Shorter Median Hospital Length Research Articles

Systematic review of the clinical effectiveness and cost-effectiveness of oesophageal Doppler monitoring in critically ill and high-risk surgical patients.

To assess the effectiveness and cost-effectiveness of oesophageal Doppler monitoring (ODM) compared with conventional clinical assessment and other methods of monitoring cardiovascular function. Electronic databases and relevant websites from 1990 to May 2007 were searched. This review was based on a systematic review conducted by the US Agency for Healthcare Research and Quality (AHRQ), supplemented by evidence from any additional studies identified. Comparator interventions for effectiveness were standard care, pulmonary artery catheters (PACs), pulse contour analysis monitoring and lithium or thermodilution cardiac monitoring. Data were extracted on mortality, length of stay overall and in critical care, complications and quality of life. The economic assessment evaluated strategies involving ODM compared with standard care, PACs, pulse contour analysis monitoring and lithium or thermodilution cardiac monitoring. The AHRQ report contained eight RCTs and was judged to be of high quality overall. Four comparisons were reported: ODM plus central venous pressure (CVP) monitoring plus conventional assessment vs CVP monitoring plus conventional assessment during surgery; ODM plus conventional assessment vs CVP monitoring plus conventional assessment during surgery; ODM plus conventional assessment vs conventional assessment during surgery; and ODM plus CVP monitoring plus conventional assessment vs CVP monitoring plus conventional assessment postoperatively. Five studies compared ODM plus CVP monitoring plus conventional assessment with CVP monitoring plus conventional assessment during surgery. There were fewer deaths [Peto odds ratio (OR) 0.13, 95% CI 0.02-0.96], fewer major complications (Peto OR 0.12, 95% CI 0.04-0.31), fewer total complications (fixed-effects OR 0.43, 95% CI 0.26-0.71) and shorter length of stay (pooled estimate not presented, 95% CI -2.21 to -0.57) in the ODM group. The results of the meta-analysis of mortality should be treated with caution owing to the low number of events and low overall number of patients in the combined totals. Three studies compared ODM plus conventional assessment with conventional assessment during surgery. There was no evidence of a difference in mortality (fixed-effects OR 0.81, 95% CI 0.23-2.77). Length of hospital stay was shorter in all three studies in the ODM group. Two studies compared ODM plus CVP monitoring plus conventional assessment vs CVP monitoring plus conventional assessment in critically ill patients. The patient groups were quite different (cardiac surgery and major trauma) and neither study, nor a meta-analysis, showed a statistically significant difference in mortality (fixed-effects OR 0.84, 95% CI 0.41-1.70). Fewer patients in the ODM group experienced complications (OR 0.49, 95% CI 0.30-0.81) and both studies reported a statistically significant shorter median length of hospital stay in that group. No economic evaluations that met the inclusion criteria were identified from the existing literature so a series of balance sheets was constructed. The results show that ODM strategies are likely to be cost-effective. More formal economic evaluation would allow better use of the available data. All identified studies were conducted in unconscious patients. However, further research is needed to evaluate new ODM probes that may be tolerated by awake patients. Given the paucity of the existing economic evidence base, any further primary research should include an economic evaluation or should provide data suitable for use in an economic model.

Long-term histological effects of preemptive antiviral therapy in liver transplant recipients with hepatitis C virus infection

