Reduction In Hospital Days Research Articles

Ethics consultation in the intensive care unit

To review the medical literature for recent reports of the role of ethics consultations in the intensive care setting. Ethical principles can provide important guidelines for dealing with value conflicts in medical treatment decisions, particularly treatment decisions to limit life-sustaining treatment in the intensive care unit. Until recently, advocates of ethics consultations have had to rely on inconclusive supporting data. In the past few years, however, a single-site and multi-site prospective randomized controlled trial of the ethics consultations offered in response to treatment conflicts in the intensive care unit demonstrated significant reductions in hospital days, hospital costs, and ventilator days in patients who did not survive to hospital discharge. The consultations were very well received by all the parties. Ethics consultations seem to be useful in resolving conflicts that may be inappropriately prolonging nonbeneficial or unwanted treatments at the end of life. Further research on whether ethics consultations are beneficial in other settings is needed to establish the optimal scope of this intervention. Also, because these benefits were achieved by highly skilled and experienced consultants, it is not certain how successful other hospitals will be when adopting this intervention.

The Costs Of Nonbeneficial Treatment In The Intensive Care Setting

Ethics consultations have been shown to reduce the use of "nonbeneficial treatments," defined as life-sustaining treatments delivered to patients who ultimately did not survive to hospital discharge, when treatment conflicts occurred in the adult intensive care unit (ICU). In this paper we estimated the costs of nonbeneficial treatment using the results from a randomized trial of ethics consultations. We found that ethics consultations were associated with reductions in hospital days and treatment costs among patients who did not survive to hospital discharge. We conclude that consultations resolved conflicts that would have inappropriately prolonged nonbeneficial or unwanted treatments in the ICU instead of focusing on more appropriate comfort care.

Cost-effectiveness of integrated stroke services

Randomized trials have shown that integrating services for acute stroke care may lead to organizational improvements, higher efficiency and better patient outcomes in the acute phase. To compare the costs and effects of stroke services in an experimental group of patients compared to a group of patients receiving conventional care. Prospective non-randomized controlled trial. We compared all consecutively hospitalized stroke patients in three experimental stroke service settings (Delft, Haarlem and Nijmegen, n = 411) with concurrent patients receiving conventional stroke care (n = 187) over 6 months follow-up. Main end-points were total costs per patient and total health-adjusted days per 100 patients as measured by the EuroQol-5D score during follow-up. Mean total costs per patient were 16,000 Euro (95%CI 14,670 Euro-16,930 Euro): 13,160 Euro in Delft, 16,790 Euro in Haarlem, 20,230 Euro in Nijmegen, and 13,810 Euro in the control regions. Early discharge in Delft saved about 2500 Euro hospital costs per patient. General patient health in Delft was significantly better than in the control regions; Haarlem and Nijmegen showed no difference in health. Our study confirms the potential to improve stroke outcomes in a cost-effective way in Dutch settings. This was seen in the group of patients in Delft, a complete and relatively simple stroke service, but not in two other regions with more complex stroke services. Important factors are reduction of hospital days and, most likely, adequate multidisciplinary rehabilitation.

FITE diabetes: florida initiative in telehealth and education. Approach to diabetes care for children

