Total Inpatient Costs Research Articles

Medical Care Improves When Psychiatrists, Internists Join Forces

Medical Care Improves When Psychiatrists, Internists Join Forces

Cost of Chronic Hepatitis B Virus Infection in Taiwan

To estimate the direct medical costs involved in the treatment of chronic hepatitis B (CHB) patients in Taiwan from a public resource perspective. Taiwan is a hepatitis B virus (HBV)-hyperendemic area that has considerable expertise in conducting hepatitis studies. To date, however, these studies have focused on basic science or clinical research associated with hepatitis B, and little attention has been paid to the social and monetary consequences of treatment and vaccination programs in Taiwan. Total per-patient annual costs were calculated for each of five disease states associated with hepatitis B infection. Claims data of National Health Insurance in 2000 were used to identify patients with CHB and to estimate breakdown costs of their medical usage. Medical costs included hospital admissions and outpatient visits, with fees being reimbursed by the National Health Insurance system and patient co-payments. The average total costs per patient for each disease state in the year 2000 were as follows: CHB without cirrhosis, 4905 new Taiwan dollars (NT dollars); compensated cirrhosis, NT 6,574 dollars; decompensated cirrhosis, NT 36,621 dollars; hepatocellular carcinoma, NT 95,741 dollars; and liver transplantation, NT 199,725 dollars. These values indicate that, as the disease progresses, the cost of medical care increases significantly. The total inpatient cost for CHB infection in Taiwan for the year 2000 was almost NT 800 million dollars, which accounts for approximately 1% of the total inpatient expenditure. CHB is a significant burden on the Taiwanese healthcare system that could be limited by slowing or reversing liver disease progression.

Health-Care Costs and Exercise Capacity

While the beneficial effect of exercise capacity on mortality is well-accepted, its effect on health-care costs remains uncertain. This study investigates the relationship between exercise capacity and health-care costs. The Veterans Affairs Health Care System recently implemented a Decision Support System that provides data on patterns of care, patient outcomes, workload, and costs. Total inpatient and outpatient costs were derived from existing administrative and clinical data systems, were adjusted for relative value units, and were expressed in relative cost units. We used univariable and multivariable analyses to evaluate the 1-year total costs in the year following a standard exercise test. Costs were compared with exercise capacity estimated in metabolic equivalents (METs), other test results, and clinical variables for 881 consecutive patients who were referred for clinical reasons for treadmill testing at the Palo Alto Veterans Affairs Health Care System facility between October 1, 1998, and September 30, 2000. The patients had a mean age of 59 years, 95% were men, and 74% were white. Eight patients (< 1%) died during the year of follow-up. Exercise testing showed an average maximum heart rate of 138 beats/min, 8.2 METs, and a peak Borg scale of 17. In unadjusted analysis, costs were incrementally lower by an average of 5.4% per MET increase (p < 0.001). In a multivariable analysis adjusting for demographic variables, treadmill test performance and results, and clinical history, METs were found to be the most significant predictor of cost (F-statistic, 21.8; p < 0.001). These findings are consistent with the hypothesis that exercise capacity is inversely associated with health-care costs.

Surgical workload and cost of postoperative adhesion-related intestinal obstruction: importance of previous surgery.

Postoperative intraabdominal adhesions cause morbidity of varying degree. Intestinal obstruction is the most severe complication of adhesions. This study examined the importance of previous surgery on clinical and economic workloads caused by intestinal obstruction due to postoperative intraabdominal adhesions. All emergency hospitalizations due to adhesion-related intestinal obstruction from January 1, 1999 to December 31, 1999 in a hospital district serving roughly 450,000 inhabitants was reviewed retrospectively. The patient population was divided into six groups according to the site of previous surgery, and the total as well as group-related surgical workload and direct costs of inpatient care were analyzed. There were 123 hospitalizations due to postoperative adhesion-related intestinal obstruction during the study period. A total of 101 patients had experienced 176 operations. The most prevalent operations were colorectal (with or without other operations), upper abdominal, and female reproductive system procedures. Colorectal surgery preceded 40% and 38% of inpatient episodes and inpatient days, respectively. Altogether, 40 operations were performed because of adhesion-related intestinal obstruction. No differences between groups were seen in terms of the mean operating or theater time. Total annual inpatient costs due to emergency hospitalizations for intestinal adhesion-related obstruction related to colorectal surgery in a hospital district serving roughly 450,000 inhabitants was 72,520.60 (U.S. dollars) which accounted for 35.3% of all annual costs caused by postoperative adhesion-related intestinal obstructions. There were no significant differences between groups regarding the total mean inpatient episode costs. Intestinal obstruction due to postoperative adhesions poses substantial costs for the society. Colorectal operations are the most important procedures preceding adhesion-related intestinal obstruction, accounting for 35.3% to 46.8% of the total clinical workload or costs attributable to postoperative adhesion-related obstruction.