The long-term effects of preemptive antiviral therapy on fibrosis progression in liver transplant recipients with hepatitis C virus (HCV) were examined in a cohort of consecutive liver transplant recipients who received preemptive antiviral therapy for 48 weeks (95% were virologic nonresponders). Control patients were transplanted during this same period but did not receive preemptive therapy. Patients were followed to the date of last biopsy and censored at the time of subsequent HCV treatment. Eighty-six patients surviving >/=90 days were included. Treated and control patients were similar, except that treated patients had longer histological follow-up (60 versus 50 months), a lower median Model for End-Stage Liver Disease score at liver transplant (17 versus 23), and a shorter median length of hospital stay (6 versus 9.5 days). In the uncensored analysis, the cumulative probability of a Batts-Ludwig fibrosis score >/= 2 at 48 months post-liver transplant was 22% in the preemptive therapy group and 49% in the nonpreemptive therapy group (P = 0.08). In multivariate analysis, preemptive therapy was associated with a 48% reduced risk of a fibrosis score >/= 2 (hazard ratio = 0.52, 95% confidence interval = 0.24-1.12, P = 0.09), but this failed to achieve statistical significance. Receipt of preemptive therapy was associated with a delay in subsequent HCV therapy for moderate to severe disease (fibrosis score >/= 2 or moderate necroinflammatory activity) with a median time of 36.3 months versus 20.3 months in the preemptive and nonpreemptive groups (P = 0.004). We conclude that preemptive antiviral therapy in virologic nonresponders delays the time to subsequent HCV treatment and may confer a reduced risk of fibrosis progression. Further study of preemptive antiviral therapy is warranted.

Rural Versus Urban Trauma: Demographic Influences on Autopsy Rates

The autopsy has long been considered the gold standard for quality assurance review. Studies characterizing autopsies have been completed in large urban centers, but there is a paucity of research regarding autopsies at rural trauma centers. This is problematic considering that a majority of preventable trauma deaths occur in rural areas and death rates for unintentional injuries in rural populations are higher than urban populations. Rural trauma centers have differing characteristics warranting further research into the demographic differences between rural and urban trauma patients and the effects on autopsy rates. This is a demographic study of a rural trauma center, University of Iowa Hospitals and Clinics (UIHC), with the goal of identifying characteristics of trauma patients on whom autopsy was performed. Four hundred ninety-six deaths were identified from the trauma registry between January 2002 and May 2007 (231 of which were autopsied) and demographic data (including age, race, length of hospital stay, etc.) regarding these patients was gathered into a database. Univariate and multivariate linear regression models were used to analyze differences between autopsied and non-autopsied trauma patients. Autopsy rate and basic demographics were also compared with 2 recent reports from urban trauma centers. Autopsied patients were younger than non-autopsied patients (mean age 45 y versus 71 y; P < 0.0001) and have a shorter median length of hospital stay (1 d versus 4 d; P < 0.0001). Autopsy rates for patients with blunt trauma were lower than rates for patients with penetrating or burn trauma (42% versus 67% and 56%; P = 0.004). If patients died while on a subspecialty service, they were less likely to have an autopsy. Compared with urban centers, this rural trauma center had lower autopsy rates, higher rates of blunt trauma, a higher mean age of deceased patients, and a lower percentage of males. UIHC, a rural trauma center, has a number of demographic characteristics that make it unique from urban trauma centers: an older population, lower percentage of male trauma patients, higher rates of blunt trauma, and lower rates of penetrating trauma. All of these factors influenced the lower rate of autopsies completed at rural trauma centers. Within a rural trauma center, those patients less likely to receive autopsy were older patients, those who died after 48 h in the hospital, and patients who suffered blunt injuries. The demographics of trauma patients most likely to receive an autopsy tend to correspond with those of an urban trauma population, thus providing a demographic explanation for the variation in autopsy rates among trauma systems.

A clinical pathway for patients undergoing primary cytoreductive surgery with rectosigmoid colectomy for advanced ovarian and primary peritoneal cancers

