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PubMed1993

Postoperative utilization of critical care services by cardiac surgery: a multicenter study in the Canadian healthcare system.

OBJECTIVES: To describe patterns of critical care services used after cardiac surgery and to evaluate whether variations in the process of care influence outcome. DESIGN: Multicenter, prospective study. SETTING: A convenience sample of four cardiac surgical units: three in university-affiliated (teaching) hospitals and one in a nonteaching regional referral center. PATIENTS: A "consecutive sample" of 335 patients after cardiac surgery in four hospitals. INTERVENTIONS: Data were collected regarding all cardiac surgery patients admitted to the critical care units in the four test hospitals. MEASUREMENTS AND MAIN RESULTS: The critical care unit and hospital lengths of stay and survival were followed. The Therapeutic Intervention Scoring System (TISS) was used to assess the intensive care unit (ICU) interventions used during the first 24 hrs in the ICU and for the final 24 hrs before discharge from the ICU. The severity of illness on admission was assessed using the Acute Physiology and Chronic Health Evaluation (APACHE) scoring system. For patients having similar procedures (e.g., aortocoronary bypass and nonaortocoronary bypass procedures) and with similar outcome (mortality/total hospital length of stay), we found significant differences in the pattern of ICU resource utilization among hospitals. Significant (p < .05) differences in unit length of stay were related to varying factors in different hospitals. In hospital unit A, the type of procedure and preoperative chronic health status influenced unit length of stay (aortocoronary bypass 2.8 +/- 1.7 days; nonaortocoronary bypass 8.7 +/- 8.9 days) because length of stay was different for differing procedure groups. In hospital unit B, the critical care management system and lack of step-down (intermediate care) unit availability resulted in an increased unit length of stay for aortocoronary bypass patients (5.1 +/- 4.5 days) as compared with the other units (mean ICU lengths of stay of 2.8, 2.3, and 3.0 days, respectively). Unit B kept patients for monitoring purposes and had a reduced need for critical care nursing on the day of discharge (TISS = 7.5 +/- 5.5) as compared with the other units (mean TISS scores of 27.4, 23.2, and 21.5). CONCLUSIONS: Significant differences exist among hospitals in the same healthcare system in the utilization of critical care services for cardiac surgery. In spite of these differences, for similar patient "input," the outcome (mortality and hospital lengths of stay) appeared similar. Assessments of utilization of critical care must focus on more detailed specific issues than unit length of stay, and must include factors such as availability of intermediate care areas, the unit management system, chronic health status, and the operative procedures performed, if a utilization management process is to effect improved resource use in critical care.

Canada↗
PubMed1999

Motivation for change in patients with prolonged musculoskeletal disorders: a qualitative two-year follow-up study.

BACKGROUND AND PURPOSE: The purpose of this study was to obtain a deeper understanding of the process of motivation for change in patients with prolonged musculoskeletal disorders and to identify factors that might influence change resulting in increased independence. METHOD: A qualitative two-year follow-up study. Data collection and analysis were performed according to the qualitative case study design. An initial conceptual framework was developed to bound and guide the study. Twenty patients were selected using purposive sampling with respect to motivation level (highly motivated to less-motivated) to create a sample of maximum variation. Data were collected using repeated interviews and standardized scales. The study comprised three data collection periods. RESULTS: Motivation for change followed different processes depending on the level at entry to the study. The highly motivated patients improved in independence, the moderately motivated ones remained at an unchanged level and the less-motivated patients became more dependent. Central themes of importance to the process of motivation for change were: the utilization of professional networks (healthcare, regional social insurance office), emotional support (nuclear family, close relatives), use of personal coping resources (energy, positive beliefs, problem-solving) and social support at work (employers, colleagues). CONCLUSIONS: The performance of a structured motivation analysis, including questions about emotional networks and social support at work in addition to the clinical examination of the patient, is recommended. This might guide healthcare professionals when it comes to motivation for change in the patient.

Adult↗
PubMed1990

New York University Medical Center's Cooperative Care Unit: patient education and family participation during hospitalization--the first ten years.

