Reduction In Hospital Charges Research Articles

Prospective development of a cost-efficient program for the pubovaginal sling

Objectives We designed and implemented a cost-containment program for patients undergoing a pubovaginal sling procedure. We sought to test the hypothesis that preoperative patient education could reduce the length of hospital stay in these patients. Our goal was to decrease hospital charges while maintaining quality of care. Methods A multidisciplinary group of clinic and hospital staff identified factors that contribute to a patient's hospital charges for a pubovaginal sling procedure. A program of preoperative patient education to teach intermittent self-catheterization was combined with the elimination or control of items considered unnecessary to the delivery of safe, efficient care. Patient care was standardized from the preoperative visit to discharge planning. The difference in the mean values of 38 prestudy patients was compared with 15 study patients with a Wilcoxon rank sum test. Results Length of hospital stay was reduced from a mean of 2.8 to 1.1 days after implementation of the program ( P <0.0001). This decreased length of stay, combined with a reduction in routine laboratory studies (97% decrease; P <0.0001), operating room charges (11% decrease; P <0.01), and medications (35% decrease; P <0.01), led to significantly reduced hospital charges. Total hospital charges decreased by 35%, from a mean of $4862 to a mean of $3153 ( P <0.0001). There was no increase in morbidity. Patient satisfaction with length of hospital stay did not change significantly following implementation of the program. Conclusions With a program of preoperative patient education combined with a critical review of the factors contributing to a patient's hospital charges, it is possible to implement a cost-efficient program for a pubovaginal sling, leading to a 35% reduction in mean total hospital charges. This approach directed toward other incontinence procedures could be expected to yield comparative results.

The Efficacy and Cost of Aprotinin in Children Undergoing Reoperative Open Heart Surgery

We performed a prospective, randomized, placebo-controlled, double-blind trial to assess the efficacy of aprotinin in 61 children (median age 3.7 yr) undergoing reoperative open heart surgery (OHS). Three demographically similar groups were studied: large-dose aprotinin (ALD), small-dose aprotinin (ASD), and placebo (P). Over the first 24 postoperative hours fewer patients in the aprotinin groups received packed red cells (ALD, 53%; ASD, 89%; and P, 95%; P = 0.001), platelets (ALD, 32%; ASD, 50%; and P, 65%; P = 0.04), and fresh frozen plasma (ALD, 16%; ASD, 17%; and P, 60%; P = 0.003) than placebo patients. Most importantly, aprotinin patients had fewer exposures to banked blood components (ALD, median 1 U; and ASD, median 2 U) than P (median 6 U; P = 0.001), with no difference in overall complication rate. Use of aprotinin was associated with a savings in the patient charges for blood components, operating room time, and duration of hospitalization. In conclusion, aprotinin decreased the number of units of banked blood components used during the first 24 postoperative hours in reoperative pediatric OHS. Aprotinin thus decreases the risks associated with exposure to banked blood components and reduces hospital charges. (Anesth Analg 1996;83:1193-9)

Outcomes and resource utilization in a managed care setting for lower extremity vein bypass grafts

This 17-year review was undertaken to examine clinical outcomes and the changing trends in resource utilization for lower extremity bypass grafts performed in a managed care setting. Between 1979 and 1995, 338 bypasses in 276 patients (199 men, 77 women; 62% diabetics) were carried out for limb salvage. Autogenous vein bypasses (AVB) were performed in 324 (96%) of the cases, which included 150 (43%) femoropopliteal (FP) and 174 (57%) femoro-tibial (FT) bypasses. There were 32 secondary AVB reconstructions included in the study group. The 30-day mortality rate was 2.2% and patient survival was 46% and 21% at 5 and 10 years. At 1 and 5 years, primary patency rates for the AVB were 87% and 79% for FP; 80% and 67% for FT AVB, whereas the limb salvage rates at those intervals were 96% and 94% for FP; 87% and 77% for FT, respectively. Despite an average annual inflation rate of 8%, significant reductions in hospital charges were noted during the study period. These were made possible by decreasing lengths of hospital stay, the development and application of guidelines and protocols for the management of leg ischemia, and the implementation of angioscopy for improving the surgical technique for in situ AVB. High-quality outcomes for lower extremity AVB are possible in a managed care setting with demonstrated improvements in the efficiency of resource utilization.

