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Hospital costs for treatment of acute heart failure: economic analysis of the REVIVE II study.

Eur J Health Econ. 2010 Apr;11(2):185-93

Authors: de Lissovoy G, Fraeman K, Teerlink JR, Mullahy J, Salon J, Sterz R, Durtschi A, Padley RJ

BACKGROUND: Acute heart failure (AHF) is the leading cause of hospital admission among older Americans. The Randomized EValuation of Intravenous Levosimendan Efficacy (REVIVE II) trial compared patients randomly assigned to a single infusion of levosimendan (levo) or placebo (SOC), each in addition to local standard treatments for AHF. We report an economic analysis of REVIVE II from the hospital perspective. METHODS: REVIVE II enrolled patients (N = 600) hospitalized for treatment of acute decompensated heart failure (ADHF) who remained dyspneic at rest despite treatment with intravenous diuretics. Case report forms documented index hospital treatment (drug administration, procedures, days of treatment by care unit), as well as subsequent hospital and emergency department admissions during follow-up ending 90 days from date of randomization. These data were used to impute cost of admission based on an econometric cost function derived from >100,000 ADHF hospital billing records selected per REVIVE II inclusion criteria. RESULTS: Index admission mean length of stay (LOS) was shorter for the levo group compared with standard of care (SOC) (7.03 vs 8.96 days, P = 0.008) although intensive care unit (ICU)/cardiac care unit (CCU) days were similar (levo 2.88, SOC 3.22, P = 0.63). Excluding cost for levo, predicted mean (median) cost for the index admission was levo US $13,590 (9,458), SOC $19,021 (10,692) with a difference of $5,431 (1,234) favoring levo (P = 0.04). During follow-up through end of study day 90, no significant differences were observed in numbers of hospital admissions (P = 0.67), inpatient days (P = 0.81) or emergency department visits (P = 0.41). Cost-effectiveness was performed with a REVIVE-II sub-set conforming to current labeling, which excluded patients with low baseline blood pressure. Assuming an average price for levo in countries where currently approved, there was better than 50% likelihood that levo was both cost-saving and improved survival. Likelihood that levo would be cost-effective for willingness-to-pay below $50,000 per year of life gained was about 65%. CONCLUSIONS: In the REVIVE II trial, patients treated with levo had shorter LOS and lower cost for the initial hospital admission relative to patients treated with SOC. Based on sub-group analysis of patients administered per the current label, levo appears cost-effective relative to SOC.

PMID: 19582491 [PubMed - indexed for MEDLINE]

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Numbers needed to hospitalize-risks and benefits of admission in the new decade.

Eur J Intern Med. 2010 Jun;21(3):233-5

Authors: Subbe CP, Gemmell L

While hospitals are central to western style health care systems it is unclear which patients benefit from hospitalization and who might be put at risk. The high cost means that reasons for hospitalization will need to be reviewed in the current economic climate. Accepted grounds for hospitalization include life threatening illness, diagnostic uncertainty with the threat of deteriorating health, the need for specialist expertise or experience or the need for nursing care, including the care of the dying. Some of the traditional surveillance functions of the hospital can now be taken over by technology or alternative settings. These changes will lead to a blurring of margins between Outpatient, Inpatient and Critical Care. Beyond the care of the critically ill patient it is unlikely that all patients currently admitted to hospital benefit from this process and would be admitted in future. A generally accepted system for risk assessment of medial inpatients is urgently needed to allow researchers to examine the effectiveness of health care systems involving hospitalization and the circumstances under which hospitalization is cost effective and improves mortality, morbidity and patient reported outcomes.

PMID: 20493429 [PubMed - indexed for MEDLINE]

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Patients imaged early during admission demonstrate reduced length of hospital stay: a retrospective cohort study of patients undergoing cross-sectional imaging.

