Hospital performance and acute coronary syndrome outcomes.
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Angina, Unstable↗
Biomedical subjects
Kirsten Hall Long
Publications and source records attributed to Kirsten Hall Long.
A total of 1,007 percutaneous coronary interventions without onsite cardiac surgery: acute and long-term outcomes.
OBJECTIVES: We sought to compare clinical outcomes of elective percutaneous coronary intervention (PCI) and primary PCI for ST-segment elevation myocardial infarction (STEMI) at a community hospital without onsite cardiac surgery to those at a tertiary center with onsite cardiac surgery. BACKGROUND: Disagreement exists about whether hospitals with cardiac catheterization laboratories, but without onsite cardiac surgery, should develop PCI programs. Primary PCI for STEMI at hospitals without onsite cardiac surgery have achieved satisfactory outcomes; however, elective PCI outcomes are not well defined. METHODS: A total of 1,007 elective PCI and primary PCI procedures performed from March 1999 to August 2005 at the Immanuel St. Joseph's Hospital-Mayo Health System (ISJ) in Mankato, Minnesota, were matched one-to-one with those performed at St. Mary's Hospital (SMH) in Rochester, Minnesota. Strict protocols were followed for case selection and PCI program requirements. Clinical outcomes (in-hospital procedural success, death, any myocardial infarction, Q-wave myocardial infarction, and emergency coronary artery bypass surgery) and follow-up survival were compared between groups. RESULTS: Among 722 elective PCIs, procedural success was 97% at ISJ compared with 95% at SMH (p = 0.046). Among 285 primary PCIs for STEMI, procedural success was 93% at ISJ and 96% at SMH (p = 0.085). No patients at ISJ undergoing PCI required emergent transfer for cardiac surgery. Survival at two years' follow-up by treatment location was similar for patients with elective PCI and primary PCI. CONCLUSIONS: Similar clinical outcomes for elective PCI and primary PCI were achieved at a community hospital without onsite cardiac surgery compared with those at a tertiary center with onsite cardiac surgery using a prospective, rigorous protocol for case selection and PCI program requirements.
Aged↗
Direct medical costs associated with Parkinson's disease: a population-based study.
The objective was to provide population-based estimates of incremental medical costs associated with Parkinson's disease (PD) from onset forward. All Olmsted County, Minnesota, residents with confirmed PD onset from 1987 through 1995 (n = 92) and one age- and sex-matched non-PD referent subject per case were identified with retrospective record review and followed in provider-linked billing data for direct medical costs (excluding outpatient pharmaceutical costs) from 1 year before index (i.e., year of symptom onset) through 10 years after index. Costs for each referent subject were subtracted from those for his/her matched case. Tests for statistical significance used Wilcoxon signed ranks. Preindex costs were similar [median difference in annual costs (MD) = -3 dollars; P = 0.59]. One year post index, PD subjects exhibited borderline significantly higher costs compared to referent subjects (MD = 581 dollars; P = 0.052); the difference diminished over 5 years (MD = 118 dollars; P = 0.82). By 5 to 10 years, however, PD subjects exhibited significantly higher costs (MD = 1,146 dollars; P = 0.01). Over the full 10 years, excess costs were concentrated among PD subjects without rest tremor (MD = 2,261 dollars, P < 0.01, for those without tremor and -229 dollars, P = 0.99, for those with tremor). These population-based estimates of PD-associated direct medical costs from onset forward can uniquely inform policy decisions and cost-effectiveness research.
Adult↗
Elective percutaneous coronary intervention without on-site cardiac surgery: clinical and economic implications.
BACKGROUND: Low procedural complication rates, barriers to access, and patient preference have encouraged the development of percutaneous coronary intervention (PCI) programs at centers that are often closer to home but without on-site cardiac surgical capability. OBJECTIVES: We compared clinical and economic outcomes associated with performing low-risk elective PCI at a community hospital without on-site cardiac surgery with those obtained at a more remote tertiary care center with on-site cardiac surgery. DESIGN AND MEASURES: We matched 257 patients undergoing low-risk, elective PCI at a community hospital (Immanuel St. Joseph's Hospital [ISJ] between January 27, 2000, and July 31, 2002) to 514 PCI patients treated at a tertiary care hospital (Saint Marys Hospital [SMH] between January 27, 2000, and April 30, 2002) based on clinical and lesion criteria. Clinical outcomes (in-hospital procedural success and target vessel failure during long-term follow up) and economic outcomes (direct medical costs, billed charges, and hospital length of stay [LOS]) were compared between groups. The Mayo Clinic PCI Registry (containing clinical, angiographic, and follow-up data) and administrative data were used in matching and outcomes assessment. RESULTS: Procedural success was achieved more often among ISJ-treated patients (99% vs. 95%; P = 0.02); however, no difference in target vessel failure rates was observed during a median follow-up time of 3.1 years (estimated 1-year event rate: 15.2% vs. 14.8%; P = 0.46). ISJ-treated patients incurred, on average, $3024 more in estimated total costs ($13,771 vs. $10,746; P < 0.001) and $6084 more in billed charges (P < 0.001), but incurred similar LOS post procedure (1.53 days). CONCLUSIONS: Similar clinical outcomes were achieved at a community hospital without on-site cardiac surgery but at significantly increased direct medical cost. Patients, providers, hospitals, payers, and policymakers should consider whether the benefits associated with locally provided specialized cardiovascular services warrant this additional cost.