Potentially ineffective care. A new outcome to assess the limits of critical care.

To examine the limits of the effectiveness of critical care through the study of patients for whom it was ineffective. We studied the relationship between resource use and long-term outcome (2-year follow-up) in 402 consecutively admitted critical care patients to develop a benchmark for ineffective applications of critical care. We defined an outcome called potentially ineffective care (PIC), developed and evaluated a model with an independent data set to predict PIC from a patient's response to treatment, and estimated the economic effects of limiting care after a prediction of PIC. The combined medical and surgical intensive care unit at a 600-bed university teaching hospital. Two groups of 402 consecutively admitted critical care patients, one from 1989, the other from 1991. Based on observations from a two-dimensional plot of resource use vs benefit for 402 critical care patients, PIC was defined as resource use in the upper 25th percentile and survival for less than 100 days after discharge. Thirteen percent of the patients fell into the PIC category and used 32% of the resources. A product of the APACHE risk estimates on days 1 and 5 of at least 0.35 predicted 37% of PIC outcomes with a specificity of 98%. In a second data set, PIC outcome prediction had a sensitivity of 43% and a specificity of 94%, and a positive predictive value of 80%. For the hospital studied, reduction of intensity of treatment after a prediction of a PIC outcome would result in a reduction of hospital charges in the range of $1.8 million to $5 million per year. Patients in the PIC category consumed a large portion of the resources devoted to critical care at an academic teaching hospital. We suggest a change in focus from assessment of the quality of critical care and risk-adjusted mortality to an assessment of ineffective care based on outcome and resource use and a patient's response to treatment over time.

Bronchoscopic guidance makes percutaneous tracheostomy a safe, cost-effective, and easy-to-teach procedure

We wanted to assess the efficiency of instituting a modified technique of percutaneous tracheostomy (PET) with bronchoscopic guidance. During a 10-month period 48 consecutive trauma patients requiring tracheostomy were divided between a standard tracheostomy control group (ST) and a PET group. All patients were followed prospectively. The hospital charges were reviewed retrospectively. Age, gender, body habitus, and principal diagnosis were similar in the 21 ST patients and the 27 PET patients. All STs and 15 of the PETs were performed in the operating room (OR), and the 12 remaining PETs were done in the intensive care unit (ICU). Four patients in the ST group and six in the PET group died. One of these deaths occurred in a patient in the PET group with severe adult respiratory distress syndrome. Procedure time was shorter for PET (16 versus 45 minutes, p < 0.0001). Junior residents performed more PETs than STs (33% versus 10%), and PET was considered "easier" to perform than ST (81% versus 47%). Hospital charges for PET in the ICU were $3400 less per patient compared with ST or PET in the OR. PET was performed easily and safely in the OR and at the ICU bedside. PET required one-third the time of ST. Bronchoscopic supervision of PET may have contributed to the small number of complications and the educational experience of junior residents. PET in the ICU can reduce hospital charges significantly and avoids transport of patients to the OR. PET is as safe as ST and should be considered the procedure of choice for an ICU patient requiring an elective tracheostomy.