J Am Coll Radiol. 2010 Apr;7(4):269-76

Authors: Batlle JC, Hahn PF, Thrall JH, Lee SI

PURPOSE: The aim of this study was to relate the early use of advanced imaging to length of hospital stay. MATERIALS AND METHODS: Among all 33,226 admissions to an urban tertiary care hospital in 2005, the authors identified the 10,005 admissions (30.1%) that included >or=1 advanced imaging study (CT, MRI, or nuclear scintigraphy) during the period from 1 day before admission (day -1) through discharge. The length of stay was calculated, and using the date of the first advanced imaging study performed relative to date of admission (date of service), the residual length of stay (length of stay minus date of service) of each admission was also calculated. For admissions of >or=3 days in duration, the mean length of stay of patients with early imaging (on day -1 or 0) was compared using t test to that of patients with later imaging (on day 1 or 2). For all admissions with advanced imaging, linear regression analysis was applied to length of stay and residual length of stay as a function of date of service. Similar analysis was performed on subgroups classified by examination type (modality and body part) and International Classification of Diseases, Ninth Revision (ICD-9) diagnostic code. RESULTS: The mean length of stay was significantly shorter for those imaged on day -1 or 0 compared with day 1 or 2 for all admissions of >or=3 days (8.6 vs 9.0 days, P = .015) and for the following specific subgroups: abdominal CT (8.4 vs 9.7 days, P = .003) and neurologic MR examination types (7.6 vs 8.7 days, P = .03) and abdominal ICD-9 codes (7.5 vs 8.8 days, P = .007). A statistically significant positive correlation was noted between length of stay and date of service for all admissions (slope, 0.27; P < .001) and for the following subgroups: neurologic CT, chest CT, abdominal CT, and nuclear scintigraphy examination types and abdominal ICD-9 codes. CONCLUSION: Early imaging with CT, MRI, or nuclear scintigraphy, particularly on the day before or the day of admission, was associated with significantly shorter lengths of stay of inpatients compared with patients who underwent advanced imaging later.

PMID: 20362942 [PubMed - indexed for MEDLINE]

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Attending and resident physician perceptions of an EMR-generated rounding report for adult inpatient services.

Fam Med. 2010 May;42(5):343-9

Authors: Kochendorfer KM, Morris LE, Kruse RL, Ge BG, Mehr DR

BACKGROUND: With limited work hours, efficient rounding and effective hand-offs have become essential. We created a completely electronic medical record (EMR)-generated rounding report for use during pre-rounding, team rounds, and sign-out/hand-offs. We hypothesized that this would reduce workloads. METHODS: We used a pre- and post-implementation survey of the residents and faculty members of the Departments of Family and Community Medicine and Internal Medicine. RESULTS: After 5 months of use, residents and attending physicians reported a daily time savings of 44 minutes. Seventy-six percent of users also agreed that the rounding report improved patient safety. Rounding report users were more satisfied with the rounding process, spent less time updating other lists or documents, and less time pre-rounding. In addition, there were trends toward spending more time with patients, adherence to work-hour rules, increased accuracy of information during sign-out, improved satisfaction, confidence while cross-covering, and decreased clinically relevant errors. CONCLUSIONS: Utilization of well-designed, EMR-generated reports for the use of patient transfer, sign-out, and rounding should become more commonplace considering the improved efficiency, satisfaction, and potential for improved patient care.

PMID: 20461566 [PubMed - indexed for MEDLINE]

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European Society of Gastrointestinal Endoscopy (ESGE) Guideline: prophylaxis of post-ERCP pancreatitis.

Endoscopy. 2010 Jun;42(6):503-15

Authors: Dumonceau JM, Andriulli A, Deviere J, Mariani A, Rigaux J, Baron TH, Testoni PA,

Pancreatitis is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP). Risk factors for post-ERCP pancreatitis (PEP) are both patient-related and procedure-related. Identification of patients at high risk for PEP is important in order to target prophylactic measures. Prevention of PEP includes administration of nonsteroidal inflammatory drugs (NSAIDs), use of specific cannulation techniques, and placement of temporary pancreatic stents. The aim of this guideline commissioned by the European Society of Gastrointestinal Endoscopy (ESGE) is to provide practical, graded, recommendations for the prevention of PEP.

PMID: 20506068 [PubMed - indexed for MEDLINE]

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A validated value-based model to improve hospital-wide perioperative outcomes: adaptability to combined medical/surgical inpatient cohorts.

