was associated with 39% higher costs to the hospital, which could not be accounted for by any single cost center. The patients in the 2 groups had similar medical and surgical complexity, as well as similar clinical outcomes and hospital duration of stay. Gap times were greatest during peak elective operating room activity (7 am to 11 pm); however, the total hospital costs were not related to the time of day of the case. A short delay in operating room availability for urgent cases is associated with significantly increased total hospital costs. Our data suggest this finding is attributable to inefficient care when the operating room volume nears total capacity.

Delayed Operating Room Availability Significantly Impacts The Total Hospital Costs Of An Urgent Surgical Procedure

Background Financial pressures drive efforts to optimize hospital resource use, but inefficiencies occur in systems as volume nears total capacity. We examined how operating room use impacts efficiency and costs of treating an urgent surgical condition. Methods A retrospective review of patients who underwent appendectomy for appendicitis at a single hospital from 2004 to 2009 was performed. Patient demographics, operative characteristics, pathologic diagnoses, hospital time intervals, and costs were analyzed. Gap time (time from case booking to surgery start) was used to measure operating room availability. Results In all, 453 patients met inclusion criteria. Longer gap times were associated with increased hospital-based costs. A gap time of greater than 2 h was associated with 39% higher costs to the hospital, which could not be accounted for by any single cost center. The patients in the 2 groups had similar medical and surgical complexity, as well as similar clinical outcomes and hospital duration of stay. Gap times were greatest during peak elective operating room activity (7 am to 11 pm ); however, the total hospital costs were not related to the time of day of the case. Conclusion A short delay in operating room availability for urgent cases is associated with significantly increased total hospital costs. Our data suggest this finding is attributable to inefficient care when the operating room volume nears total capacity.

Predicting prolonged intensive care unit length of stay in patients undergoing coronary artery bypass surgery - development of an entirely preoperative scorecard

We sought to develop a predictive model based exclusively on preoperative factors to identify patients at risk for PrlICULOS following coronary artery bypass grafting (CABG). Retrospective analysis was performed on patients undergoing isolated CABG at a single center between June 1998 and December 2002. PrlICULOS was defined as initial admission to ICU exceeding 72 h. A parsimonious risk-predictive model was constructed on the basis of preoperative factors, with subsequent internal validation. Of 3483 patients undergoing isolated CABG between June 1998 and December 2002, 411 (11.8%) experienced PrlICULOS. Overall in-hospital mortality was higher among these patients (14.4% vs. 1.2%, P<or=0.0001). The following variables were found to be independent predictors of PrlICULOS: increased age, recent myocardial infarction, preoperative renal failure, cerebral and/or peripheral vascular disease, chronic obstructive pulmonary disease, ejection fraction <40%, previous CABG, triple-vessel and/or left main disease, NYHA class IV symptoms and urgent or emergent status. Subsequent validation of this model demonstrated a c-statistic of 78%. An internally-validated, risk predictive model of PrlICULOS in patients undergoing CABG was constructed. Based on preoperative clinical factors, a scorecard was developed allowing identification of these patients prior to surgery and allowing for strategies aimed at optimizing hospital resources.