Description and evaluation of a program for the early discharge of infants from a neonatal intensive care unit

The effect of a cost-containment program focused on decreasing the lengths of hospital stay of high-risk neonates was assessed by comparison of discharge weights and lengths of stay for 257 study infants, discharged from a neonatal intensive care unit (NICU) after an early-discharge program began, with those of 477 control infants discharged during a prior 1-year period. Demographic data and costs, as well as data on emergency department use and hospital readmissions, were included in the comparisons. There was a significant decrease in mean discharge weight and length of stay for infants in the study group. During a 7-month period, an estimated 2073 days of hospital care and approximately $2,700,000 in hospital charges were saved, or $10,609 per infant discharged. The cost of instituting and maintaining the program was $120,413, or $468 per infant. Seven visits were made to the emergency department by the study infants during the first 14 days after discharge. One infant was readmitted for a 4-day hospital stay for suspected sepsis. Significantly earlier discharge of high-risk neonates produced a decrease in hospital charges without causing excessive morbidity. The success of the program was coincident and presumed related to the institution of multiple elements focused toward family support through early-discharge planning. The reduction in hospital charges was 30 times higher than program expenses. (J P EDIATR 1995;127:285-90)

Perinatal care across the continuum

Efforts to control health care costs have resulted in earlier hospital discharge of both perinatal and neonatal patients. While earlier discharge may reduce hospital charges, it can increase families' burden of care, stress, and expenses and postdischarge complications may go undetected. A number of programs of home follow-up care have been developed in response to earlier hospital discharge. Nursing's challenge is to develop and implement the most effective and cost-efficient services acceptable and available to all perinatal and neonatal patients who need them.

Short-stay carotid endarterectomy is safe and cost-effective

Carotid endarterectomy (CEA) is conventionally performed following a contrast arteriogram, under general anesthesia, and with postoperative admission to an intensive care unit (ICU). We investigated whether any of these traditional adjuncts to CEA is necessary. Eighteen consecutive patients had CEA performed according to a protocol of duplex scanning only, operation under regional anesthesia, and admission to the ICU only in cases of a proven need for services unique to the ICU (group I). Utilization of preoperative arteriography, admission to the ICU, postoperative complications, total hospital length of stay, and hospital charges were calculated for this group and results were compared with a group of 178 patients undergoing conventional CEA (arteriography, general anesthesia, routine ICU admission) during the same period (group II). In group I, 1 patient (6%) underwent preoperative arteriography and 4 patients (22%) were admitted to the ICU after CEA. Most group II patients (114 of 178, or 64%) underwent preoperative arteriography and virtually all (175 of 178, or 98%) were admitted to the ICU. Compared with group II, the average hospital length of stay for group I was significantly shorter (1.3 +/- 0.1 versus 3.1 +/- 0.3 days, P = 0.03) and hospital charges were significantly reduced ($5,861 +/- 229 versus $11,140 +/- 729, P = 0.02). This pilot study suggests that CEA can be safely performed without routine preoperative carotid arteriography; that routine ICU admission is unnecessary for the majority of cases; and that elimination of routine arteriography and ICU admission can reduce hospital charges for CEA by nearly one half.

Treatment of Infants With Indirect Hyperbilirubinemia

Indirect hyperbilirubinemia is a common cause for readmission to a hospital during the first week of life. Many newborn nurseries are ill equipped to readmit such newborns. The purpose of this study was to compare the care and treatment of infants with indirect hyperbilirubinemia who were readmitted to their birth hospital with those who were admitted to a hospital that differed from their birth hospital. Retrospective cohort study. Children's and community hospitals. We reviewed the records of 100 newborns who were readmitted during the first week of life (36 were readmitted to their birth hospital) with a primary admission diagnosis of indirect hyperbilirubinemia. Infants who were admitted to their birth hospital were less likely to have blood cultures (none of 36 vs 17 of 64, P = .0005), urine cultures (none of 36 vs eight of 64, P = .02), or more than one complete blood cell count (two of 36 vs 18 of 64, P = .001) performed compared with infants who were admitted to a nonbirth hospital. Antibiotic, intravenous therapy (P = .0005), and emergency department (P = .0001) use was more common among infants who were admitted to a nonbirth hospital. Infants who were admitted through the emergency department at a nonbirth hospital had phototherapy started later (mean +/- SD, 5.3 +/- 1.6 vs 2.2 +/- 1.7 hours; P = .0001) than did infants who were directly readmitted to the same nonbirth hospital. Readmitting infants with indirect hyperbilirubinemia to birth hospitals or ensuring that accurate, timely, and complete information is obtained from the birth centers by admitting hospital personnel before laboratory studies and treatment are performed will reduce diagnostic workups and should reduce hospital charges for these infants. Phototherapy should be initiated in the emergency department if stabilization is required before admission.