Diabetes-related utilization and costs for inpatient and outpatient services in the Veterans Administration.

-The purpose of this study was to calculate the total number of inpatient hospitalizations, outpatient clinic visits, and total direct health care costs associated with veterans with diabetes receiving care in Veterans Administration (VA) facilities. RESEARCH DESIGN AND METHODS-The number of inpatient hospitalizations is tracked for years 1994-1998, and outpatient clinic visits are tracked for years 1997 and 1998. Trends in utilization across different age and racial groups, as well as total direct inpatient and outpatient costs for 1998, are presented. -Between 1994 and 1998, hospitalization rates decreased from 1.68 to 1.61. The average number of outpatient visits was 4.5 in 1997 and 4.6 in 1998. VA incurred $214.8 million in outpatient expenditures and $1.45 billion in inpatient expenditures for veterans with diabetes receiving VA care. -Health care delivery systems and payors track the cost and utilization of services by specific patient groups to support disease management, quality improvement, external reporting, and cost containment. Tracking the utilization and cost of diabetes care is necessary to understand the financial impact of diabetes on health care systems and the overall burden of diabetes on individuals.

Comparative estimates of the financial burden to the UK health system of hospital care for people with and without diabetes in the year before death

Objective: To quantify hospital costs prior to death for patients with and without diabetes. Research design and methods: Using the Cardiff Diabetes Database, mortality data from the UK Office of National Statistics for 1996 were linked to existing hospital records using probability matching techniques. Costs were attributed using a statistical costing technique (healthcare resource groups (HRGs)) with UK 2000 prices. Results: There were 4394 deaths of which 412 (9.4%) were for patients with diabetes. In the year before death 380 (92%) patients with diabetes (DM+) were admitted as an inpatient compared with 73% of those without diabetes (DM−), a relative rate of 1.27. Total inpatient costs were UK£ 12.2M (US$ 20M) of which costs for patients with diabetes were UK£ 1.6M (US$ 2.6M), accounting for 15.6% of revenue. This translates to a rate of UK£ 2.8M (US$ 4.0M) per 100,000 population per year. The mean annual inpatient cost before death was UK£ 3997 (US$ 5676) for DM+ compared with UK£ 2656 (US$ 3772) for DM−. Mean annual outpatient costs ranged from UK£ 185 (US$ 263: year minus 4) to UK£ 248 (US$ 352: year minus 2) in DM+, and UK£ 91 (US$ 129: year minus 4) to UK£ 116 (US$ 165: year minus 2) in DM−. Mean annual outpatient costs associated with the care of people with diabetes are consistently higher: +80% at minus 1-year rising to +120% at minus 3 years. Conclusions: The costs of inpatient care for all patients increases markedly in the final year of life. People with diabetes were found to be more financially costly, even in this stage of their care, than were people who did not have diabetes.