Ann Surg. 2010 Sep;252(3):486-98

Authors: Ravikumar TS, Sharma C, Marini C, Steele GD, Ritter G, Barrera R, Kim M, Safyer SM, Vandervoort K, De Geronimo M, Baker L, Levi P, Pierdon S, Horgan M, Maynor K, Maloney G, Wojtowicz M, Nelson K

OBJECTIVES:: Authors hypothesized that building safe hospital systems to improve value-based surgical outcomes is predicated on workflow redesign for dynamic risk stratification, coupled with "real-time" mitigation of risk. We developed a comanagement model for hospitalized surgical cohort, and determined whether this iterative process redesign for surgery will be adaptable to disparate hospital systems and will be beneficial for combined medical/surgical adult inpatients. CONTEXT:: Concerns about preventable harm in hospitalized patients have generated a plethora of both, process-driven and outcome-based strategies in US Healthcare. Although comparison between hospitals is a common mechanism to drive quality, other innovative approaches are needed for real-time risk mitigation to improve outcomes. METHODS:: Prospective implementation of Surgical Continuum of Care (SCoC) model in hospitals initially for surgery patients; subsequently Continuum of Care (CoC) for medical/surgical population. Redesign of hospital care delivery model: patient cohorting, floor-based team building, and intensivist/hospitalist staffing of progressive care unit (PCU). Work flow redesign for clinical effectiveness: multidisciplinary team rounds, acuity stratified care rounding based on dynamic risk assessment into a novel HAWK (high risk)/DOVE (low risk) patient grouping, intensivist/hospitalist comanagement of surgical patients, and targeted response. STUDY:: Pre- and postintervention with concurrent cohort control design. SETTING:: Academic medical centers for SCoC and integrated health system hospital for CoC. PATIENT GROUPS:: SCoC Pilot Study-Campus A: Preintervention control group 1998-2000, Intervention Group 2001-2004; Campus B: Comparator Control Group 1998-2004.SCoC Validation Study-Campus C: Preintervention Group 2001-2005; Intervention Group 2006-2008. CoC Study-Campus D: Hospital-wide Group 2009. METRICS:: Mortality, length of stay (LOS): overall, surgical intensive care unit and PCU, readmission rates, and cost. Case mix index for risk adjustment. RESULTS:: Total >100,000 admissions. There was a significant reduction in overall surgical mortality in both, pilot (P < 0.002) and validation (P < 0.02) SCoC studies and overall hospital mortality in the medical/surgical CoC study (risk-adjusted mortality index progressively declined in CoC study from 1.16 pre-CoC to 0.77 six months post-CoC implementation; significant at 75% confidence level). Case mix index was unchanged during study period in each campus. Nested study in validation cohort of hospital-wide versus surgery alone (observed/expected mortality index) demonstrated significant benefit to SCoC in intervention group. The mortality benefit was primarily derived from risk-stratified rounding and actively managing risk prone population in the PCU. Surgical intensive care unit, PCU, and total hospital patient-days significantly decreased in SCoC pilot study (P < 0.05), reflecting enhanced throughput. LOS reduction benefit persisted in SCoC validation and CoC studies. In addition to decreased LOS, cost savings were in PCU (range, $851,511-2,007,388) and top diagnosis-related groups, for example, $452 K/yr for diagnosis-related group 148. CONCLUSIONS:: SCoC is patient-centered, outcomes-driven, value-based approach for hospital-wide surgical patient safety. The principles of this value paradigm are adaptable to other hospitals as demonstrated in our longitudinal study in 3 hospital systems, and the initial experience of CoC suggests that this model will have benefit beyond surgical hospital cohort.

PMID: 20739849 [PubMed - in process]

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Hyponatremia-what is cerebral salt wasting?

