Outpatient Patients Research Articles

Transitioning ifosfamide chemotherapy regimens to the ambulatory setting: reviewing cost savings and safety profile.

PurposeTo characterize and compare both the outcome and cost of treatment of outpatient (OP) and inpatient (IP) ifosfamide therapy.MethodsA single-center retrospective chart review of patients 18 years and older receiving ifosfamide therapy. The primary endpoint compares and evaluates the side effect profiles of ifosfamide-treated patients in the OP/IP settings. The adverse event grading system was characterized using the CTCAE Version 5.0. The highest grade was documented per cycle. The secondary endpoint of this study compares the costs of OP/IP therapy. It was assumed that the cost of medication was equivalent for IP/OP treatments. The cost saved with OP administration was determined by the average cost of hospital stay for IP admission.ResultsIfosfamide therapy of 86 patients (57 OP, 29 IP) was reviewed. The predominant OP regimens were doxorobucin-ifosfamide-mesna (AIM) with 43.9% and ifosfamide-etoposide (IE) with 29.8%. Grade 4 anemia, thrombocytopenia, and neutropenia were most frequent in IP vs OP therapies (22.9% IP vs 4.3% OP, 21.6% IP vs 9.2% OP, and 22.8% IP vs 19.6% OP respectively). Neutropenic fever (NF) occurred in 20 OP patients which were predominantly treated with AIM or IE and led to average hospital stay of 6 days. Neurotoxicity, treated with methylene blue (MB) occurred in 4 OP patients. OP therapy saved a total of 783 hospital days, leading to a cost savings of $2,103,921.ConclusionsTransitioning ifosfamide to the OP setting is feasible for academic and community infusion centers with the OP administration being safe, well-tolerated, and associated with decreased total cost of care. The current processes allow for safe transition of chemotherapy of chemotherapy under times of COVID.

Outcomes of Same-Day Orthopedic Surgery: Are Spine Patients More Likely to Have Optimal Immediate Recovery From Outpatient Procedures?

Spinal surgery is associated with an inherently elevated risk profile, and thus far there has been limited discussion about how these outpatient spine patients are benefiting from these same-day procedures against other typical outpatient orthopedic surgeries. Orthopedic patients who received either inpatient or outpatient surgery were isolated in the American College of Surgeons National Surgical Quality of Improvement Program (2005-2016). Patients were stratified by type of orthopedic surgery received (spine, knee, ankle, shoulder, or hip). Mean comparisons and chi-squared tests assessed basic demographics. Perioperative complications were analyzed via regression analyses in regard to their principal inpatient or outpatient orthopedic surgery received. This study included 729 480 surgical patients: 32.5% received spinal surgery, 36.5% knee, 24.1% hip, 4.9% shoulder, and 1.7%ankle. Of those who received a spinal procedure, 74.7% were inpatients (IN), and 25.3% were outpatients (OUT): knee: 96.1% IN, 3.9% OUT; hip:98.9% IN, 1.1% OUT; ankle: 29% IN, 71% OUT; and shoulder: 52.6% IN, 47.6% OUT. Hip patients were the oldest, and knee patients had the highest body mass index out of the orthopedic groups (P < .00). Spine IN patients experienced more complications than the other orthopedic groups and had the lowest OUT complications(both P < .05). This same trend of having higher IN complications than OUT complications was identified for hip, shoulder, and knee. However, ankle procedures had greater OUT procedure complications than IN (P < .05). After controlling for age, body mass index, and Charlson Comorbidity Index, IN procedures, such as knee, hip, spine, and shoulder, were significantly associated with experiencing postoperative complications. From 2006 to 2016, IN and OUT surgeries were significantly different among complications experienced for all of the orthopedic groups (P < .05) with complications decreasing for IN and OUT patients by 2016. Over the past decade, spine surgery has decreased in complications for IN and OUT procedures along with IN/OUT knee, ankle, hip, and shoulder procedures, reflecting greater tolerance for risk in an outpatient setting. 3. Despite the increase in riskier spine procedures, complications have decreased over the years. Surgeons should aim to continue to decrease inpatient spine complications to the level of other orthopedic surgeries.

Longitudinal analysis of cost and dental utilization patterns for older adults in outpatient and long-term care settings in Minnesota.