Health care costs and exercise capacity

Background: While the beneficial effect of exercise capacity on mortality is well-accepted, its effect on health-care costs remains uncertain. This study investigates the relationship between exercise capacity and health-care costs. Methods: The Veterans Affairs Health Care System recently implemented a Decision Support System that provides data on patterns of care, patient outcomes, workload, and costs. Total inpatient and outpatient costs were derived from existing administrative and clinical data systems, were adjusted for relative value units, and were expressed in relative cost units. We used univariable and multivariable analyses to evaluate the 1-year total costs in the year following a standard exercise test. Costs were compared with exercise capacity estimated in metabolic equivalents (METs), other test results, and clinical variables for 881 consecutive patients who were referred for clinical reasons for treadmill testing at the Palo Alto Veterans Affairs Health Care System facility between October 1, 1998, and September 30, 2000. Results: The patients had a mean age of 59 years, 95% were men, and 74% were white. Eight patients (< 1%) died during the year of follow-up. Exercise testing showed an average maximum heart rate of 138 beats/min, 8.2 METs, and a peak Borg scale of 17. In unadjusted analysis, costs were incrementally lower by an average of 5.4% per MET increase (p < 0.001). In a multivariable analysis adjusting for demographic variables, treadmill test performance and results, and clinical history, METs were found to be the most significant predictor of cost (F-statistic, 21.8; p < 0.001). Conclusion: These findings are consistent with the hypothesis that exercise capacity is inversely associated with health-care costs. (CHEST 2004; 126:608 – 613)

Cost analysis of myomectomy, hysterectomy, and uterine artery embolization

Objective: The purpose of this study was to compare inpatient hospital costs of different treatments of uterine fibroid tumors, including myomectomy, hysterectomy, and uterine artery embolization in a teaching hospital. Study Design: We reviewed the hospital database of 545 women with uterine fibroid tumors who were treated with abdominal myomectomy, total abdominal hysterectomy, vaginal hysterectomy, and uterine artery embolization between April 1997 and October 2001. Results: Women who underwent hysterectomies and uterine artery embolization were significantly older than the women who underwent myomectomy. Uterine artery embolization was associated with the shortest hospital stay, although the hospital stay in the vaginal hysterectomy group was shorter than in the abdominal myomectomy and the total abdominal hysterectomy groups. Compared with other groups, the inpatient cost of nursing in the uterine artery embolization group was the lowest. The total inpatient cost of uterine artery embolization ($1007.44 ± $60.65 [Canadian dollars]) was significantly lower than the cost of total abdominal hysterectomy ($1933.37 ± $47.68 [Canadian dollars]), abdominal myomectomy ($1781.73 ± $47.16 [Canadian dollars]), and vaginal hysterectomy ($1515.39 ± $66.72 [Canadian dollars]; P <.001). Sixteen of the 85 patients (18.8%) were hospitalized after uterine artery embolization, mainly for abdominal pain. Conclusion: Compared with abdominal myomectomy, abdominal hysterectomy, and vaginal hysterectomy, uterine artery embolization is associated with a lower hospital cost and a shorter hospital stay. Hospitalization after uterine artery embolization is mainly for abdominal pain after the procedure. A better method of pain control to reduce the rate of hospitalization and its cost is needed. (Am J Obstet Gynecol 2002;187:1401-4)

End-stage renal disease in the Northern Territory: current and future treatment costs.

To compare hospital costs of Aboriginal and non-Aboriginal patients having haemodialysis treatment and forecast the future treatment cost. The costs of patients with HD in the "Top End" of Australia's Northern Territory were estimated for the financial years 1996/97 and 1997/98 using a hospital costing model. We used an Autoregression Integrated Moving Average model to predict future demand. 165 patients (101 Aboriginal and 64 non-Aboriginal) were treated at a total cost of $12.4 million in this two-year period. These 165 patients represented 0.7% of inpatients, 8.8% of total inpatient costs and 31.6% of total inpatient episodes of care in the Top End region. $9.5 million (77%) was spent on routine haemodialysis treatment and $2.9m (23%) on other hospitalisations. The average cost per routine haemodialysis treatment over the two-year period was $527, or $78 600 per patient treatment year. Hospitalisations for comorbidities occurred in 86% of Aboriginal and 39% of non-Aboriginal patients. Average cost per patient, number of admissions and length of hospital stays were all significantly greater for Aboriginals. We predict an average increase in the number of treatments of 12% each year over the next five years and a five-year cost of $49.8m. A multipronged strategy designed to reduce the prevalence and costs of renal failure is required.