Perm J. 2010;14(2):62-5

Authors: Momi J, Tang CM, Abcar AC, Kujubu DA, Sim JJ

Background: Hyponatremia is a common electrolyte imbalance in hospitalized patients. It is associated with significant morbidity and mortality, especially if the underlying cause is incorrectly diagnosed and not treated appropriately. Often, the hospitalist is faced with a clinical dilemma when a patient presents with hyponatremia of an unclear etiology and with uncertain volume status. Syndrome of inappropriate antidiuretic hormone (SIADH) is frequently diagnosed in this clinical setting, but cerebral salt wasting (CSW) is an important diagnosis to consider.Objective: We wanted to describe the diagnosis, treatment, and history of CSW to provide clinicians with a better understanding of the differential diagnosis for hyponatremia.Conclusion: CSW is a process of extracellular volume depletion due to a tubular defect in sodium transport. Two postulated mechanisms for CSW are the excess secretion of natriuretic peptides and the loss of sympathetic stimulation to the kidney. Making the distinction between CSW and SIADH is important because the treatment for the two conditions is very different.

PMID: 20740122 [PubMed - in process]

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The impact of Trendelenburg position and positive end-expiratory pressure on the internal jugular cross-sectional area.

Anesth Analg. 2010 Aug;111(2):432-6

Authors: Marcus HE, Bonkat E, Dagtekin O, Schier R, Petzke F, Wippermann J, Böttiger BW, Teschendorf P

BACKGROUND: Increasing the cross-sectional area (CSA) of the right internal jugular vein facilitates cannulation and decreases complications. Maneuvers such as the Trendelenburg tilt position and ventilation with a positive end-expiratory pressure (PEEP) may increase the CSA of the right internal jugular vein. We determined the changes in the CSA in response to different maneuvers. METHODS: The CSA (cm(2)) of the right internal jugular vein was assessed in 50 anesthetized adult cardiothoracic surgery patients using 2-dimensional ultrasound. First, the CSA was measured in response to supine position with no PEEP (control condition, S0) and compared with 5 different randomly ordered maneuvers: (1) PEEP ventilation with 5 cm H(2)O (S5), (2) PEEP with 10 cm H(2)O (S10), (3) a 20 degrees Trendelenburg tilt position with a PEEP of 0 cm H(2)O (T0), (4) a 20 degrees Trendelenburg tilt position combined with a PEEP of 5 cm H(2)O (T5), and (5) a 20 degrees Trendelenburg tilt position combined with a PEEP of 10 cm H(2)O (T10). RESULTS: All maneuvers increased the CSA of the right internal jugular vein with respect to the control condition S0 (all P < 0.05). S5 increased the CSA on average by 15.9%, S10 by 22.3%, T0 by 39.4%, T5 by 38.7%, and T10 by 49.7%. CONCLUSION: In a comparison of the effectiveness of applying different PEEP levels and/or the Trendelenburg tilt position on the CSA of the right internal jugular vein, the Trendelenburg tilt position was most effective.

PMID: 20484538 [PubMed - indexed for MEDLINE]

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Obstructive sleep apnea: preoperative assessment.

Anesthesiol Clin. 2010 Jun;28(2):199-215

Authors: Seet E, Chung F

Obstructive sleep apnea is the most prevalent breathing disturbance in sleep. It is linked to a host of preexisting medical conditions, and associated with poorer postoperative outcomes. Screening and vigilance during the preoperative assessment identifies patients at high risk of obstructive sleep apnea. Further diagnostic tests may be performed, and plans can be made for tailored intraoperative care. The STOP and the STOP-Bang questionnaires are useful screening tools. Patients with a known diagnosis of obstructive sleep apnea should be seen in the preoperative clinic, where risk stratification and optimization may be done before surgery. This review article presents functional algorithms for the perioperative management of obstructive sleep apnea based on limited clinical evidence, and a collation of expert knowledge and practices. These recommendations may be used to assist the anesthesiologist in decision-making when managing the patient with obstructive sleep apnea.

PMID: 20488390 [PubMed - indexed for MEDLINE]

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Necrotizing soft tissue infections in the intensive care unit.