BackgroundDental utilization patterns and costs of providing comprehensive oral healthcare for older adults in different settings have not been examined.MethodsRetrospective longitudinal cohort data from Apple Tree Dental (ATD) were analyzed (N = 1,159 total; 503 outpatients, 656 long-term care residents) to describe oral health status at presentation, service utilization patterns, and care costs. Generalized estimating equation (GEE) repeated measures analysis identified significant contributors to service cost over the three-year study period.ResultsCohort mean age was 74 years (range = 55–104); the outpatient (OP) group was younger compared to the long-term care (LTC) group. Half (56%) had Medicaid, 22% had other insurance, and 22% self-paid. Most (72%) had functional dentitions (20+ teeth), 15% had impaired dentitions (9–19 teeth), 6% had severe tooth loss (1–8 teeth), and 7% were edentulous (OP = 2%, LTC = 11%). More in the OP group had functional dentition (83% vs. 63% LTC). The number of appointments declined from 5.0 in Year 1 (OP = 5.7, LTC = 4.4) to 3.3 in Year 3 (OP = 3.6, LTC = 3.0). The average cost to provide dental services was $1,375/year for three years (OP = $1,427, LTC = $1,336), and costs declined each year, from an average of $1,959 (OP = $2,068, LTC = $1,876) in Year 1 to $1,016 (OP = $989, LTC = $1,037) by Year 3. Those with functional dentition at presentation were significantly less costly than those with 1–19 teeth, while edentulous patients demonstrated the lowest cost and utilization. Year in treatment, insurance type, dentition type, and problem-focused first exam were significantly associated with year-over-year cost change in both OP and LTC patients.ConclusionCosts for providing comprehensive dental care in OP and LTC settings were similar, modest, and declined over time. Dentate patients with functional dentition and edentulous patients were less costly to treat. LTC patients had lower utilization than OP patients. Care patterns shifted over time to increased preventive care and decreased restorative care visits.

Longitudinal, Nationwide, Cohort Study to Assess Incidence, Outcomes, and Costs Associated with Complicated Urinary Tract Infection

AbstractAbstract Introduction Complicated urinary tract infections (cUTI) are common infections. Despite their frequency, limited data are available on the incidence and healthcare burden associated with cUTIs. This study details the epidemiology and 30-day health care resource utilization associated with cUTI in the US. Methods Retrospective study of PharmMetrics Plus database from 1/1/2013 to 12/31/2017. Inclusion criteria: age ≥ 18 years, ICD-9/10 cUTI diagnosis, and continuous enrollment for ≥ 6 months pre- and ≥ 30 days post-index dates. Two mutually exclusive study cohorts for cUTI patients were identified based on the setting of the first observed cUTI diagnosis (inpatient (IP) and outpatient (OP)). Results In total 543,502 adults with cUTI met the inclusion criteria (104,866 IP cohort; 438,636 OP cohort). Mean (SD) age was 48.1 (16.5) years and 68.1% were female. The overall incidence of cUTI was 1.01%, equating to approximately 2,882,195 annual cUTI cases in the US. In the IP cohort, overall median (IQR) 30-day health care costs were $13,028 ($4,855-$26,781). Median (IQR) costs for the initial admission were $9,441 ($2,079-$19,027), with median (IQR) length of stay (LOS) of 4 (3-8) days. Among IP patients, 12,933 (12.3%) had a subsequent readmission. In the OP cohort, median (IQR) 30-day health care costs were $1,531 ($305-$4,998). Of OP patients, 40,457 (9.2%) had a 30-day admission. Conclusions This study demonstrates that the economic burden associated with cUTIs is substantial, especially among patients requiring hospitalization. These findings highlight the need for new treatment approaches and antibiotics that avert hospitalization and reduce LOS.

Costing of Febrile Illness among Under Five Children, A Study in a Tertiary Care Teaching Hospital in Odisha, India.

Objective:The objective of this study was to determine the cost of treatment, both direct and indirect costs, of febrile illness among under-five children in Odisha, India.Methods:This was a cross-sectional study of thirty under-five children with febrile illness reporting to the pediatric outpatient (OP) department and thirty more under-five children admitted to the pediatric ward who were included in the study during January–April 2018. The parents/caretakers of the ailing children were interviewed using the WHO questionnaire contextualized to the local situation. Both direct (medicine, diagnostics, registration/doctor's fees, bed charges, and cost of personal medical appliances) and indirect (transportation, food, loss of income, and lodging) costs of febrile illness and pre-, during, and posthospital visit cost were estimated.Results:The median direct and indirect costs for OP cases were Rs. 1201.00 and Rs. 1375.00, respectively. For the hospitalization (indoor patients), direct and indirect costs were Rs. 7015.00 and Rs. 5190.00, respectively. People also spent money in pre-, during, and posthospital visits for the same episode of febrile illness. Only four OP cases had some kind of medical insurance.Conclusion:High expenditure on both OP and indoor patients calls for appropriate policy for provision of financial protection while seeking health-care services. Health facilities should be tuned to do cost analysis enabling comparison among health facilities.

An assessment on pre analytical preparation of patients for fasting and post prandial blood glucose estimation.