Economic implications of current surgical management of gastroesophageal reflux disease

Background/Purpose: Surgical management of gastroesophageal reflux disease in children has evolved with the development of laparoscopy. Because concerns persist regarding increased costs associated with this technique, the authors studied the economic parameters of antireflux surgery at their institution. Methods: Seventy-eight patients undergoing either laparoscopic or open fundoplication were studied retrospectively between June 1998 and June 2000 comparing average operating room costs, total inpatient costs, and length of stay. Univariate comparisons were performed using Student's t test, and multivariate analysis was performed using multiple linear regression. Results: Univariate analysis showed that patients receiving the laparoscopic procedure had significantly shorter inpatient stays (2.4 v. 3.96 days; P = .004) than those receiving open procedures. Average operating room costs were similar (laparoscopic, $2,611; open, $2,162; P = .237), but total costs for the laparoscopic procedure were lower ($4,484 v $5,129; P = .006). Multivariate analysis results suggested that in addition to procedure type, patients who required an intensive care unit admission incurred $6,595 in additional total costs ( P [lt ] .0001) and 4.8 additional hospital days ( P [lt ] .0001). After controlling for other variables, the laparoscopic procedure did not significantly reduce total hospital costs ($447; P = .192) but was associated with a significant decrease in length of stay of 1.3 days ( P [lt ] .0001). Conclusion: These results suggest that laparoscopic procedures are comparable with open operations in terms of operative costs and that other factors are important determinants of the costs associated with antireflux surgery in children.

Two methods of estimating health costs linked to alcoholism in France (with a note on social costs)

The health costs of alcohol-related problems in France were estimated using two cost evaluation approaches: (1) estimate based on the proportion of cases attributable to alcohol abuse (the alcohol abuse factor); (2) estimate based on prevalence of alcohol abuse for in- and out-patients. For a 10% prevalence of alcohol abuse in the general population, the minimum cost in 1996 was about US$ 2300 million; for a prevalence of 15% it was US$ 2700 million. This cost concerns the health disorders that are linked directly or indirectly to alcohol abuse. It did not allow for injuries from accidents caused by alcohol intoxication and undervalued the cost of out-patient care. Based on the prevalence of alcohol-related disorders seen at hospitals, a percentage of the total in-patient and out-patient costs due to effects of alcohol could be estimated. However, this did not permit an estimate of the cost of care in which alcohol abuse was a risk factor only. Based on the available data showing that between 3% and 10% of inpatients have a directly alcohol-related condition, estimates of in-patient treatment costs varied from US$ 1300 to 2100 million. Among adult out-patients, 20% present with a disorder in which alcohol is a factor or suffer from an alcohol-related illness, which corresponds to a cost of about US$ 1600 million. Thus, these methods yield minimum year's cost estimated between US$ 2500 and 3300 million. These costs are high, compared to the low level of financing for the specialized facilities offering treatment to people in difficulty due to alcohol excess, which was US$ 23 million in that year. As regards social and total costs, estimates from four Western countries have found that about 75% of the total costs of alcohol abuse was attributable to social harm, and 25% to medical costs. Applying this ratio to the French data gives an estimated total cost to French society of about US$ 13 200 million, i.e. 1.04% of the gross national product.

The inpatient care of patients with diabetes mellitus and foot ulcers. A validation study of the correspondence between medical records and the Swedish Inpatient Registry with the consequences for cost estimations.

To compare the correspondence of discharges and diagnoses between medical records and an administrative database in diabetic patients with foot ulcers and to calculate inpatient costs from the different sources. Discharge data from 117 prospectively followed patients were compared with information from the Swedish Inpatient Registry during the same treatment period for each patient. Non corresponding discharges were retrospectively reviewed in patient records. Costs of inpatient care were calculated from clinical sources and from data selected in three different ways from the database. Information in medical records was assumed to represent the 'Gold Standard'. In-hospital treatment, multidisciplinary foot-care team. A total of 117 diabetic patients with deep foot infections. Degree of database completeness and inpatient costs. The degree of completeness of discharges in the database was 98%, but 8.6% of discharges had no code for diabetes and 13% were registered without any foot related diagnosis code. Less than 20% of discharges were found with selection based on primary diagnosis 250.G only. Total inpatient costs varied from 2.7 to 13.3 million SEK (Swedish Kronor) depending on selected diagnosis codes. Approximately 84% of all foot ulcer discharges could be found in the database if codes with both diabetes mellitus and foot ulcer diagnoses were selected. Inpatient costs for foot complications cannot be accurately estimated from the Inpatient Registry when based on primary diagnosis exclusively. Fairly good estimates at a low data acquisition cost can be made with a combination of foot related diagnoses together with codes for diabetes.