Individualized Developmental Care for the Very Low-Birth-Weight Preterm Infant

To investigate the effectiveness of individualized developmental care in reducing medical and neurodevelopmental sequelae for very low-birth-weight infants. Randomized controlled trial. Newborn intensive care unit. Thirty-eight singleton preterm infants, free of known congenital abnormalities, weighing less than 1250 g, born before 30 weeks' gestation, mechanically ventilated within 3 hours of delivery and for more than 24 hours in the first 48 hours, randomly assigned to a control or an experimental group. Caregiving by nurses specifically trained in individualized developmental care; observation and documentation of the infants' behavior within 12 hours of admission, and subsequently every 10th day; developmental care recommendations and ongoing clinical support for the nurses and parents based on regular observation of the infant by developmental specialists; and the availability of special caregiving accessories. Medical outcome, including average daily weight gain; number of days the infant required mechanical ventilation, oxygen, gavage tube feeding, and hospitalization; severity of retinopathy of prematurity, bronchopulmonary dysplasia, pneumothorax, and intraventricular hemorrhage; pediatric complications; age at discharge; and hospital charges. Neurodevelopmental outcome, including Assessment of Preterm Infants' Behavior scale and quantified electroencephalography (2 weeks after due date); and Bayley Scales of Infant Development and Kangaroo Box Paradigm (9 months after due date). The infants in the experimental group had a significantly shorter duration of mechanical ventilation and supplemental oxygen support; earlier oral feeding; reduced incidence of intraventricular hemorrhage, pneumothorax, and severe bronchopulmonary dysplasia; improved daily weight gain; shorter hospital stays; younger ages at hospital discharge; and reduced hospital charges compared with the infants in the control group. At 2 weeks after their due dates, these infants also showed improved autonomic regulation, motor system functioning, self-regulatory abilities, and visual evoked potential measures; and at 9 months, they had improved Bayley Mental and Psychomotor Developmental Index scores, as well as Kangaroo Box Paradigm scores. Very low-birth-weight preterm infants may benefit from individualized developmental care in the neonatal intensive care unit in terms of medical and neurodevelopmental outcome.

Individualized developmental care for the very low-birth-weight preterm infant. Medical and neurofunctional effects