Crit Care Med. 2010 Sep;38(9 Suppl):S460-8

Authors: Phan HH, Cocanour CS

Necrotizing soft tissue infection is a severe illness that is associated with significant morbidity and mortality. It is often caused by a wide spectrum of pathogens and is most frequently polymicrobial. Care for patients with necrotizing soft tissue infection requires a team approach with expertise from critical care, surgery, reconstructive surgery, and rehabilitation specialists. The early diagnosis of necrotizing soft tissue infection is challenging, but the keys to successful management of patients with necrotizing soft tissue infection are early recognition and complete surgical debridement. Early initiation of appropriate broad-spectrum antibiotic therapy must take into consideration the potential pathogens. Critical care management components such as the initial fluid resuscitation, end-organ support, pain management, nutrition support, and wound care are all important aspects of the care of patients with necrotizing soft tissue infection. Soft tissue reconstruction should take into account both functional and cosmetic outcome.

PMID: 20724879 [PubMed - in process]

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Alcohol withdrawal syndromes in the intensive care unit.

Crit Care Med. 2010 Sep;38(9 Suppl):S494-501

Authors: Sarff M, Gold JA

This article reviews the pathophysiology, diagnosis, and treatment of alcohol withdrawal syndromes in the intensive care unit as well as the literature on the optimal pharmacologic strategies for treatment of alcohol withdrawal syndromes in the critically ill. Treatment of alcohol withdrawal in the intensive care unit mirrors that of the general acute care wards and detoxification centers. In addition to adequate supportive care, benzodiazepines administered in a symptom-triggered fashion, guided by the Clinical Institute Withdrawal Assessment of Alcohol scale, revised (CIWA-Ar), still seem to be the optimal strategy in the intensive care unit. In cases of benzodiazepine resistance, numerous options are available, including high individual doses of benzodiazepines, barbiturates, and propofol. Intensivists should be familiar with the diagnosis and treatment strategies for alcohol withdrawal syndromes in the intensive care unit.

PMID: 20724883 [PubMed - in process]

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Prospective evaluation of a clinical guideline recommending early patients discharge in bleeding peptic ulcer.

J Gastroenterol Hepatol. 2010 Sep;25(9):1525-9

Authors: Chaparro M, Barbero A, Martín L, Esteban C, Espinosa L, de la Morena F, Sánchez A, Martín I, Santander C, Moreno-Otero R, Gisbert JP

Abstract Background and Aim: To validate an early discharge policy in patients admitted with upper gastrointestinal bleeding (UGIB) due to ulcers. Methods: Patients with gastroduodenal ulcer or erosive gastritis/duodenitis were included in a previous study aiming to develop a practice guideline for early discharge of patients with UGIB. Variables associated with unfavorable evolution were analyzed in order to identify patients with low-risk of re-bleeding. After that, a one-year prospective analysis of all UGIB episodes was carried out. Results: A total of 341 patients were identified in the retrospective study. Variables associated with unfavorable evolution were: systolic blood pressure </= 100 mmHg, heart rate >/= 100 bpm, and a Forrest endoscopic classification of severe. 10% of patients were immediately discharged; however, if predictive variables obtained in the multivariate analysis had been used, hospitalization could have been prevented in 34% of patients. A total of 77 patients were included in the prospective analysis. Although only 19.5% of patients were immediately discharged without complications, 29 patients (37.7%) were theoretically suitable for early discharge. Conclusions: Patients with UGIB who have clean-based ulcers and are stable on admission can be safely discharged immediately after endoscopy. Implementation of the clinical practice guideline safely reduced hospital admission for those patients.

PMID: 20796150 [PubMed - in process]

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Low alpha-fetoprotein hepatocellular carcinoma.

J Gastroenterol Hepatol. 2010 Sep;25(9):1543-9

Authors: Carr BI, Pancoska P, Branch RA

Abstract Background and Aim: A large proportion of hepatocellular carcinoma (HCC) patients do not secrete elevated levels of the tumor marker alpha-fetoprotein (AFP). There is little published guide to prognostic features of this patient subset. Methods: We interrogated a large HCC database in which all patients had been followed until death, to examine which features might be prognostically useful. Results: We found 413 biopsy-proven unresectable HCC patients with low serum AFP values. Serum gamma glutamyl transpeptidase (GGTP) levels were one of the most significant factors for survival. This dichotomization into low and high GGTP levels separated the patients into distinctive survival ranges. Patients with GGTP levels < 110 U/100 mL and small tumors had longest survival > 795 days. Patients with GGTP >/= 110 U/mL and large tumors with the presence of portal vein thrombosis had the shortest survival range of 300-560 days. Conclusions: Serum levels of the onco-fetal protein GGTP represent a useful prognostic parameter in HCC patients with low AFP levels.