Cost of treating an episode of variceal bleeding in a VA setting

OBJECTIVES: The specific aims of this study were to develop a demographic description of a sample of patients presenting with bleeding esophageal varices and determine the direct health care costs of variceal bleeding. METHODS: This was a retrospective evaluation of patients who underwent esophagogastroduodenoscopy at the Portland VA Medical Center between January 1993 and May 1997. Data sources included both electronic databases and patient medical charts. The primary unit of analysis was an episode of care, defined as an index bleed plus 6 months of follow-up or death, whichever came first. RESULTS: The total inpatient direct cost was $1,566,904 and outpatient direct cost was $104,611, for a total of $1,671,515 for 100 bleeding episodes in 79 patients. Episodes of care for patients receiving ≤2 units of packed red blood cells were approximately a third as costly as those receiving >2 units of packed red blood cells (n = 17, $6,470 and n = 83, $17,553). The difference in costs was statistically significant ( p < 0.05), and primarily attributable to hospital bed costs. CONCLUSIONS: There is a substantial financial burden associated with this illness, primarily attributable to inpatient costs. In addition to severity of bleeding, Child’s class, endoscopic findings, and the timing of pharmacological therapy seem to influence the overall cost of managing esophageal varices.

Cost of Treating An Episode of Variceal Bleeding in A Va Setting

The specific aims of this study were to develop a demographic description of a sample of patients presenting with bleeding esophageal varices and determine the direct health care costs of variceal bleeding. This was a retrospective evaluation of patients who underwent esophagogastroduodenoscopy at the Portland VA Medical Center between January 1993 and May 1997. Data sources included both electronic databases and patient medical charts. The primary unit of analysis was an episode of care, defined as an index bleed plus 6 months of follow-up or death, whichever came first. The total inpatient direct cost was $1,566,904 and outpatient direct cost was $104,611, for a total of $1,671,515 for 100 bleeding episodes in 79 patients. Episodes of care for patients receiving < or =2 units of packed red blood cells were approximately a third as costly as those receiving >2 units of packed red blood cells (n = 17, $6,470 and n = 83, $17,553). The difference in costs was statistically significant (p < 0.05), and primarily attributable to hospital bed costs. There is a substantial financial burden associated with this illness, primarily attributable to inpatient costs. In addition to severity of bleeding, Child's class, endoscopic findings, and the timing of pharmacological therapy seem to influence the overall cost of managing esophageal varices.

Hospital cost of endovascular versus open repair of abdominal aortic aneurysms: A multicenter study

Background: Technology-driven innovation in medicine is frequently associated with higher costs than conventional therapy. A significantly higher cost for endovascular ($21,250, n = 190) versus open abdominal aortic aneurysm (AAA) repair ($12,342, n = 60) was suggested by a direct cost analysis of patients in a multicenter trial. Estimated inpatient costs (not charges) incurred nationwide by hospitals for endovascular and open repair of AAA were studied to validate these observed trends.Methods: A retrospective analysis of 131 patients undergoing endovascular AAA repair was compared with 49 patients undergoing open repair as part of a Food and Drug Administration phase II prospective multicenter clinical investigation (AneuRx-Medtronic). A model to estimate costs was constructed using important clinical descriptors of these patients. These clinical characteristics where then matched with those from 22,460 patients undergoing AAA repair obtained from a large national database (Medicare Provider Analysis and Review). Estimated hospital cost was then assigned to each study patient according to the national average of the total hospital costs for the respective matched patients in Medicare Provider Analysis and Review.Results: Total inpatient hospital costs of endovascular repair were significantly higher than that of open repair ($19,985 ± 7396 versus $12,546 ± 5944, respectively, P =.0001). Endograft device cost ($10,400) accounted for 52% of the total cost of endovascular repair. The 1999 mean blended Medicare reimbursement for AAA repair was $18,989.Conclusion: In this early development stage, hospital cost for endovascular AAA repair is significantly greater than open repair when device cost greatly exceeds $5000. Although incremental reductions in cost of endovascular repair may be anticipated if use of diagnostic studies, operating time, and length of stay decrease, device cost has the single greatest impact on the expense of endovascular AAA repair. At current device pricing, mean blended Medicare reimbursement does not cover the cost of endovascular AAA repair.