The New York University Medical Center Cooperative Care (CC) program is a model of a delivery system of acute inpatient hospital care characterized by a live-in family member or friend acting as a "care partner". It has an emphasis on education in order to encourage full patient and family involvement in care during the acute hospitalization, thereby preparing both parties for management at home after discharge. The education-intensive experience of CC provides an alternative to traditional inpatient hospital care with the expected outcome of CC being to increase patient and family knowledge and satisfaction, adherence to the medical regimen, and appropriate self-management. The functioning ability of the patient-care partner team should be improved on discharge, which may result in decreased subsequent utilization of high cost healthcare resources such as rehospitalization. This paper describes the structure of the CC form of inpatient care, the types of patients appropriate for such care, and the experience of its first ten years of operation, with its implications as a replicable model for other institutions.

Academic Medical Centers↗
PubMed2005

Cost-benefit analysis of universal varicella vaccination in the U.S. taking into account the closely related herpes-zoster epidemiology.

Many models concur that universal varicella vaccination of children is beneficial from the perspective of reducing societal costs. Yet, the majority of such cost analyses have been modeled under the assumption that varicella vaccination has no adverse effect on the closely related herpes-zoster (HZ) epidemiology. Historical models have assumed that asymptomatic endogenous reactivation is the chief mechanism of boosting that suppresses the reactivation of HZ and that immunity wanes due to the aging process. Recent studies suggest instead that periodic exogenous exposures to wild-type varicella are the predominant factor influencing the curve of increasing HZ incidence rate with advancing age among individuals <50, after which an age-related decline dominates in the elderly. Based on a realistic age-structured model, we compare differences in outcomes of the number of HZ cases and direct medical costs associated with the population existing in 2000 and as it ages (according to the mortality given in the 2000 U.S. census) during the following 50 years with and without implementation of universal varicella vaccination. Under universal varicella vaccination, we assume that 15 years post-licensure, the boosting mechanism known as asymptomatic endogenous reactivation principally serves to limit HZ incidence to 550 per 100,000 person-years in unvaccinated individuals <50 with a previous history of natural varicella--since there has been a vaccine-induced decline in exogenous boosting. We estimate universal varicella vaccination has the impact of an additional 14.6 million (42%) HZ cases among adults aged <50 years during a 50 year time span at a substantial cost burden of 4.1 billion US dollars or 80 million US dollars annually utilizing an estimated mean healthcare provider cost of 280 US dollars per HZ case.

Adolescent↗
PubMed2000

Breast milk supplementation for preterm infants: parental preferences and postdischarge lactation duration.

Breast milk supplementation is frequently used to improve preterm infant growth and to achieve satisfactory intakes of minerals and vitamins. In the North American market there are commercial preparations: two powders and a liquid. The nutritional data available suggest these products are similar and their utilization is based on healthcare team choice. Parental perception about supplementation has not been previously evaluated although parental attitudes are known to impact on lactation success. The objectives of this paper are to determine parental preference and breastfeeding duration for very-low-birth-weight infants given commercial breast milk enrichment products. The study design is a randomized clinical trial with parental interviews. Sixty-three families with 71 infants were enrolled. Parents expressed their preference for the addition of a powder over a liquid preparation (p<0.01). Those mothers whose infants received the liquid enrichment had a shorter lactation relative to their goal, compared with the mothers of the infants who received the powder (p = 0.017). Parents prefer a powder product for breast milk supplementation and this choice positively impacts on the duration of breastfeeding for very-low-birth-weight infants.

Adult↗
PubMed2003

Development of the Irish National Perception of Quality of Care Survey.