Proper preanalytical preparation of the patients in terms of hours of fasting, time of collection, type of food and also patients' compliance to the given instruction, is quintessential for fasting and post prandial blood glucose estimation. The present study is aimed to analyze the preanalytical preparation and patients' compliance for investigation of blood glucose. It is a cross sectional study and the study was done at the patients attending Chennai Medical College Hospital and Research Centre, Irungalur, Tiruchirappalli, Tamilnadu, India. A sample size of 100 adult patients, which includes 60 out patients (OP) and 40 in patients (IP) were taken for the present study. The present study results shows that 10 OP (16.6%) for fasting, 30 OP (50%) for post prandial and all the 40 IP (100%) patients for fasting and post prandial sample collections, were properly instructed. The results shows 10% IP and 20% OP patients are not adhering to given instructions. The study concludes adequate training is needed for the healthcare providers in giving preanalytical preparation instructions and patients' compliance for prudent report.

Use of Patients' Mobile Phones to Store and Share Personal Health Information: Results of a Questionnaire Survey

To explore the opinions of outpatients concerning a new communication method: the self-management of assessed personal problems in health information records (SAPPHIRE) using patients' mobile phones to store and share medical content (medical SAPPHIRE, or m-SAPPHIRE). A cross-sectional questionnaire survey. Patients Outpatients who visited us from March 1 to May 30, 2012, were asked to complete a questionnaire survey regarding SAPPHIRE and m-SAPPHIRE. The m-SAPPHIRE data consisted of a problem list, height, weight, waist size and active medication list. Ten questions were asked regarding the usefulness of m-SAPPHIRE, the sharing of m-SAPPHIRE and the use of mobile phones to store m-SAPPHIRE data. One hundred and ninety-three patients (male/female, 79/114; mean age, 57±21 years) were registered: 95.9% answered that m-SAPPHIRE would be useful, 98% agreed to manage their personal health records by themselves, and 95.8%, 93.8%, and 92.8% of the patients responded that they would allow m-SAPPHIRE information to be shared with family members, medical workers, and health care providers, respectively. Of the patients, 75.1% responded that they owned a mobile phone, and 43.5% answered that they could enter m-SAPPHIRE information into a mobile phone by themselves, while 27.5% responded that they could do so with someone's help. Patients believe that m-SAPPHIRE would be useful for retrieving their health records during emergency situations or for sharing with family members and medical and health care providers. SAPPHIRE using mobile phones could be an inexpensive and legal method for sharing medical data.

Guidelines for identification and management of outpatient percutaneous endoscopic gastrostomy tube placement

Introduction We sought to determine if percutaneous endoscopic gastrostomy (PEG) could be safely performed in an outpatient fashion. Methods One hundred consecutive inpatient (IP) and outpatient (OP) PEGs were analyzed. Patient demographics, PEG indication, nutritional status, complications, and 30-day mortality were determined. Data were analyzed with Student t tests (STTs) and Fisher exact tests (FETs). All OP PEG candidates were evaluated by our dietician, and postprocedure management was discussed before PEG placement. Results Seventy-four IP and 26 OP PEGs were attempted. All OP PEGs were placed for head and neck cancers, whereas only 18 of 74 (24%) of IP PEGs were performed for that reason ( P < .0001 by FET). Mean pre-PEG albumin levels in OP patients were 3.86 g/dL versus 2.79 g/dL for IP patients ( P < .0001 by STT). No differences were found in complication rates (OP vs IP, P = .56 by FET). Thirty-day mortality for OP patients was 0% and 9.5% for IP patients. Discussion OP PEG placement is safe and feasible in carefully selected patients. It requires a care path–driven team approach.

Acetaminophen and Other Risk Factors for Excessive Warfarin Anticoagulation

Context Warfarin is highly effective in preventing thromboembolism, but increases the risk of hemorrhage, particularly at an international normalized ratio (INR) greater than 4.0. Identifying causes of excessive anticoagulation in clinical practice could help target patients at risk for elevated INRs. Objective To determine causes of INRs greater than 6.0 in a clinical practice setting. Design Case-control study. Setting Outpatient anticoagulant therapy unit. Patients Outpatients followed up prospectively from April 1995 to March 1996 who had been taking warfarin for more than 1 month, had a target INR of 2.0 to 3.0, and were able to be interviewed within 24 hours of their reported INR. Case patients had INRs greater than 6.0; controls were randomly selected from patients having INRs between 1.7 and 3.3. Main outcome measures Factors associated with INRs greater than 6.0, including medication use, recent diet, illness, alcohol consumption, and actual warfarin use. Results A total of 93 cases and 196 controls were interviewed; they did not differ in age, indication for warfarin, length of therapy, warfarin dose, number of prescription medications, or previous INR or long-term INR variability. Acetaminophen ingestion was independently associated in a dose-dependent manner with having an INR greater than 6.0 (P for trend Conclusions These data suggest that acetaminophen is an underrecognized cause of overanticoagulation in the outpatient setting. Several other clinically important risk factors were identified. Increased monitoring of INR values when such risk factors are present or modification of the risk factors themselves should reduce the frequency of dangerously high levels of anticoagulation.