Remote clinics for children with diabetes in under-served areas are necessary due to increasing numbers of patients, and shortages and centralisation of specialists at tertiary care centres. Lack of resources (professional and financial) to continue travelling to remote clinics. Lack of resources to allow for families to travel to hub clinics. Poor metabolic control and high rate of hospitalisation for the under-served population of the remote clinic. Lack of medical home contributing to a low rate of phone management of acute illness and a high rate of emergency department visits. Disproportionate use of financial resources for a small number of children with poor adherence to the medical plan. Lack of financial incentive and time for diabetes education, coupled with the correlation of adherence with education. Low rate of literacy and ‘new readers’ in the target population to be educated. Lack of adequate education programme to address the needs of this programme. Telemedicine clinic offered semi-monthly allowing improved frequency of patient visits without the necessity for families or providers to travel. Provision of a medical home with clear instructions regarding whom and when to call for additional guidance. Link secondary care providers in the school with the family and health care team for assimilation of all data collected through the day. Improved accountability of non-adherent patients by incorporating all data and increasing interaction with the health care team. Creation of web-based animated instruction covering all aspects of diabetes care. Pre- and post-testing provides the health care team with progress reports on patients enrolled. Access to website for patients and secondary caretakers (for example, teachers, grandparents, school nurses). Continuing education units offered to nurses to increase the understanding of diabetes by the health workforce. Establishment of a medical home and guidelines of when to call has reduced the frequent emergency department visits and hospitalisations for the group. Avoidance of travel costs, and work and school absences for travel to hub clinic by families. Efficiency of the health care team improved by avoiding travel to a remote clinic. Web education of new caretakers, guardians and others does not incur additional cost. Web education is available statewide. Line charges and equipment costs (amortised over five years) were £9993. (The line charges are dramatically reduced now as we are using one or two ISDN lines versus three.) The reduction in hospital days saved £23 572/year. The reduction in emergency department visits saved £1202/year. Additional savings of £34 462/year if Medicaid family transportation costs to the hub were necessary in the absence of the telemedicine clinic. Many academic centres provide health care by travelling to remote centres. Replication of this programme elsewhere has the potential to improve the efficiency of, and save time for, physicians and diabetes treatment teams already trying to meet the demands of their busy schedules. Reduction in line charges, through creative technology such as Internet Protocol encryption, will allow a more cost-effective provision of service than in-person visits to outreach sites. When other cost reductions such as decreased hospitalisation and emergency department use are considered, the costs of telemedicine services are readily justified.

Prediction of Outcome from the Dartmouth Assertive Community Treatment Fidelity Scale

Assertive community treatment (ACT) is an intensive and comprehensive treatment for clients with severe mental illness (SMI) who do not readily benefit from clinic-based services. Monitoring the implementation of such programs is critical, because better-implemented programs have been found to be effective in improving client outcomes. We tested the hypothesis that fidelity to the ACT model would be positively correlated with improved client outcomes, as measured by reduction in psychiatric hospital use. A scale measuring fidelity of program implementation, the Dartmouth ACT Scale, was examined in 10 newly formed ACT teams. Using the team as the unit of measure, the mean reduction in state hospital days for a 1-year period before and after program admission was calculated. Mean effect size in reduction in hospital days was used as the outcome measure in a correlational design. Pre/post comparisons showed a 43 percent reduction in hospital days for 317 clients (t=8.61, P<.001). The Pearson correlation between DACTS fidelity and reduction of state hospital days was .49, P=.08, one-tailed. Several possible reasons are offered for why the study hypothesis was not confirmed. However, even if predictive validity of the Dartmouth ACT Scale is limited, it continues to be a useful tool for program monitoring and for providing corrective feedback.

Intermittent Outpatient Use of Nesiritide Reduces Hospitalizations in Patients with Advanced Congestive Heart Failure

Background: Among people older than age 65, heart failure (HF) is the most common Medicare diagnosis-related group (DRG) as well as the most expensive. Hospitalizations for HF continue to increase and account for close to 1 million hospitalizations annually. Nesiritide (human B-type natriuretic peptide, BNP) is approved for the treatment of patients with acutely decompensated CHF is used in our clinic to manage advanced HF patients. We wanted to evaluate the potential of this out patient therapy added to standard care in reducing hospitalization rates in this population. Methods: This was a retrospective evaluation of 65 patients treated in our clinic with nesiritide who were initially NYHA Class III/IV on maximally tolerated standard care with a poor quality of life. Patients received nesiritide 1–3 times a week as a 2-mcg/kg bolus followed by a 4-hour infusion at 0.01-mcg/kg/min. Patients were on Natrecor between 4 and 77 weeks. The number of days hospitalized in the year prior to starting nesiritide was compared to the number of days hospitalized since beginning nesiritide therapy. Results: 65 patients received intermittent treatment with nesiritide for 4 to 77 weeks (mean treatment time 33 weeks). Patients were predominantly male (66%) and Caucasian (89%). To date, 50 patients are still on nesiritide therapy. In the year prior to starting nesiritide therapy the average number of hospital days was 6.1±7.2 (median 4.0 days). After beginning nesiritide treatment the average number of days hospitalized was reduced to 0.4±1.3 days (median 0 days). This was a reduction of 5.7 days/patient/year±7.0 days (median reduction 4 days/patient/year), or 94%. Conclusions: Outpatient serial treatment with nesiritide resulted in significant reduction in hospital days.