OBJECTIVES: This study aimed to develop a methodology suitable for assessing patients' perception of quality of care received in Irish hospitals nationwide. SETTING: Thirteen acute care hospitals throughout Ireland participated in the study. Patients were surveyed approximately 3-6 weeks following discharge. The development work was undertaken by the Irish Society for Quality in Healthcare. DESIGN: The survey utilized Computer Aided Telephone Interviews to receive and collate patient feedback. The questionnaire was developed through utilization of focus groups and extensive piloting. Patients perceptions in a wide range of areas were examined including admission procedures, pain management, adherence to the patient charter, medication, and overall satisfaction. STUDY PARTICIPANTS: A total of 3757 patients were randomly selected for interview during the study period, of whom 3276 were eligible. The remaining 481 patients were unable to participate because of death, hospital re-admission, illness or severe cognitive impairments. With a total of 1950 respondents, this entire study yielded a response rate of 59.5%. RESULTS: This paper indicates how a national society may assist the health system in developing a survey for assessment of patients' perception of quality of care. The results of the survey assisted organizations in identifying many improvement opportunities, mainly in relation to information and communication.

Health Care Surveys↗
PubMed2000

Choice of surgical technique influences perioperative outcomes in liver transplantation.

OBJECTIVE: To examine how the choice of surgical technique influenced perioperative outcomes in liver transplantation. SUMMARY BACKGROUND DATA: The standard technique of orthotopic liver transplantation with venovenous bypass (VVB) is commonly used to facilitate hemodynamic stability. However, this traditional procedure is associated with unique complications that can be avoided by using the technique of liver resection without caval excision (the piggyback technique). METHODS: A prospective comparison of the two procedures was conducted in 90 patients (34 piggyback and 56 with VVB) during a 2.5-year period. Although both groups had similar donor and recipient demographic characteristics, posttransplant outcomes were significantly better for the patients undergoing the piggyback technique. The effect of surgical technique was examined using a stepwise approach that considered its impact on two levels of perioperative and postoperative events. RESULTS: The analysis of the first level of perioperative events found that the piggyback procedure resulted in a 50% decrease in the duration of the anhepatic phase. The analysis of the second level of perioperative events found a significant relation between the anhepatic phase and the duration of surgery and between the anhepatic phase and the need for blood replacement. The analysis of the first level of postoperative events found that the intensive care unit stay was significantly related to both the duration of surgery and the need for blood replacement. The intensive care unit stay was in turn related to the second level of postoperative events, namely the length of hospital stay. Finally, total charges were directly related to length of hospital stay. The overall 1-year actuarial patient and graft survival rates were 94% in the piggyback and 96% in the VVB groups, respectively. CONCLUSIONS: These data demonstrate that surgical choices in complex procedures such as orthotopic liver transplantation trigger a chain of events that can significantly affect resource utilization. In the current healthcare climate, examination of the sequence of events that follow a specific treatment may provide a more complete framework for choosing between treatment alternatives.

Extracorporeal Circulation↗
PubMedDate not supplied

The Model of Whole-Person Caring: creating and sustaining a healing environment.

At Three Rivers Community Hospital, Grants Pass, Ore, the theoretical Model of Whole-Person Caring has resulted in quantifiable and sustainable results in the areas of increased patient and employee satisfaction and decreased nursing turnover, and serves as the foundation for a comprehensive healing environment. The model is a useful framework for healthcare education and its utilization as the theoretical construct for The New England School of Whole-Health Education illustrates its congruency in an educational setting.

Health Facility Environment↗
PubMed2003

Differences in length of stay in Veterans Health Administration and other United States hospitals: is the gap closing?