Cardiac Care Facilities↗
Economic and clinical outcomes of a physician-led continuous quality improvement intervention in the delivery of percutaneous coronary intervention.
OBJECTIVE: To compare clinical and economic outcomes associated with percutaneous coronary intervention (PCI) in cohorts before and after continuous quality improvement (CQI) was instituted. STUDY DESIGN: Observational study. METHODS: Clinical, angiographic, procedural, and outcome data on 1441 pre-CQI and 1760 post-CQI PCIs (performed in 1997 and 1998, respectively) were derived from an institutional PCI registry. Administrative data were used to estimate total procedural and postprocedural costs and length of stay (LOS). Logistic and generalized linear modeling was used to adjust in-hospital clinical and economic outcomes, respectively, for differences in patient characteristics. RESULTS: The 2 cohorts were similar in terms of age, sex, and rate of diabetes. Post-CQI patients more often received intracoronary stents, had urgent PCIs, had a history of prior PCI, and received glycoprotein IIb/IIIa inhibitors. Procedural success without in-hospital complications occurred in 90% of both cohorts and did not differ statistically in adjusted analyses. Compared with patients treated pre-CQI, those treated post-CQI had a reduced adjusted odds ratio for in-hospital death or any myocardial infarction (odds ratio = 0.66; 95% confidence interval = 0.46, 0.95). Models predicted a mean postprocedural LOS difference of 0.8 days (2.8 days pre-CQI vs 2.0 days post-CQI; P <.001) and an average post-CQI cost savings of $5430 (P <.001). CONCLUSION: Physician-led, multidisciplinary practice management efforts were successful at significantly reducing PCI-related costs in an era of rapid technological advances while maintaining and perhaps improving quality of care.
Aged↗
Effects of a hospitalist model on elderly patients with hip fracture.
BACKGROUND: Hospitalists' increased role in perioperative medicine allows for examination of their effects on surgical patients. This study examined the effects of a hospitalist service created to medically manage elderly patients with hip fracture. METHODS: During a 2-year historical cohort study of 466 patients 65 years or older admitted for surgical repair of hip fracture, we examined outcomes 1 year prior to and subsequent to the change from the standard to the hospitalist model. RESULTS: The mean (SD) time to surgery (38 [47] vs 25 [53] hours; P<.001), time from surgery to dismissal (9 [8] vs 7 [5] days; P = .04), and length of stay (10.6 [9] vs 8.4 [6] days; P<.001) were shorter in the hospitalist group. Predictors of shorter time to surgery were care by the hospitalist group (P = .002), older age (P = .01), and fall as the mechanism of fracture (P<.001), while American Society of Anesthesia scores of 3 and 4 were associated with increased time to surgery (P<.001). Receiving care by the hospitalist group (P<.001) and diagnosis of delirium (P<.001) were associated with increased chance of earlier dismissal, while admission to the intensive care unit decreased this chance (P<.001). Diagnosis of delirium was more frequent in the hospitalist group (74 [32.2%] of 230 vs 42 [17.8%] of 236; P<.001). There were no differences in inpatient deaths or 30-day readmission rates. CONCLUSION: In elderly patients with hip fracture, a hospitalist model decreased time to surgery, time from surgery to dismissal, and length of stay without adversely affecting inpatient deaths or 30-day readmission rates.
Aged↗
Evaluating the performance of an institution using an intensive care unit benchmark.