Cost of health care for a community of older adults in an urban academic healthcare system.

Urban academic medical centers provide care for large populations of vulnerable older adults. These patients often suffer a disproportionate share of chronic illnesses, disabilities, and social stressors that may increase health care costs. To describe the distribution and content of total healthcare costs accrued over a 4-year period by a community of older adults cared for in an urban academic healthcare system and to describe high-cost patients and utilization patterns. A cohort study. A tax-supported public healthcare system consisting of a 450-bed hospital and seven community-based ambulatory care centers. 12,581 patients aged 60 years and older who had at least two ambulatory visits and/or one hospitalization within the healthcare system from 1993 through 1995. Patient demographic and clinical characteristics, hospital and ambulatory utilization rates, and all healthcare costs accrued from 1993 through 1996 were determined. Costs were estimated from the perspective of the healthcare system using cost to charge ratios. The mean patient age was 70 years, 60% were women, 44% were Black, and 83% were covered by Medicare and/or Medicaid. Nearly 25% of patients were obese, 15.8% had a history of smoking, and 15.5% had evidence of malnutrition. The mean number of ambulatory visits per year was 4.3 (+/-7.2), and 38.1% of patients had been hospitalized one or more times. Within the 4-year window, 24.1% of patients had missed five or more appointments with their primary care physicians, 32.7% of patients had five or more unscheduled clinic visits, and 12.5% had five or more emergency room visits. Total health care costs for 4 years for this cohort of older adults was $125.2 million dollars, with per capita annual mean costs of $3893. Expenditures associated with hospitalizations accounted for 63.6% of healthcare costs. Total inpatient and outpatient costs for the 38% of patients hospitalized at least once accounted for 85.3% of all health care expenditures. Patients who died in the hospital did not accrue significantly greater costs than patients who died out of the hospital. Simulations of a random 5% adverse selection of high-cost patients among two capitated systems resulted in cost shifts of $11.1 million. Recorded smoking history, obesity, and low serum albumin were significantly associated with excess costs. Healthcare costs are concentrated in a significant minority of older adults. Costs accrued in conjunction with hospital stays dominate healthcare expenditures for this cohort of older adults. However, most older adults (83%) have one or fewer hospital episodes in a 4-year period. Although patients who died accrued greater healthcare costs, these costs were not higher when the death occurred in the hospital. Self-care behaviors are an important target for interventions to reduce costs.

Teaching hospital costs: implications for academic missions in a competitive market.

As the managed care environment demands lower prices and a greater focus on primary care, the high cost of teaching hospitals may adversely affect their ability to carry out academic missions. To develop a national estimate of total inpatient hospital costs related to graduate medical education (GME). Using Medicare cost report data for fiscal year 1993, we developed a series of regression models to analyze the relationship between inpatient hospital costs per case and explanatory variables, such as case mix, wage levels, local market characteristics, and teaching intensity (the ratio of interns and residents to beds). A total of 4764 nonfederal, general acute care hospitals, including 1014 teaching hospitals. Actual direct GME hospital costs and estimated indirect GME-related hospital costs based on the statistical relationship between teaching intensity and inpatient costs per case. In 1993, academic medical center (AMC) costs per case were 82.9% higher than those for urban nonteaching hospitals (actual cost per case, $9901 vs $5412, respectively). Non-AMC teaching hospital costs per case were 22.5% higher than those for nonteaching hospitals (actual cost per differences in case, $6630 vs $5412, respectively). After adjustment for case mix, wage levels, and direct GME costs, AMCs were 44% more expensive and other teaching hospitals were 14% more costly than nonteaching hospitals. The majority of this difference is explained by teaching intensity. Total estimated US direct and indirect GME-related costs were between $18.1 billion and $22.8 billion in 1997. These estimates include some indirect costs, not directly educational in nature, related to clinical research activities and specialized service capacity. The cost of teaching hospitals relative to their nonteaching counterparts justifies concern about the potential financial impact of competitive markets on academic missions. The 1997 GME-related cost estimates provide a starting point as public funding mechanisms for academic missions are debated. The efficiency of residency programs, their consistency with national health workforce needs, financial benefits provided to teaching hospitals, and ability of AMCs to maintain higher payment rates are also important considerations in determining future levels of public financial support.