The Effect of Preoperative Clonidine in a Laparoscopically-Assisted Vaginal Hysterectomy

Background: Laparoscopic surgery is a technique with cosmetic advantage, reduction of hospital days, postoperative pain and morbidity. However, in terms of anesthetic care, increase of airway pressure and blood pressure, decrease of ventilatory capacities, and hypercarbia have been problematic issues. The purpose of this study was to evaluate the effect of preoperative administration of clonidine for controlling blood pressure during laparoscopic surgery. Methods: Forty patients who underwent a laparoscopically-assisted vaginal hysterectomy were randomly allocated into clonidine administered group (group C) or a control group (group N) before the operation. Clonidine 0.15 mg was given intravenously for group C patients, then induction was started. Blood pressure and pulse rates were measured at times of entering the operating room, intubation, post-intubation 1, 3, and 5 minutes, post-insulfflation 10 minutes, and postoperatively 1 hour. Blood sugar was checked at post-insulfflation 10 minutes and postoperatively 1 hour. Results: In both groups blood pressure and pulse rate increased significantly compared to the control value after intubation and this feature continued to post-intubation 1 minute in group N. There was significant increase of blood pressure in the postoperative 1 hour period only in group N. Blood sugar also increased significantly at post-insufflation 10 minutes in group N and 1 hour in both groups. Comparing the two groups, blood pressure values of group N at postintubation 1, 3, and 5 minutes were significantly higher than group C, and pulse rate at postinsuflation 1 hour was significantly higher than group C. In addition, the blood sugar in group N was significantly higher than group C at postinsufflation 10 minutes. Conclusions: Preoperative clonidine administration is an effective and convenient method to control hypertension and the blood sugar level during laparoscopic surgery.

Between Scylla and Charybdis: The choice of inotropic agent for decompensated heart failure

Interventions in advanced heart failure that provide symptom relief and decrease hospital readmission are important. Chronic intravenous inotropic therapy represents a pharmacologic approach that has been advocated for palliative treatment. However, little is known about associated mortality and cost. Therefore, we sought to describe the impact of chronic infusions on resource use and survival.Data were reviewed for a 17-state Medicare region from 1995 to 2002. We obtained hospital and outpatient expenditures accrued up to 180 days before and after the initiation of chronic infusions. Health care use was defined by dollars reimbursed for drug and hospitalizations per beneficiary. Average accumulated cost curves were generated for dollars reimbursed for drug and for hospitalizations by days at risk.The mean age of the cohort (n = 331) was 69.1 ± 11.3 years. Mortality exceeded 40% at 6 months. Reductions in hospital days were observed at all time points. The amounts reimbursed at 30 and 60 days before and after initiation of inotrope favor drug therapy; however, at six months, the amounts reimbursed were greater due to the cost of milrinone.Chronic intravenous inotrope use was associated with a high mortality. The cost for milrinone was significant, but there was a decrease in expenditures for subsequent hospitalizations. In the absence of appropriately designed clinical trials, the data suggest that the decision to use inotropes, the choice of inotrope, and the duration of treatment should reflect the impact on resource use.

Is HCFA's reimbursement policy controlling quality of care for end-stage renal disease patients?

Is HCFA's reimbursement policy controlling quality of care for end-stage renal disease patients?

A new model of integrated home care for the elderly: impact on hospital use

The objective of the present study was to examine the effect of a home care program based on comprehensive geriatric assessment—Minimum Data Set for Home Care—and case management on hospital use/cost of frail elderly individuals. We determined all hospital admissions and days spent in hospital during the first year since the implementation of the home care program, and compared them to the rate of hospitalization that the same patients had experienced in the year preceding the implementation of such program. Following the implementation of this program, there was a significant reduction of the number of hospitalizations (pre 44% vs. post 26%, P < 0.001), associated with a reduction of hospital days, both at the individual patient level and for each admission. In conclusion, an integrated home care program based on the implementation of a comprehensive geriatric assessment instrument guided by a case manager has a significant impact on hospitalization and is cost-effective.