OBJECTIVES: To describe the performances of selected intensive care units (ICUs) in a single institution using the Acute Physiology and Chronic Health Evaluation (APACHE) III benchmark and to propose interventions that may improve performance. PATIENTS AND METHODS: In this retrospective study, we analyzed APACHE III data from critically ill patients admitted to ICUs at the Mayo Clinic in Rochester, Minn, between October 1994 and December 2003. We retrieved ICU performance measures based on first ICU day APACHE III values. Standardized ratios were defined as ratios of measured to predicted values. The primary performance measure was the standardized mortality ratio, and secondary performance measures were length of stay (LOS) ratios, low-risk monitor ICU admission rates, and ICU readmission rates. We calculated 95% confidence intervals (CIs) for each performance, graded as good, average, or poor. RESULTS: Among 46,381 patients admitted during the study period, 57.5% were in surgical ICUs, 24.8% in a medical ICU, and 17.7% in a surgical-medical ICU. Low-risk monitoring accounted for 37.2% of admissions. Hospital standardized mortality ratios (95% CI) were 0.95 (0.90-0.99), 0.86 (0.81-0.91), and 0.70 (0.66-0.74) for medical, multispecialty, and surgical ICUs, respectively. Hospital LOS ratios (95% CI) were 0.83 (0.81-0.85), 0.91 (0.88-0.93), and 0.99 (0.97-1.00) for medical, multispecialty, and surgical ICUs, respectively. The ICU readmission rate for each ICU was higher than the 6.7% reported in the medical literature. Performances were good in mortality, average to good in LOS, average in low-risk admission, and poor in ICU readmission. CONCLUSIONS: A national benchmarking database can highlight the strengths and weaknesses of ICUs. The performances of ICUs in a single institution may differ; therefore, the performance of each unit should be evaluated individually.
APACHE↗
Medical and surgical comanagement after elective hip and knee arthroplasty: a randomized, controlled trial.
BACKGROUND: Hospitalists are assuming an increasing role in the care of surgical patients, but the impact of this model of care on postoperative outcomes is unknown. OBJECTIVE: To determine the impact of providing a collaborative, hospitalist-led model of care on postoperative outcomes and costs among patients having hip or knee arthroplasty. DESIGN: Randomized, controlled trial. SETTING: Academic medical center. PARTICIPANTS: 526 patients having elective orthopedic surgery who are at elevated risk for postoperative morbidity. MEASUREMENTS: Length of stay, inpatient postoperative medical complications, health care provider satisfaction, and inpatient costs. INTERVENTIONS: A comanagement medical Hospitalist-Orthopedic Team compared with standard postoperative care by orthopedic surgeons with medical consultation. RESULTS: More patients in the hospitalist group were discharged from the hospital with no complications (61.6% vs. 49.8%; difference, 11.8 percentage points [95% CI, 2.8 to 20.7 percentage points]). Fewer minor complications were observed among hospitalist patients (30.2% vs. 44.3%; difference, -14.1 percentage points [CI, -22.7 to -5.3 percentage points]). Observed length of stay was not statistically different between treatment groups. However, when adjusted for discharge delays, mean length of stay for patients in the hospitalist model of care was shorter (5.1 days vs. 5.6 days; difference, -0.5 day [CI, -0.8 to -0.1 day]). Total costs did not differ between groups. Orthopedic surgeons and nurses preferred the hospitalist model. LIMITATIONS: Care providers and patients were aware of intervention assignments, and the study could not capture all costs associated with the hospitalist model. CONCLUSIONS: The comanagement medical Hospitalist-Orthopedic Team model reduced minor postoperative complication rates with no statistically significant difference in length of stay or cost. The nurses and surgeons strongly preferred the comanagement hospitalist model. Additional research on the clinical and economic impact of the hospitalist model in other surgical populations is warranted.
Aged↗
Is physician anesthesia cost-effective?
UNLABELLED: One of the most controversial issues in anesthesia is whether nonmedically directed nurse anesthetists are relatively more cost-effective than anesthesiologists in the provision of anesthesia care. We electronically surveyed anesthesia practices throughout the United States to estimate the range in anesthesia professional costs from the payer perspective. Using this survey data on anesthesia reimbursement and published outcomes studies, we developed an ad hoc model to estimate the cost-effectiveness of physician-directed anesthesia relative to a nonmedically directed nurse anesthetist model of care from the payer perspective. Cost-effectiveness ratios were defined as the ratio of incremental costs associated with physician anesthesia relative to the estimated incremental life expectancy gains with this model of care (i.e., dollars per year of life saved [US dollars /YLS]). Reference case results suggest that physician anesthesia is cost saving with an estimated incremental cost-effectiveness ratio of -US dollars 2601/YLS for a younger privately insured patient and an estimated cost-effectiveness ratio of -US dollars 4410/YLS for an elderly Medicare insured patient. Cost-effectiveness ratios ranged from -US dollars 4410 to US dollars 38778/YLS in univariate and multivariate sensitivity analyses across payer types. Results were most sensitive to assumed differences in reimbursement (commercial conversion factors) and to mortality rate assumptions by provider type. This analysis offers economic evidence in support of the physician anesthesia model of care. IMPLICATIONS: Recent outcome studies suggest improved patient outcomes when physicians medically direct nurse anesthetists versus anesthesia care delivered with nonmedically directed nurses. The relative cost-effectiveness of this practice model is, however, unknown. This economic analysis suggests that outcome gains with physician anesthesia may be obtained at cost savings or, under conservative assumptions, at a cost deemed reasonable by society.
Age Factors↗
Study regarding anesthesia outcomes cites outdated studies.
