Reduction In Hospital Days Research Articles

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.

1057 The health economics of lung cancer and an estimate of the cost effectiveness of single agent gemcitabine in stage IV NSCLC

Statistics Canada has developed a model for costing lung cancer management and evaluating the cost-effectiveness of new therapeutic interventions, based on Canadian practice. This costing model was used to compare costs of gemcitabine versus best supportive care (BSC) (no chemotherapy) for stage IV NSCLC. Gemcitabine costs are based on chemotherapy preparation time, nursing administration time, cost of all supplies, clinic visits, and nursing and physician assessments for gemcitabine administration assuming a weekly × 3 treatment schedule every 4 weeks. As the price of gemcitabine has yet to be determined, a variety of costs per cycle were used ($Cdn 1,000–1,800). The hospitalization costs for BSC were based on the NCIC BR5 trial of BSC versus chemotherapy. The 1993 cost for the BSC arm (including terminal care) was $Cdn 20,914. The incremental cost per case to manage with gemcitabine was $Cdn 1258 (assuming $Cdn 1000 per cycle). The estimated cost per life year gained varied from $Cdn 3193 to 9529 depending on the cost of drug per treatment cycle. This high cost effectiveness is achieved in part because of the reduction in hospital days for terminal care in treated stage IV patients. The cost effectiveness analysis was repeated assuming lower survival. Cost effectiveness decreased, but even in the worst case scenario ($Cdn 1800/cycle; survival −50%), the cost per life year gained was still only $Cdn 16,230. Based on this model, gemcitabine therapy for advanced NSCLC is cost-effective over a range of costs per cycle even when sensitivity analyses are performed that reduce survival expectations.

Cardiovascular Disease

The most common cardiovascular causes of hospital admission in the United States are unstable angina and non—Q-wave myocardial infarction. The efficacy of thrombolytic therapy in patients with these disorders is unclear, and the role of routine early coronary arteriography followed by revascularization is uncertain. The Thrombolysis in Myocardial Ischemia trial randomized 1473 patients with unstable angina or non—Q-wave myocardial infarction in a 2×2 factorial design comparing (1) tissue-type plasminogen activator vs placebo and (2) an early invasive strategy vs an early conservative strategy.¹The investigators found that thrombolytic therapy was not beneficial and may be harmful. With respect to early coronary arteriography, there was no difference in mortality or recurrent myocardial infarction at 6 weeks. There was, however, a reduction in days of hospitalization and rehospitalization and in the use of antianginal drugs. The current approach to the treatment of patients with acute coronary syndromes is to administer intravenous

Does Reduced Hospital Stay Affect Morbidity and Mortality Rates Following Cleft Lip and Palate Repair in Infancy?

Insurance carriers affected decisions regarding admissions and length of stay in our hospital in 1987. Charts were reviewed retrospectively to determine whether this affected morbidity and mortality rates following cleft lip and palate operations in infants. Two periods were studied: May of 1983 through April of 1987 (group I) and April of 1987 through May of 1991 (group II). A total of 248 infants with cleft lip and/or palate underwent 398 operations: lip adhesion (74), definitive lip repair (130), and palatoplasty (194). Half were performed in each period. Admission status, length of stay, length of operation, and short-term morbidity were documented. Morbidity included spontaneous and traumatic lip dehiscence, palatal dehiscence, and palatal fistula. Intergroup analysis was performed by the chi-squared method; p < or = 0.05 was statistically significant. In group I, 93 percent of patients were admitted before surgery. In group II, 5 percent were admitted before surgery and 79 percent the day of surgery. Hospital stay decreased nearly 2 days for each operation. There was no statistically significant difference between groups in distribution of operations, length of operations, or morbidity: lip surgery complications (p = 0.263), palatoplasty complications (p = 0.624). Reductions of hospital admissions and length of stay do not affect outcome of cleft lip and palate surgery in infants. The reduction in hospital days is equivalent to a savings of $138,000 (1991 dollars).

Nasal Intermittent Positive Pressure Ventilation: Long-term Follow-up in Patients With Severe Chronic Respiratory Insufficiency