PMID: 20796153 [PubMed - in process]

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Comparison of transient elastography, serum markers and clinical signs for the diagnosis of compensated cirrhosis.

J Gastroenterol Hepatol. 2010 Sep;25(9):1562-8

Authors: Malik R, Lai M, Sadiq A, Farnan R, Mehta S, Nasser I, Challies T, Schuppan D, Afdhal N

Abstract Background and Aims: Non-invasive diagnosis of compensated cirrhosis is important. We therefore compared liver stiffness by transient elastography, APRI score, AST/ALT ratio, hyaluronic acid and clinical signs to determine which modality performed best at identifying compensated cirrhosis. Methods: Patients undergoing evaluation at a single center were recruited and had clinical, serological, endoscopy, radiological imaging, liver stiffness measurement and liver biopsy. Patients were stratified into cirrhotic and non-cirrhotic. Results: In 404 patients (124 cirrhosis), transient elastography was diagnostically superior to the other modalities yielding an AUC 0.9 +/- 0.04 compared with hyaluronic acid (AUC 0.81 +/- 0.04: P < 0.05), clinical signs (AUC 0.74 +/- 0.04: P < 0.05), APRI score (AUC 0.71 +/- 0.03: P < 0.05) and AST/ALT ratio (AUC 0.66 +/- 0.03: P < 0.05). The optimum cut-off for transient elastography was 12 kPa giving a sensitivity of 89% and specificity of 87% for cirrhosis. In 238 hepatitis C patients (87 cirrhosis), transient elastography yielded an AUC 0.899 +/- 0.02 for cirrhosis and in 166 non-HCV patients (37 cirrhosis) the results were similar with an AUC 0.928 +/- 0.03; with transient elastography being superior to HA, APRI, AST/ALT and clinical signs for all etiologies of cirrhosis (P < 0.05 for all). Importantly, transient elastography was statistically superior at identifying cirrhosis in 38 biopsy proven Childs Pugh A cirrhotics with no clinical, biochemical or radiological features of cirrhosis or portal hypertension (AUC 0.87 +/- 0.04). Conclusion: Transient elastography accurately identified compensated cirrhosis; a liver stiffness of >12 kPa represents an important clinical measurement for the diagnosis of cirrhosis.

PMID: 20796156 [PubMed - in process]

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Left Ventricular Endocardial Stimulation for Severe Heart Failure.

J Am Coll Cardiol. 2010 Aug 31;56(10):747-753

Authors: Bordachar P, Derval N, Ploux S, Garrigue S, Ritter P, Haissaguerre M, Jaïs P

Biventricular resynchronization, a therapy recommended for patients presenting with left ventricular (LV) dysfunction and ventricular dyssynchrony, requires the implantation of an LV lead, usually placed in a lateral or posterolateral tributary of the coronary sinus. Despite important progress made in the development of dedicated instrumentation, the procedure remains sometimes challenging and unsuccessful in a minority of patients. In the rare instances of unsuccessful transvenous implantations occurring in the presence of major surgical contraindications, a few operators have implanted the LV lead transseptally, an approach limited by technical difficulties and by the thromboembolic risk associated with the presence of a lead inside the LV cavity. The interest in this approach was recently renewed by 2 studies in an animal model and in humans, respectively, which both found a distinctly superior hemodynamic performance associated with endocardial compared with epicardial stimulation. This review discusses the advantages and disadvantages of LV endocardial stimulation, examines the various techniques of LV endocardial stimulation, and projects their future applications in light of these highly promising recent results. The implementation of endocardial stimulation will ultimately depend on: 1) the development of safe, effective, and durable instrumentation, and reliable and reproducible intraprocedural methods to identify the optimal site of stimulation; and 2) the completion of controlled trials confirming the superiority of this technique compared with standard cardiac resynchronization therapy.

PMID: 20797486 [PubMed - as supplied by publisher]

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