Reduction of hospital days by biventricular pacing.

The health care costs for heart failure are substantial. Studies indicate that hospital treatment constitutes 65-75% of these. The aim of this study was to assess total and heart failure related hospital days as well as safety and efficacy of biventricular pacing in 16 patients with severe heart failure and delayed intraventricular conduction (QRS duration >150 ms). They were implanted with a biventricular pacemaker and followed by NYHA class, 6-min walk test and quality of life for a mean of 291+/-76 days. Total number of hospital days and the need for hospitalisations were monitored. Thirteen responders improved by at least one functional class. After 6 months of pacing the 6-min walk test improved from 375+/-83 m to 437+/-73 m (P<0.001) and Minnesota Living with Heart Failure quality of life score from 41+/-19 to 24+/-17 (P<0.001) compared to baseline. The need for hospital care decreased significantly after biventricular pacing. The total number of hospital days in all patients was 253 the year before compared to 45 the year after biventricular pacing (P<0.01). For heart failure related hospital days the corresponding figures were 183 and 39 days, respectively (P<0.01). Biventricular pacing improved 13/16 patients with severe heart failure and wide QRS complexes in this open study. The improvement resulted in a reduced need for hospital care.

Review: assertive community treatment reduced hospital use and was cost effective when used for severely mentally ill patients with previous hospital use of 50 days yearly

Latimer EA. Economic impacts of assertive community treatment: a review of the literature. Can J Psychiatry1999 Jun; 44 : 443 –54. [OpenUrl][1][CrossRef][2][PubMed][3][Web of Science][4] QUESTION: What are the costs associated...

Savings in direct medical costs from the use of tobramycin solution for inhalation in patients with cystic fibrosis

Two identical 24-week, double-blind, placebo-controlled trials of tobramycin solution for inhalation (TOBI [PathoGenesis Corporation, Seattle, Washington]) in cystic fibrosis patients with chronic Pseudomonas aeruginosa infection were conducted in the United States. The aim of the present study was to extrapolate the US trial data to a Canadian setting, using Canadian costs to estimate the savings in direct medical costs that might result from use of a similar 24-week TOBI regimen versus usual care in 2 Canadian provinces. Cystic fibrosis is a genetic disease in which persistent respiratory infection, usually due to P. aeruginosa infection, is the major cause of morbidity and mortality. The US trials demonstrated that TOBI produced significant improvements in pulmonary function test results, reduced sputum levels of P. aeruginosa, and resulted in a 26% reduction in the probability of hospitalization (95% CI, 2%-43% vs placebo in the clinical trials). Individual patient data from the US trials were used to calculate the mean number of days in hospital as well as the mean number of days of home intravenous or oral antibiotic therapy. To adjust for Canadian pricing, pertinent economic data were obtained from Statistics Canada and the Ontario and Quebec health ministries. Demographic and baseline data were obtained from health surveys conducted by the Canadian Cystic Fibrosis Foundation. Economic analysis showed that the use of TOBI for 24 weeks would result in estimated mean per-patient savings in direct medical costs (in Canadian dollars) of $4055 in Ontario and $4916 in Quebec, which would substantially offset the Canadian acquisition price of $8602 for the same 24-week period. Assuming that the percentage of reduction in hospital days observed in the US trials would also occur in the Canadian clinical setting, use of TOBI would reduce the use of health care services, particularly hospital days, and lead to substantial savings in direct medical costs that would offset its acquisition price. Whether this reduction actually occurs after TOBI enters the Canadian market is a subject for future investigation.

Economic impacts of assertive community treatment: a review of the literature.