OBJECTIVES: Compare risk-adjusted length of stay (LOS) in VA and other United States (non-VA) hospitals and determine if relative differences in LOS have changed in recent years. RESEARCH DESIGN: Retrospective cohort study. PATIENTS: Patients with ten common medical diagnoses admitted to all VA hospitals and to non-VA hospitals included in the National Hospital Discharge Survey (NHDS) during 1996 through 1999. DATA: Comparable data elements were obtained from VA administrative databases and the NHDS. LOS was adjusted for age, gender, marital status, and comorbidity. Comorbidity was assessed using a validated methodology that considers 30 conditions. RESULTS: Unadjusted mean LOS was longer in VA than non-VA patient for all 4 years, in aggregate (7.1 vs. 4.9 days, respectively; P < 0.001), and for each year individually. However, the difference in mean LOS in VA and non-VA patients declined from 2.9 days in 1996 to 1.6 days in 1999. LOS in VA patients remained longer (P < 0.001) in linear regression analyses, adjusting for demographics and comorbidity. However, the difference in LOS declined from 28.5% (95% CI, 28.1%-29.0%) in 1996 to 17.0% (95% CI, 16.6%-17.4%) in 1999. These results were similar in analyses of individual geographic regions. CONCLUSIONS: Risk-adjusted LOS was longer in VA hospitals than in other United States hospitals. However, differences in LOS narrowed between 1996 and 1999. These findings suggest that changes in the organization and delivery of VA health care in the mid-1990s may be closing the gap between the VA and other healthcare systems in hospital utilization.

Aged↗
PubMed2006

A somewhat unorthodox explanation for the rise and fall of physician practice management companies: the application of Gaia theory.

PURPOSE: The purpose of this article is to present an alternative theory to why publicly-traded physician practice management companies in the US were popular and successful for a limited number of years and then essentially self-destructed. DESIGN/METHODOLOGY/APPROACH: The short history of publicly-traded practice management companies suggests that they had limited value and utility in the US healthcare industry. It is the premise of the paper that the sudden appearance these for-profit companies upset the natural order within the healthcare industry and created a disequilibria which ultimately resulted in their demise. While Gaia theory is most commonly applied to the natural sciences, it has been applied to a number of interdisciplinary issues. FINDINGS: Physicians gravitated to these for-profit companies either out of fear of encroaching managed care or out a desire to sell their practice to the highest bidder. Physician practice management companies, on the other hand, saw a way to entice stockholders to invest in a growth industry. The paper suggests that the physician practice management companies added little new value to the health care industry and applies Gaia theory as a possible explanation for this phenomena. Gaia theory was first postulated in 1979 to address the evolution of the material environment and corresponding organisms as a tightly coupled system which attempt to manipulate the environment for the purpose of creating biologically favorable conditions. ORIGINALITY/VALUE: The paper is one of the first to suggest that the laws of nature, as understood from the perspective of Gaia theory, may have applicability to the US health care industry.

Models, Theoretical↗
PubMed2006

Nurse educators' perceived challenges in mandatory continuing nursing education.

AIM: This paper reports a study that leads to understanding challenges facing nurse educators implementing mandatory continuing nursing education in The People's Republic of China. BACKGROUND: Mandatory continuing nursing education was instituted to maintain and develop registered nurses' competence in the context of healthcare reform in China in 1996. However, there is an increasing complaint of credit-focused and teacher-centred learning in Chinese literature. Despite an increasing appeal to improve the learning situation, little consensus has been reached. By examining nurse educators' perceived challenges and their coping strategies in implementing mandatory continuing nursing education, this study illuminates the possibilities for reform in mandatory continuing nursing education. METHODS: Data were collected through in-depth interactive dialogues between the researcher and five nurse educators in five healthcare organizations in China, utilizing Gadamer's philosophical hermeneutics. FINDINGS: Three themes were found in this study described as finding a way to support nurses' competence within a constrained situation, reconciling credit requirements and representing all stakeholders' interests. CONCLUSIONS: A tension between the mandatory continuing nursing education policy and the context of implementing the policy can contribute to credit-focused and teacher-centred learning. Regular policy review and educational support for nurse educators are crucial aspects to improve mandatory continuing nursing education.

Adaptation, Psychological↗
PubMedDate not supplied

Development and implementation of clinical pathways for the management of four trauma diagnoses.