Hospital discharges for diabetic foot disease in New Zealand: 1980–1993

The aim of this study was to determine the prevalence of hospital discharges for diabetic foot disease from 1980 to 1993 in New Zealand and identify regional variations. Data from the International Classification of Disease (ICD) discharge codes for diabetes and its complications from 1980 to 1993 were reviewed for diabetic foot disease. The total number of discharges/100 000 total population has increased from 13.56 in 1980 to 25.79 in 1993. The age and sex-standardised total bed/days per 1000 total population increased from 5.02 in 1980 to 5.85 in 1993. The total inpatient cost for the management of diabetic foot disease in New Zealand (population 3.3 million) for 1993 is estimated to be in the region of NZ$10–11 million (USD$7–7.7 million), indicating the need to put strategies in place to manage this problem. Strategies that reduce the individual and inpatient burden of this advanced stage complication of diabetes mellitus can be implemented easily for a relatively modest cost.

REDUCING INPATIENT ANTIBIOTIC COSTS.

Antibiotic use accounts for a significant portion of total inpatient costs, and prior studies suggest that up to two-thirds of treated patients may

Do clinical pathways for major vascular surgery improve outcomes and reduce cost?

This study was performed to determine whether the implementation of clinical pathways for patients who undergo major vascular procedures in a community hospital would shorten the length of stay and reduce charges when compared with Medicare standards. Length of stay, hospital costs, and morbidity, mortality, and readmission rates for the four most common vascular diagnosis-related group (DRG) categories at our institution were compared with Medicare standards. The four categories were DRG 005 (extracranial vascular procedures), DRG 110 (aortic and renal procedures), DRG 478 (leg bypass with comorbidity), and DRG 479 (leg bypass without comorbidity). Between May 1, 1994, and June 30, 1996, 112 patients underwent carotid endarterectomy, 42 patients underwent aortic or renal procedures, and 130 patients underwent lower extremity bypass procedures (68% with comorbidity). Only Medicare patients were included because exact cost/reimbursement data were available. No admissions were excluded. The average length of stay was 1.2 days for DRG 005, 6.9 days for DRG 110, and 3.2 and 2.1 days for DRGs 478 and 479, respectively. The average cost savings when compared with the Medicare reimbursement was $4338 for DRG 005, $7161 for DRG 110, $4108 for DRG 478, and $2313 for DRG 479. Readmission was necessary for 9% of peripheral bypass patients. Ten percent of patients in DRG 005 and 86% of patients in DRG 110 needed intensive care, whereas only 2% of patients who underwent complicated bypass procedures did. Ninety percent of carotid endarterectomy patients and 23% of leg bypass patients were discharged on the first postoperative day. There were two postoperative strokes (2%) after carotid surgery. Thirty-three percent of aortic/renal patients had complications that led to care outside the clinical pathway. Twenty-five percent of leg bypass patients required home care to treat open foot wounds. Total inpatient cost savings were $1,256,000 when compared with Medicare reimbursement. Clinical pathways significantly improve the length of stay and decrease inpatient charges for major vascular surgical procedures while maintaining high standards of care. Factors that favorably affected the length of stay and hospital charges were outpatient arteriography, same-day admission, early ambulation, physical therapy, home care, use of the intensive care unit on a selective basis, and early discharge. Factors that adversely affected these outcomes were emergency admission, inpatient arteriography, thrombolytic therapy, complications, and the need for dialysis or anticoagulation.