Assertive community treatment (ACT) is an extensively studied and widely imitated community support treatment model for severely mentally ill individuals. Several previous reviews have documented its favourable effects on clients and their families. This is the first review to focus on economic outcomes. Nineteen randomized studies and 15 nonrandomized studies describing ACT programs were identified based on 2 criteria: 1) provision of services primarily in the community and 2) shared caseloads. Percentage reduction in hospital days was calculated for the 34 study sites where reported data allowed it. Multiple-regression methods were used to relate reduction in hospital days to program fidelity and other contextual factors. The impacts of ACT on emergency-room use, use of outpatient services, housing, costs, and other economic outcomes were also examined. Higher-fidelity programs appear to reduce hospital days by about 23 percentage points more than lower-fidelity programs (95% CI = -41.2, -5.2). The estimated regression coefficients imply that a high-fidelity program reduces hospitalizations by about 58% over 1 year if the alternative involves some type of case management and by 78% if it does not. ACT appears to increase the proportion of clients who live in independent housing situations, but the effect on use of supervised housing, and therefore on housing costs, is ambiguous. The effects on use of most other resources are inconsistent across studies. Overall, ACT appears to result in somewhat lower costs, whatever the perspective of analysis adopted. The most reliable cost offset to ACT treatment costs appears to be reduced hospital use. Using Quebec costs, an ACT program must enroll people with prior hospital use of about 50 days yearly, on average, to break even. As care systems evolve to reduce their reliance on hospitalization as a care modality with or without ACT, this threshold will become increasingly difficult to achieve. The primary justification for implementing ACT services will then become their clinical benefits.

COMPARISON OF THERAPIES WITH TORASEMIDE OR FUROSEMIDE IN PATIENTS WITH CONGESTIVE HEART FAILURE FROM A PHARMACOECONOMIC VIEWPOINT

SUMMARY This observational study compared patients suffering from congestive heart failure (CHF) who were treated with loop diuretics torasemide or furosemide. Data documenting the course of the disease and its associated costs over a period of one year were collected retrospectively. A total of 400 CHF patients, 200 in each treatment group, were included in the analysis. Concomitant ACE inhibitor therapy was received by 46% of patients in both groups. More torasemide‐treated patients (38.0%) than furosemide‐treated patients (24.5%) achieved an improvement in NYHA class in the one‐year period. The main difference between the two groups was the number of CHF‐related hospitalisations: 62 vs 324 hospital days due to CHF were necessary among torasemide‐ and furosemide‐treated patients, respectively. Thus torasemide treatment was associated with an 80% reduction in hospital days compared with furosemide. Furthermore, about 30% fewer working days were lost in the torasemide group than in the furosemide group (441 days vs 617 days, respectively). Direct and indirect costs were evaluated, resulting in overall annual costs of DEM 1502 per torasemide‐treated patient and DEM 1863 per furosemide‐treated patient. A cost‐effectiveness analysis showed a difference between the therapies of DEM 3651 in favour of torasemide. In conclusion, treatment with torasemide improved clinical outcome and was more cost‐effective than with furosemide.

Experience with clozapine in a community mental health care setting.

Clozapine has been heralded as the first major breakthrough in antipsychotic drug therapy for treatment-resistant schizophrenia in 40 years. This study reports on the experience with clozapine in an outpatient, community mental health care setting. All clinic patients receiving clozapine during the 4-year period 1992 to 1996 were retrospectively studied. Measures of improvement were changes in the Clinical Global Improvement (CGI) Scale and reduction in the number of hospital days after clozapine therapy. Testing with the CGI scale showed moderate or marked improvement in 63% of patients. Hospital days dropped from 7,919 to 1,833 for comparable time periods. Clozapine therapy had to be discontinued in only 21% of patients, and no serious side-effects occurred. Clozapine is an effective medication for treatment-resistant schizophrenia and can be safely used in chronic mental illness. Although the drug is expensive, the cost is offset by a remarkable reduction in hospital days.