Clinical pathways are similar to the production algorithms developed by industry. They are being adapted for use in healthcare to reduce resource utilization, decrease variability, and control expenditures. At Boston Medical Center we identified four trauma diagnoses that we believed to be amenable to the design and implementation of clinical pathways: closed head injury, penetrating wound to the abdomen, penetrating wound to the chest, and penetrating wound to an extremity. Upon implementation of these pathways, appropriate nonoperative, single-system, short-stay trauma patients were enrolled in them. This article details the process by which the four diagnoses were identified and the pathways designed, implemented, and evaluated. Preliminary data demonstrate a significant decrease in resource utilization following implementation of the pathways, without an adverse impact on readmission rates, length of stay, or mortality.

Algorithms↗
PubMed2006

[Socioanthropological notes on community and health].

The notion of community utilized by planners and healthcare providers is doubly deceptive. On the one hand, it presupposes apparent equality and absence of conflicts between people in the same population group. On the other hand, it supposes a certain possibility of intervention by healthcare services in relation to behavioral patterns that are considered undesirable, from the point of view of disease control or health promotion. Used this way, this concept ends up concealing the "social nature" of the target population: poor people and the setbacks that their condition of poverty causes. To bring to light the problem of the euphemism implicit in this notion of community, the objective of the present article was to present Simmel's radically relational approach for characterizing the subordination of these population groups to healthcare policies and programs. For this purpose, the starting point was the appropriation of the sociological notion of community by the healthcare services, from Tönnies' classic formulation and its influence on the authors of the Chicago school.

Anthropology↗
PubMed1996

Sertraline. A pharmacoeconomic evaluation of its use in depression.

Depression is a common condition that is often unrecognised, misdiagnosed and/or undertreated. It is associated with substantial direct, indirect and intangible costs. The indirect costs of lost earnings/productivity and premature death account for the majority of these costs; drug costs account for only about 1 to 2% of total costs and about 10 to 12% of direct costs. Thus, better recognition and appropriate treatment of depression would increase the direct costs associated with this illness, but would also have the potential to greatly reduce indirect costs and consequently the overall cost of depression. Because of their higher acquisition costs relative to tricyclic antidepressants (TCAs), there has been much debate about whether the use of sertraline or other selective serotonin reuptake inhibitors (SSRIs) for first-line treatment of depression can be justified. While these agents have similar efficacy to TCAs, they are better tolerated and have a lower risk of death on overdosage. Despite the large economic burden of depression on society, pharmacoeconomic data on sertraline and antidepressant drugs in general are scarce. Most of the available studies on sertraline are limited to considerations of direct costs and do not assess costs from a societal perspective. In addition, a number of studies have significant methodological problems which limit determination of meaningful conclusions. Nonetheless, data from 2 more recent studies with fewer methodological problems than earlier studies indicated that sertraline was more cost-effective than TCAs because of fewer psychiatrist consultations, and less costly than fluoxetine because of fewer absences from work and fewer medical consultations. The cost-utility ratio of maintenance therapy of depression with sertraline appears to fall within the range of accepted cost-utility ratios of common healthcare interventions. Thus, studies to date have generally shown that overall treatment costs with sertraline and other SSRIs are no greater than those for TCAs; this is despite the lower acquisition costs of the latter agents. Therefore, it is clear from these data that it is misleading to classify antidepressant agents as expensive or inexpensive based solely on their acquisition costs. Sertraline, therefore, can be considered as a first-line alternative to TCAs and other SSRIs for the treatment of depression on both clinical and pharmacoeconomic grounds.

1-Naphthylamine↗
PubMed2006

Cost effectiveness of biventricular pacemakers in heart failure patients.

BACKGROUND: Biventricular pacemakers have been shown to reduce mortality and hospitalizations in heart failure (HF) patients and are indicated for those with a New York Heart Association functional class of III or IV and a QRS interval of >130 ms. However, these devices currently cost in the region of dollar US 33,500 and require replacement upon battery depletion. Therefore, determination of the cost effectiveness of resynchronization therapy is important, although little data have been published to date on this topic. METHODS AND RESULTS: A cost-utility analysis from the healthcare perspective was performed using HF patients who received a biventricular pacing device in the Cleveland Clinic Foundation. The comparator was a similarly profiled group of patients who did not receive the device but were treated medically. A Markov model was used to investigate the cost effectiveness at 1 and 5 years. Second-order Monte-Carlo simulation was used to determine the variability in results, using probabilistic sensitivity analysis. Medical treatment was dominated by biventricular pacemaker treatment at both 1 and 5 years of follow-up. CONCLUSION: Biventricular device insertion is an economically attractive treatment option for clinically indicated HF patients.