Prior studies have shown that nasal intermittent positive pressure ventilation (NIPPV) can improve arterial blood gas values, prevent symptoms resulting from alveolar hypoventilation, and decrease hospitalization in patients with chronic respiratory failure. Most studies have involved small samples of patients followed up for a limited time. This study reviews our experience during 5 years use of NIPPV in 276 patients with kyphoscoliosis, posttuberculosis sequelae, Duchenne-type muscular dystrophy, COPD, and bronchiectasis followed up for > or = 3 years while receiving NIPPV. Outcomes were compared for patients who survived short term eg, died or converted to management with a tracheostomy and intermittent positive ventilation (TIPPV) during year 1 or year 2 on a regimen of NIPPV and long term, eg, survived more > or = 2 years on a regimen of NIPPV. The most favorable outcome was achieved by patients with kyphoscoliosis and posttuberculosis sequelae with improvement in PaO2 and PaCO2 (p < 0.0001) and a reduction in days of hospitalization for respiratory illness (p < 0.0001) for > or = 2 years while receiving NIPPV. Patients with Duchenne-type muscular dystrophy also had fewer hospital days during NIPPV (p < 0.003) but only 9 of 16 patients (56 percent) continued using NIPPV for the duration of followup. Benefit was also more short term for patients with COPD and bronchiectasis. NIPPV can sustain improvement in gas exchange, while reducing hospitalization for substantial periods of time. NIPPV can be an attractive and effective alternative to other methods of assisted ventilation such as TIPPV.

Outcome of short-term hospitalization for children with severe asthma

This study presents results of a family-centered, short-term residential program in which medical, behavioral, and treatment assessments were provided to the child with severe asthma and the family. After a median stay of 15 days, forty-four consecutively admitted children with severe asthma achieved a 93% reduction in hospital days (median, 7 hospital days for the year before treatment versus median 0 hospital days per patient per year at 20 1/2-month follow-up; p less than 0.001) and an 81% reduction in emergency care (median, 4 visits for the year previously versus median, 0.4 visits per patient per year at follow-up; p less than 0.01). There was also a significant reduction in corticosteroid bursts and improvement in FEV1. Unique to this program was mandatory family participation focusing on the child's and family's adaptation to severe asthma and development of family-specific interventions to promote compliance with the treatment regimen. Child and family functioning was assessed at admission and follow-up. Hospital use at follow-up was greater for children from dysfunctional families. Families demonstrating difficulties in disciplining the child with asthma required more hospital days both before admission and at follow-up. Short-term hospitalization for children with severe asthma is associated with significant improvement in pulmonary morbidity when the family of the child is included in assessment and treatment.

Why managed care cannot contain hospital costs--without rationing.

Managed care has long been considered by many health policy analysts as a mechanism that can contain costs without intrusive governmental regulation or sacrifice of medical benefits. Indeed, managed care is the centerpiece of current efforts by business, Congress, and the Bush administration to slow the rise in health expenditures as well as the focus of the Winter 1991 volume of Health Affairs. We believe that this optimism is misplaced. While managed care providers historically have had significantly lower costs than other insurers, the rate of increase in their costs has been virtually indistinguishable from that of the fee-for-service sector. This is because managed care is subject to the same upward pressure on costs-resulting from a flow of new technology and rising wages-that other providers face. Unable to control these forces, managed care providers have instead kept costs below those of fee-for-service providers by using fewer hospital days. For example, health maintenance organizations (HMOs) traditionally have used some 30 percent fewer days than fee-for-service providers. During the 1980s, the growth of managed care, the introduction of prospective payment, and other efforts to contain costs caused a reduction in hospital days throughout the entire hospital sector roughly equal to that traditionally associated with HMOs. The result was a brief slowing in the rate of increase in community hospital costs. But this very success has made it unlikely that any conceivable further reduction in unnecessary days can have more than a slight, brief effect on the cost spiral. Indeed, despite the rapid diffusion of managed care in recent years, few additional days have been saved. In this Commentary, we argue that neither managed care nor fee-for-service providers will be

Percutaneous endoscopic treatment of cholelithiasis

Surgical management of gallstones was first performed successfully in 1878. Over the past decade, several new treatment alternatives have evolved that challenge the supremacy of traditional surgical cholecystectomy. Two endoscopic alternatives, e.g., percutaneous cholecystolithotomy (PCCL) and laparoscopic cholecystectomy (LC) are the latest additions to the growing armamentarium. Our initial experience with PCCL and LC as compared with our traditional cholecystectomy experience shows a 57% reduction in hospital days, a 58% reduction in postoperative analgesic dose, and 50% or more reduction in disabling convalescence in favor of the endoscopic alternatives. A review of the efficacy and morbidity of traditional surgery, peroral drug chemolysis (PDC), shockwave lithotripsy plus PDC, and percutaneous transhepatic lavage with methyl terbutyl ether suggests that the endoscopic alternatives are less morbid than traditional surgery and more efficacious and perhaps less morbid than other non-invasive or minimally invasive alternatives. Both original data and a literature review are presented.