Replacing Inpatient Care by Outpatient Care in the Treatment of Deep Venous Thrombosis – An Economic Evaluation

Two clinical trials in patients with acute deep venous thrombosis have indicated that the outpatient management with fixed-dose, subcutaneous low-molecular-weight heparin is at least as effective and safe as inpatient treatment with unfractionated intravenous heparin with respect to recurrent venous thromboembolism and major bleeding. We performed an economic evaluation alongside one of these trials to assess the cost consequences of the outpatient management strategy. Data were collected through case record forms, complemented by a prospective questionnaire in 78 consecutive patients, interviews with health care providers, and hospital data bases. Our study demonstrated that seventy-five percent of patients allocated to low-molecular-weight heparin received treatment either entirely at home or after a brief hospital stay. Fifteen percent of these patients required professional domiciliary care. Within-centre comparisons of resource utilisation in terms of natural units showed that outpatient management with low-molecular-weight heparin reduced the average number of hospital days in the initial treatment period in nine centres by 59 percent (95% CI: 43 to 71 percent) accompanied by a limited increase in outpatient and professional domiciliary care. The average reduction in hospital days at the end of follow up was 40 percent (95% CI: 25 to 54 percent). A cost-minimisation analysis, focusing on resource utilisation directly related to the treatment of deep venous thrombosis and associated costs in one centre demonstrated a cost reduction of 64 percent (95% CI: 56 to 72 percent) with the outpatient management with low-molecular-weight heparin. These data suggest that outpatient management of patients with proximal venous thrombosis using low-molecular-weight heparin reduces resource utilisation and total treatment cost. Implementation should be preceded by a cautious evaluation of a potential cost shifting and organisational prerequisites.

P.3.025 - Reduction of hospital days in sertindole treated patients-one year findings

P.3.025 - Reduction of hospital days in sertindole treated patients-one year findings

Treatment of Venous Thrombosis with Intravenous Unfractionated Heparin Administered in the Hospital as Compared with Subcutaneous Low-Molecular-Weight Heparin Administered at Home

An intravenous course of standard (unfractionated) heparin with the dose adjusted to prolong the activated partial-thromboplastin time to a desired length is the standard initial in-hospital treatment for patients with deep-vein thrombosis, but fixed-dose subcutaneous low-molecular-weight heparin appears to be as effective and safe. Because the latter treatment can be given on an outpatient basis, we compared the two treatments in symptomatic outpatients with proximal-vein thrombosis but no signs of pulmonary embolism. We randomly assigned patients to adjusted-dose intravenous standard heparin administered in the hospital (198 patients) or fixed-dose subcutaneous low-molecular-weight heparin administered at home, when feasible (202 patients). We compared the treatments with respect to recurrent venous thromboembolism, major bleeding, quality of life, and costs. Seventeen of the 198 patients who received standard heparin (8.6 percent) and 14 of the 202 patients who received low-molecular-weight heparin (6.9 percent) had recurrent thromboembolism (difference, 1.7 percentage points; 95 percent confidence interval, -3.6 to 6.9). Major bleeding occurred in four patients assigned to standard heparin (2.0 percent) and one patient assigned to low-molecular-weight heparin (0.5 percent; difference, 1.5 percentage points; 95 percent confidence interval, -0.7 to 2.7). Quality of life improved in both groups. Physical activity and social functioning were better in the patients assigned to low-molecular-weight heparin. Among the patients in that group, 35 percent were never admitted to the hospital at all, and 40 percent were discharged early. This treatment was associated with a mean reduction in hospital days of 67 percent, ranging from 29 percent to 86 percent in the various study centers. In patients with proximal-vein thrombosis, treatment with low-molecular-weight heparin at home is feasible, effective, and safe.

The challenge of changing healthcare systems.

Healthcare systems are in flux throughout the world. Traditional structures and attitudes are changing. The balance of power between political bodies, payers, providers and patients is being destabilised. New approaches by governments and forward integration by drug companies and payers into care management are all major changes from the past. In the future, healthcare providers, particularly hospitals, will have to complement medical with business skills to survive in a more competitive environment. Experience shows that there is major potential for improvement in terms of radical rethinking of how care is provided (e.g. at least a 30% reduction in hospital days per insured life together with quality-of-care improvements). In particular, the economic value of changes in treatment (e.g. ambulatory surgery, switch to home therapy) should be understood and optimised. In a new world scenario, payers and providers will shape the healthcare environment by introducing novel approaches and integrating healthcare delivery. This process, coupled with the introduction of new approaches to competition and risk sharing by the government, could cause the emergency of high performance and more cost-effective healthcare systems.