Cardiac Pacing, Artificial↗
PubMed2002

Managed competition using both market-driven and regulatory strategies.

The market-driven managed competition concept has been successful in reducing increases in healthcare costs by controlling utilization and price, but has failed to date to produce an effective and efficient delivery of health services. The proposed health reform plan calls for universal access (excluding illegal aliens), a relatively broad range of clinically effective basic benefits, an option to purchase supplementary benefits, a ceiling placed on the nation's total health expenditures, local decisionmakers allocating available resources, existing insurers administering the plan and providing consumers with additional quality of care comparisons.

Cost Control↗
PubMed2003

Gone in 24 hours: the feasibility of performing pubovaginal sling surgery with an overnight hospital stay.

INTRODUCTION: Numerous management strategies are available for stress urinary incontinence, a significant problem for many women. The pubovaginal sling (PVS) with rectus fascia has proven efficacy with minimal morbidity. Historically, patients were admitted for an average of 4 days at the Ottawa Hospital. Since November 2001, patients have spent one night in hospital thereby cutting their total length of stay to less than 24 hours. This study assesses the feasibility of this approach. MATERIALS AND METHODS: Ethics approval was obtained. All patient charts were reviewed retrospectively. Exclusion criteria included women booked for combined procedures or patient refusal. Each case was reviewed to determine if admission to hospital following surgery was required or if subsequent visits to emergency occurred. The Financial Department of the Ottawa Hospital provided financial information to estimate cost savings. Each patient was contacted and administered a standard satisfaction questionnaire. RESULTS: The length of stay was less than 24 hours in all but one case. One patient required a 48-hour stay secondary to post operative nausea. No patient returned to the ER for assessment following discharge. The estimated cost savings were $2709 per case. Patients tolerated having this procedure performed on a daycare basis. CONCLUSIONS: PVS may be performed safely as short stay surgery with a high degree of patient satisfaction. This results in increased efficiency and improved utilization of increasingly limited healthcare resources.

Fascia↗
PubMed2004

Epidemiology of genital herpes simplex virus infection in developed countries.

Comparisons of the seroepidemiology of genital herpes simplex virus (HSV) infection within and between countries are hampered by variations in tests, methods and populations sampled. Differences in seroprevalence may partly reflect variability in diagnostic efforts and healthcare awareness, expectations and utilization. To allow comparison between surveys and to improve their performance, seroepidemiological studies should use validated HSV type-specific tests, report age-specific or age-adjusted prevalence and define the period of time over which samples were collected. Despite the difficulty of comparing studies, the prevalence of HSV-2 infection varies between developed countries. Among healthy adult populations, HSV-2 seroprevalence is higher in the USA than in Europe. Furthermore, HSV-2 seroprevalence varies widely among European countries. For example, in 1989 HSV-2 seroprevalence among pregnant women was reported to be 33% in Sweden compared with 8.3% in Germany. In some, but not all, countries, HSV-2 seroprevalence appears to be increasing. In the USA, the National Health and Nutrition Examination Surveys found that HSV-2 seroprevalence increased by almost one third from 16.4% to 21.8% from 1976 to 1994 in people over 12 years old. The incidence of HSV infection is a measure of primary infection. HSV incidence is difficult to quantify, partly due to unrecognized or asymptomatic infections. However, estimates of incidence in North American and European populations range from 5 to 24 per 100 people per year. Prevention programmes should recognize that HSV-2 seroprevalence increases rapidly in early adult life. The proportion of genital herpes infections caused by HSV-1 is increasing in the developed world, possibly due to changes in oral-genital sexual behaviour and lower rates of HSV-1 acquisition in childhood.

Australia↗