<h3>Objective.</h3> —To investigate the effectiveness of individualized developmental care in reducing medical and neurodevelopmental sequelae for very low-birth-weight infants. <h3>Design.</h3> —Randomized controlled trial. <h3>Setting.</h3> —Newborn intensive care unit. <h3>Patients.</h3> —Thirty-eight singleton preterm infants, free of known congenital abnormalities, weighing less than 1250 g, born before 30 weeks' gestation, mechanically ventilated within 3 hours of delivery and for more than 24 hours in the first 48 hours, randomly assigned to a control or an experimental group. <h3>Intervention.</h3> —Caregiving by nurses specifically trained in individualized developmental care; observation and documentation of the infants' behavior within 12 hours of admission, and subsequently every 10th day; developmental care recommendations and ongoing clinical support for the nurses and parents based on regular observation of the infant by developmental specialists; and the availability of special caregiving accessories. <h3>Main Outcome Measures.</h3> —Medical outcome, including average daily weight gain; number of days the infant required mechanical ventilation, oxygen, gavage tube feeding, and hospitalization; severity of retinopathy of prematurity, bronchopulmonary dysplasia, pneumothorax, and intraventricular hemorrhage; pediatric complications; age at discharge; and hospital charges. Neurodevelopmental outcome, including Assessment of Preterm Infants' Behavior scale and quantified electroencephalography (2 weeks after due date); and Bayley Scales of Infant Development and Kangaroo Box Paradigm (9 months after due date). <h3>Results.</h3> —The infants in the experimental group had a significantly shorter duration of mechanical ventilation and supplemental oxygen support; earlier oral feeding; reduced incidence of intraventricular hemorrhage, pneumothorax, and severe bronchopulmonary dysplasia; improved daily weight gain; shorter hospital stays; younger ages at hospital discharge; and reduced hospital charges compared with the infants in the control group. At 2 weeks after their due dates, these infants also showed improved autonomic regulation, motor system functioning, self-regulatory abilities, and visual evoked potential measures; and at 9 months, they had improved Bayley Mental and Psychomotor Developmental Index scores, as well as Kangaroo Box Paradigm scores. <h3>Conclusion.</h3> —Very low-birth-weight preterm infants may benefit from individualized developmental care in the neonatal intensive care unit in terms of medical and neurodevelopmental outcome. (<i>JAMA</i>. 1994;272:853-858)

Comparative effects of granulocyte-macrophage colony-stimulating factor (GM-CSF) and granulocyte colony-stimulating factor (G-CSF) on priming peripheral blood progenitor cells for use with autologous bone marrow after high-dose chemotherapy

Two hematopoietic colony-stimulating factors, granulocyte colony-stimulating factor (G-CSF) and granulocyte-macrophage CSF (GM-CSF), have been shown to accelerate leukocyte and neutrophil recovery after high-dose chemotherapy and autologous bone marrow (BM) support. Despite their use, a prolonged period of absolute leukopenia persists during which infections and other complications of transplantation occur. We collected large numbers of peripheral blood (PB) progenitors after CSF administration using either G-CSF or GM-CSF and tested their ability to affect hematopoietic reconstitution and resource utilization in patients undergoing high-dose chemotherapy and autologous BM support. Patients with breast cancer or melanoma undergoing high-dose chemotherapy and autologous BM support were studied in sequential nonrandomized trials. After identical high-dose chemotherapy, patients received either BM alone, with no CSF; BM with either G-CSF or GM-CSF; or BM with G-CSF or GM-CSF and G-CSF or GM-CSF primed peripheral blood progenitor cells (PBPC). Hematopoietic reconstitution, as well as resource utilization, was monitored in these patients. The use of CSF-primed PBPC led to a highly significant reduction in the duration of leukopenia with a white blood cell (WBC) count under 100 and 200 cells/mL, and neutrophil count under 100 and 200 cells/mL with both GM- and G-CSF primed PB progenitor cells, compared with the use of the CSF with BM or with historical controls using BM alone. In addition, the use of CSF-primed PBPC resulted in a significant reduction in median number of antibiotics used, days in the Bone Marrow Transplant Unit, and hospital resources used. Patients receiving G-CSF primed PBPC also experienced a reduction in the median number of days in the hospital, red blood cell (RBC) transfusions, platelet transfusions, days on antibiotics, and discounted hospital charges. Phenotypic analysis of the CSF-primed PBPC indicated the presence of cells bearing antigens associated with both early and late hematopoietic progenitor cells. The use of CSF-primed PBPC can significantly improve hematopoietic recovery after high-dose chemotherapy and autologous BM support. In addition, the use of G-CSF-primed PBPC was associated with a significant reduction in hospital resource utilization, and a reduction in hospital charges.