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Anesthesia↗
Open versus laparoscopic splenectomy for idiopathic thrombocytopenic purpura: clinical and economic analysis.
BACKGROUND: Since 1991, laparoscopic splenectomy (LS) has gained acceptance in the treatment of hematologic disorders, including idiopathic thrombocytopenic purpura (ITP). Several studies suggest that LS provides benefits over open splenectomy (OS). However, study design flaws hinder formal technology assessment. METHODS: We retrospectively reviewed medical and administrative records of patients who underwent splenectomy for ITP between January 1995 and December 2000 to compare clinical and economic outcomes associated with LS and OS. RESULTS: Eighty-six patients were identified; 42 underwent an attempted LS and 44 had OS. Preoperative patient characteristics were similar between groups. Mean operative and anesthesia times for LS and OS were 167 and 201 minutes and 119 and 151 minutes, respectively (P <.001). Overall transfusion and postoperative complication rates were similar between groups. On average, LS patients required 1.2 fewer days of parenteral analgesia and were able to tolerate a general diet 1.7 days earlier. Mean postoperative stay was 2 days lower for LS patients and mean total direct costs did not differ by surgical method (US dollars 8134 vs US dollars 8200). CONCLUSIONS: This observational study shows that LS is safe and offers advantages over OS: less postoperative pain, earlier general diet tolerance, and shorter hospital stay. These benefits are obtained at no significant additional cost.
Adolescent↗
Economic implications of attention-deficit hyperactivity disorder for healthcare systems.
Attention-deficit hyperactivity disorder (ADHD) is one of the most common chronic conditions of childhood, with adverse consequences that persist through adolescence into adulthood. Thus, the burden of illness associated with ADHD is high for affected individuals, their families, and society at large. This article reviews available information about ADHD-associated utilisation of healthcare resources, direct medical costs, and the costs or cost effectiveness of pharmacological interventions. Published estimates suggest that direct medical costs for youth with ADHD are approximately double those for youth without ADHD. Cross-sectional studies suggest that ADHD-associated incremental costs are highest for mental health services and pharmaceutical costs, and are greatest for youth with comorbid psychiatric conditions and for those being treated with stimulant medication. To guide relevant clinical and health policy, additional research is warranted on the following: source of increased costs observed among persons with ADHD; patient characteristics of those accruing high medical costs; and the long-term effect of ADHD treatment on direct and indirect costs.
Adolescent↗
Factors influencing clinical decisions to initiate thyroxine therapy for patients with mildly increased serum thyrotropin (5.1-10.0 mIU/L).
OBJECTIVE: To determine factors that influence clinicians' decisions to treat subclinical hypothyroidism. PATIENTS AND METHODS: We studied patients living within 120 miles of our institution in Rochester, Minn, whose serum thyrotropin value was between 5.1 and 10.0 mIU/L from January 1, 1995, through December 31,1996. Exclusion criteria were history of thyroid disease or prior abnormal thyrotropin level and fewer than 5 follow-up visits or fewer than 2 follow-up thyrotropin measurements. Of the 2655 patients in this cohort, only 55% (1466) had measurement of thyroid microsomal antibodies (TMAb). From this group, records of 539 patients were selected randomly according to antibody status (238 with positive, 199 with negative, and 102 with no TMAb measurement). After exclusion of patients receiving thyroxine replacement and other medications affecting thyroid function, patients with postpartum thyroiditis, and patients in the intensive care unit, data from 450 patients were analyzed. RESULTS: Thyroxine therapy was prescribed for 39% of the patients with thyrotropin levels between 5.1 and 10.0 mIU/L. In multivariate analysis, TMAb status (P < .001), index thyrotropin (P < .002), and free thyroxine (FT4) (P = .03) were the strongest predictors for the decision to treat. Fifty-nine percent of the patients with positive TMAb were treated compared with 24% of those with negative TMAb and 30% of those who did not have a TMAb test. The mean thyrotropin level in the treated group was 7.1 mIU/L compared with 63 mIU/L in the untreated group. The mean FT4 level was 1.08 ng/dL in the treated group who had this measured compared with 1.16 ng/dL in the untreated group. Treated patients were younger than untreated patients (56.5 years vs 60.6 years), and the proportion of female patients was higher in the treated group compared with the untreated group (75.8% vs 65.2%); however, neither of these differences was significant after correction for the multiple comparisons. In multivariate analysis neither age nor sex was a significant predictor of treatment, but in the subgroup comparison, patients aged 31 to 50 years were twice as likely to be treated compared with those aged 61 to 80 years. CONCLUSION: Among patients with serum thyrotropin levels of 5.1 to 10.0 mIU/L, those with positive TMAb values, those with higher thyrotropin values, and those with lower FT4 values were more likely to receive thyroxine therapy. Younger patients were more likely to be treated than older patients.
Adult↗