Objectives. To evaluate the safety, feasibility, and economic impact of a clinical pathway, including rapid diet advancement, for patients undergoing rectosigmoid colectomy as part of cytoreductive surgery for advanced ovarian and primary peritoneal cancers. Methods. Between 8/1/98 and 6/30/06, 64 consecutive patients met study inclusion criteria. Using case–control methodology, post-operative management was dictated by a prescribed clinical pathway in 19 patients (Group A) and directed by individual surgeon preference in 45 patients (Group B). Critical elements of the clinical pathway included: rapid diet advancement, early discontinuance of nasogastric suction, criteria-based utilization of parenteral nutrition, selective laboratory testing, and deferring initiation of chemotherapy until after discharge. Results. Stage IIIC/IV disease was present in 94% of all patients. The median time to flatus was 6 days for both groups ( p = 0.95); however, the median time to tolerance of diet was 3 days for Group A and 6 days for Group B ( p = 0.013). Compared to Group B, patients in Group A had a significantly shorter median length of hospital stay (7 days vs 10 days, p = 0.014) and lower median 30-day post-operative hospital cost ($19,700 vs $25,110, p = 0.028), with no significant difference in 30-day readmission rate (21% vs 33%, p = 0.379). Clinical pathway-directed management was associated with a median reduction in hospital cost of $5410 per patient. Conclusions. A critical pathway incorporating rapid diet advancement for patients undergoing primary cytoreductive surgery with rectosigmoid colectomy for ovarian and primary peritoneal cancers is feasible, safe, and associated with a significant reduction in length of hospital stay and hospital-related costs.

Factors Influencing Length of Stay after Primary Total Hip Replacement: The Role of Anaesthesia and the Anaesthetist

We studied 121 consecutive total hip replacements (THRs) in 109 patients in order to establish the influence of anaesthetic technique, anaesthetist concerned, age of the patient, and body mass index (BMI) on the length of hospital stay after primary total hip replacement. Patients received either general anaesthesia alone (50 THRs) or a combination of general and local anaesthesia (lumbar plexus block; 71 THRs) from three separate anaesthetists. Our analysis showed that those patients who received a combination of anaesthesia showed shorter median length of hospital stay (three days) than those who received general anaesthesia alone (five days; p<0.0001). The age of the patient was also critical (p=0.003) as was the anaesthetist concerned (p=0.01). BMI was unimportant.

Factors influencing length of stay after primary total hip replacement: the role of anaesthesia and the anaesthetist

We studied 121 consecutive total hip replacements (THRs) in 109 patients in order to establish the influence of anaesthetic technique, anaesthetist concerned, age of the patient, and body mass index (BMI) on the length of hospital stay after primary total hip replacement. Patients received either general anaesthesia alone (50 THRs) or a combination of general and local anaesthesia (lumbar plexus block; 71 THRs) from three separate anaesthetists. Our analysis showed that those patients who received a combination of anaesthesia showed shorter median length of hospital stay (three days) than those who received general anaesthesia alone (five days; p<0.0001). The age of the patient was also critical (p=0.003) as was the anaesthetist concerned (p=0.01). BMI was unimportant.

Does age affect benefits of stroke unit rehabilitation?

The influence of age on benefits of stroke unit rehabilitation is largely unknown. A prospective controlled study was undertaken in 245 stroke survivors randomized to a stroke unit or to general wards 2 weeks after stroke. Patients were divided into older (75 years and over) and younger (under 75 years) age groups, and their characteristics, prognosis, duration, and type of therapy input and outcome were compared in different settings. Younger (n = 101) and older (n = 144) stroke patients were comparable for neurological and functional deficits and were distributed equally between the stroke unit and general wards. The duration of therapy input was similar in younger patients in either setting. Older patients received more occupational therapy in both settings (10.7 +/- 2.4 versus 7.9 +/- 04.1) and more physiotherapy (18.4 +/- 9.6 versus 15.2 +/- 7.8) on general wards. Younger patients on the stroke unit showed better outcome compared with those on general wards (discharge home, 83% versus 60%; median Barthel score, 17 versus 13; median length of hospital stay, 27 versus 56 days) and with older patients on the stroke unit (discharge home, 83% versus 65%; median Barthel score, 17 versus 14). Outcome in older stroke patients was similar in both settings except for a shorter median length of hospital stay on the stroke unit (36 versus 84 days). Outcome in younger patients managed on general wards was worse than that in older patients with similar prognostic expectations (discharge home, 41% versus 61%; median Barthel score, 11 versus 13). Younger stroke patients benefited more by stroke unit rehabilitation compared with older patients, not only because of their age but also because of differences in the multidisciplinary input available for elderly patients outside the stroke unit.