Comparative Effects of Granulocyte-Macrophage Colony-Stimulating Factor (GM-CSF) and Granulocyte Colony-Stimulating Factor (G-CSF) on Priming Peripheral Blood Progenitor Cells for Use With Autologous Bone Marrow After High-Dose Chemotherapy

Abstract Two hematopoietic colony-stimulating factors, granulocyte colony- stimulating factor (G-CSF) and granulocyte-macrophage CSF (GM-CSF), have been shown to accelerate leukocyte and neutrophil recovery after high-dose chemotherapy and autologous bone marrow (BM) support. Despite their use, a prolonged period of absolute leukopenia persists during which infections and other complications of transplantation occur. We collected large numbers of peripheral blood (PB) progenitors after CSF administration using either G-CSF or GM-CSF and tested their ability to affect hematopoietic reconstitution and resource utilization in patients undergoing high-dose chemotherapy and autologous BM support. Patients with breast cancer or melanoma undergoing high-dose chemotherapy and autologous BM support were studied in sequential nonrandomized trials. After identical high-dose chemotherapy, patients received either BM alone, with no CSF; BM with either G-CSF or GM-CSF; or BM with G-CSF or GM-CSF and G-CSF or GM-CSF primed peripheral blood progenitor cells (PBPC). Hematopoietic reconstitution, as well as resource utilization, was monitored in these patients. The use of CSF- primed PBPC led to a highly significant reduction in the duration of leukopenia with a white blood cell (WBC) count under 100 and 200 cells/mL, and neutrophil count under 100 and 200 cells/mL with both GM- and G-CSF primed PB progenitor cells, compared with the use of the CSF with BM or with historical controls using BM alone. In addition, the use of CSF-primed PBPC resulted in a significant reduction in median number of antibiotics used, days in the Bone Marrow Transplant Unit, and hospital resources used. Patients receiving G-CSF primed PBPC also experienced a reduction in the median number of days in the hospital, red blood cell (RBC) transfusions, platelet transfusions, days on antibiotics, and discounted hospital charges. Phenotypic analysis of the CSF-primed PBPC indicated the presence of cells bearing antigens associated with both early and late hematopoietic progenitor cells. The use of CSF-primed PBPC can significantly improve hematopoietic recovery after high-dose chemotherapy and autologous BM support. In addition, the use of G-CSF-primed PBPC was associated with a significant reduction in hospital resource utilization, and a reduction in hospital charges.

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.

Economic impact of reducing hospitalization for mastectomy patients.

In 1985, two policies designed to reduce hospitalization charges for mastectomy patients were instituted at the M.D. Anderson Cancer Center at Houston. The first was a policy of "same-day" admissions for elective surgery patients, and the second was early postoperative discharge for mastectomy patients with suction catheter drains in place. The economic savings resulting from these policies was analyzed by comparing demographics, operation, stage of disease, hospital stay, hospital charges, and complications for two groups of patients. Fifty-nine consecutive mastectomy patients treated between 1983 and 1984, before these policy changes, had "standard management" consisting of hospital admission 24 hours before surgery and discharge only after the surgical drains were removed. Sixty-one consecutive mastectomy patients treated between 1986 and 1987, after these policy changes went into effect, were admitted from the recovery room after surgery and were discharged with drainage catheters in place, usually within 72 hours. All operations were performed by the same faculty surgeon as a representative experience of the General Surgery faculty. The average hospital stay was reduced from 10.5 to 4.3 days. A mean 39% reduction in hospital charges (from $4867.00 to $2981.00) was achieved by instituting the policies of "same-day" admission and early postoperative discharge with drainage catheters in place. Complication rates were not changed. Implementation of this policy resulted in an estimated savings of $750,000.00 in the hospital care of approximately 400 patients treated at the M.D. Anderson Cancer Center at Houston each year. Adjustments in patient care delivery systems from a predominantly inpatient to an outpatient setting required changes in outpatient nursing responsibilities (although not in new personnel). Patient education and written instructions for home care of surgical wounds and drainage catheters were essential for implementing an early discharge policy. With these facts in mind, hospital admission on the day of operation and early postoperative discharge with drainage catheters in place should be the goal for most mastectomy patients.