The Value of Assessing Falls in an Elderly Population

To measure the effects of a specialized postfall assessment intended to detect causes and underlying risk factors for falls, and to recommend preventive and therapeutic interventions. Randomized, controlled trial. A long-term residential care facility for elderly persons. Within 7 days of a fall, 160 ambulatory subjects (mean age, 87 years) were randomly assigned to receive either a comprehensive postfall assessment (intervention group, n = 79) or usual care (control group, n = 81). The postfall assessment included a detailed physical examination and environmental assessment by a nurse practitioner; laboratory tests; electrocardiogram; and 24-hour Holter monitoring. Probable cause or causes for the fall, identified risk factors, and therapeutic recommendations were given to the patient's primary physician. Through use of the assessment, many remediable problems (for example, weakness, environmental hazards, orthostatic hypotension, drug side effects, gait dysfunction) were detected. At the end of the 2-year follow-up period, the intervention group had 26% fewer hospitalizations (P less than 0.05) and a 52% reduction in hospital days (P less than 0.01) compared with controls. Patients in the intervention group had 9% fewer falls and 17% fewer deaths than controls by 2 years, but these trends were not statistically significant. Our study suggests that falls are a marker of underlying disorders easily identifiable by a careful postfall assessment, which in turn can reduce disability and costs.

Post-hospital support program for the frail elderly and their caregivers: a quasi-experimental evaluation.

This paper evaluates the Post-Hospital Support Program for the frail elderly and their caregivers using a quasi-experimental design. The program goals were to reduce stress in the caregivers, improve functioning and reduce mortality in patients, and reduce health service utilization in patients. Subjects were patients at the Johns Hopkins Hospital in Baltimore, Maryland, age 65 or over, who were returning home to the care of a non-paid caregiver and who had extensive post-hospital care needs which were expected to continue for at least one year. The 93 comparison group patient/caregiver pairs were discharged between May 15, 1983 and May 14, 1984. The 98 treatment group pairs were discharged between May 15, 1984 and May 14, 1985. Interviews were conducted with patients and caregivers at 1, 3, 6, 9, and 12 months after discharge. Results showed a slight reduction in caregiver stress and a substantial reduction in hospital days used by the treatment group. When confounding and history effects are taken into consideration, an average difference of 6.5 days per patients remains. The data also suggest that the treatment program may have postponed some deaths and nursing home placements. The results suggest that support services for the frail elderly and their caregivers can be cost efficient by reducing hospital length-of-stay. Savings were estimated at $4,585 per patient per year in this study. However, further work is needed to design programs which more effectively reduce caregiver stress.

Defining and measuring stabilization of patients during 4 years of intensive community support.

The first 4 years of an intensive community support program were evaluated in terms of key variables of patient stabilization. Patients (N = 196) had previously demonstrated an inability to manage themselves without repeated and/or lengthy hospitalizations. During program participation, there were significant reductions in hospital days and events (80%), jail incarcerations and charges, billings per patient, and stressful events. Patients reported increased satisfaction both with their lives and the program. The results support the value of continued multidimensional and multimethod examinations of patient stabilization.

Continuous therapy with sulfamethoxazole-trimethoprim in patients with chronic granulomatous disease

In a retrospective study, the effect of long-term treatment with sulfamethoxazole-trimethoprim was evaluated in nine male patients with chronic granulomatous disease. During this treatment, a marked reduction was observed in the number of infectious episodes, the number of causative agents, and the number of surgical interventions. Furthermore, a significant reduction in days of hospitalization per year was found. The mean observation period was six years before and four years during treatment. Transient alopecia was observed in one patient during therapy. We conclude that prophylactic treatment with sulfamethoxazole-trimethoprim is beneficial in patients with chronic granulomatous disease.

Medical Care by Nurses

To the Editor.— This letter is prompted by the article of Spector et al (232:1234, 1975). The authors were not aware of our recent reports relating to outcome data and costs of the physician-backed nursing care provided chronic disease patients. 1,2 Our studies showed, as did Spector et al, that professional contacts increased after patients were transferred to nurse and physician care but differed in that hospital days were reduced by about 50% over a four-year period. The larger share of this reduction in hospital days was due to a decrease in the preventable complications of hypertension, diabetes, and cardiac disease. Our outcome data suggest that blood pressure levels in hypertensive patients and blood glucose values in diabetics are maintained adequately by the nurse physicianbacked nursing care. We also agree that the care provided in our program is not possible using algorithms but do find that detailed protocols define courses

Utilization and cost experience of low-income families in four prepaid group-practice plans.

Abstract A number of low-income families through arrangements supported by the Office of Economic Opportunity received medical care through four community-based prepaid group-practice plans. These families required six months to achieve a utilization level not exceeding that of the regular-plan members. As compared to national data, costs were less because of reductions in hospital days for the poor under prepaid group-practice arrangements. The average number of inpatient days per 1000 Office of Economic Opportunity enrollees was 600 days under the group plan; the national average for low-income persons under the age of 65 was about 1000 days. Cost differences between the low-income families and the regular-plan members were minimal when similar benefits were compared. A package of services including comprehensive physician services, prescriptions, mental health and hospital services cost from $137 to $180 per person per year. Support of broader health services may add from $47 to $65 per person per year to the cost. (N Engl J Med 289: 67–72, 1973)