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INTRODUCTION: Injured children may be transported to trauma centers by helicopter air ambulance (HAA); however, a benefit in outcomes to this expensive resource has not been consistently shown in the literature and there is concern that HAA is over-utilized. A study that adequately controls for selection biases in transport mode is needed to determine which injured children benefit from HAA. The purpose of this study was to determine if HAA impacts mortality differently in minimally and severely injured children and if there are predictors of over-triage of HAA in children that can be identified. METHODS: Children ≤18 years of age transported by HAA or ground ambulance (GA) from scene to a trauma center were identified from the 2010-2011 National Trauma Data Bank. Analysis was stratified by Injury Severity Score (ISS) into low ISS (≤15) and high ISS (>15) groups. Following propensity score matching of HAA to GA patients, conditional multivariable logistic regression was performed to determine if transport mode independently impacted mortality in each stratum. Rates and predictors of over-triage of HAA were also determined. RESULTS: Transport by HAA occurred in 8218 children (5574 low ISS, 2644 high ISS) and by GA in 35305 (30506 low ISS, 4799 high ISS). Overall mortality was greater in HAA patients (4.0 vs 1.4%, p<0.001). After propensity score matching, mortality was equivalent between HAA and GA for low ISS patients (0.2 vs 0.2%, p=0.82) but, for high ISS patients, mortality was lower in HAA (9.0 vs 11.1% p=0.014). On multivariable analysis, HAA was associated with decreased mortality in high ISS patients (OR=0.66, p=0.017) but not in low ISS patients (OR=1.13, p=0.73). Discharge within 24h of HAA transport occurred in 36.5% of low ISS patients versus 7.4% high ISS patients (p<0.001). CONCLUSIONS: Based on a national cohort adjusted for nonrandom assignment of transport mode, a survival benefit to HAA transport exists only for severely injured children with ISS >15. Many children with minor injuries are transported by helicopter despite frequent dismissal within 24h and no mortality benefit.
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Aeronaves , Ambulancias , Servicios Médicos de Urgencia , Traumatismo Múltiple/terapia , Tiempo de Tratamiento/estadística & datos numéricos , Heridas y Lesiones/terapia , Adolescente , Aeronaves/estadística & datos numéricos , Ambulancias/estadística & datos numéricos , Niño , Preescolar , Servicios Médicos de Urgencia/organización & administración , Servicios Médicos de Urgencia/estadística & datos numéricos , Femenino , Investigación sobre Servicios de Salud , Mortalidad Hospitalaria , Humanos , Lactante , Recién Nacido , Puntaje de Gravedad del Traumatismo , Modelos Logísticos , Masculino , Traumatismo Múltiple/mortalidad , Puntaje de Propensión , Estudios Retrospectivos , Triaje , Estados Unidos/epidemiología , Heridas y Lesiones/mortalidadRESUMEN
Study Design Retrospective clinical study of a prospectively collected, national database. Objective Determine the 30-day incidence, timing, and risk factors for venous thromboembolism (VTE) following thoracolumbar spine surgery. Methods The American College of Surgeons National Surgical Quality Improvement Program Participant Use File identified 43,777 patients who underwent thoracolumbar surgery from 2005 to 2012. Multiple patient characteristics were identified. The incidence and timing (in days) of deep vein thrombosis (DVT) and pulmonary embolus (PE) were determined. Multivariable regression analysis was performed to identify significant risk factors. Results Of the 43,777 patients identified as having had thoracolumbar surgery, 202 cases of PE (0.5%) and 311 cases of DVT (0.7%) were identified. VTE rates were highest in patients undergoing corpectomy, with a 1.7% PE rate and a 3.8% DVT rate. Independent risk factors for VTE included length of stay (LOS) ≥ 6 days (odds ratio [OR] 4.07), disseminated cancer (OR 1.77), white blood cell count > 12 (OR 1.76), paraplegia (OR 1.75), albumin < 3 (OR 1.73), American Society of Anesthesiologists class 4 or greater (OR 1.54), body mass index > 40 (OR 1.49), and operative time > 193 minutes (OR 1.43). LOS < 3 days was protective (OR 0.427). Conclusions We report an overall 30-day PE rate of 0.5% and DVT rate of 0.7% following thoracolumbar spine surgery. Patients undergoing corpectomy were at highest risk for VTE. Multiple VTE risk factors were identified. Further studies are needed to develop algorithms to stratify VTE risk and direct prophylaxis accordingly.
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BACKGROUND: We assessed the health literacy of trauma discharge summaries and hypothesize that they are written at higher-than-recommended grade levels. METHODS: The Flesch-Kincaid grade level (FKGL) and Flesch reading ease scores (FRES), 2 universally accepted scales for evaluating readability of medical information, were used. RESULTS: A total of 497 patients were included. The mean patient age was 56 ± 22 years. Average FKGL and FRES were 10 ± 1 and 44 ± 7, including 132 summaries classified as very or fairly difficult to read. A total of 204 (65%) patients had functional reading skills at grade levels below the FKGL of their dismissal note; only 74 patients (24%) had the reading skills to adequately comprehend their dismissal summary. Total 30-day readmissions were 40, 65% of whom were patients with inadequate literacy for dismissal summary comprehension. CONCLUSIONS: Patient discharge notes are written at too advanced of an educational level. To ensure patient comprehension, dismissal notes should be rewritten to a 6th-grade level.
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Alfabetización en Salud , Resumen del Alta del Paciente , Lectura , Heridas y Lesiones/cirugía , Adulto , Demografía , Escolaridad , Femenino , Humanos , Puntaje de Gravedad del Traumatismo , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Readmisión del Paciente/estadística & datos numéricos , Sistema de Registros , Estudios RetrospectivosRESUMEN
BACKGROUND CONTEXT: The incidence of surgical site infection (SSI) following posterior cervical surgery has been reported as high as 18% in the literature. Few large studies have specifically examined posterior cervical procedures. PURPOSE: The study aims to examine the incidence, timing, and risk factors for SSI following posterior cervical surgery. DESIGN: This is a retrospective cohort study of prospectively collected data in a national surgical outcomes database. PATIENT SAMPLE: The sample includes patients who underwent posterior cervical spine surgery between 2005 and 2012 identified in the American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) Participant Use Data File. OUTCOME MEASURES: The 30-day rate of postoperative SSI, timing of diagnosis, and associated risk factors were determined. METHODS: The ACS NSQIP was used to identify 5,441 patients who underwent posterior cervical spine surgery by Current Procedural Terminology codes from 2005 to 2012. Thirty-day readmission data were obtained for 2011-2012. The incidence and timing of SSI were determined. Multivariable logistic regression analysis was then performed to identify significant risk factors. RESULTS: Of the 5,441 patients identified as having undergone posterior cervical surgery, 3,724 had a posterior cervical decompression, 1,310 had a posterior cervical fusion, and 407 underwent cervical laminoplasty. Surgical site infection within 30 days was identified in 160 patients (2.94%), with 80 of those cases being superficial SSI. There was no significant difference in SSI rate among the three procedure groups. The average time for diagnosis of SSI was over 2 weeks. In 2011-2012, 36.9% of patients with SSI were readmitted within 30 days. Several significant predictors of SSI were identified in univariate analysis, including body mass index (BMI) >35, chronic steroid use, albumin <3, hematocrit <33, platelets <100, higher American Society of Anesthesiologists class, longer operative time, and longer hospital admission. Independent risk factors, including BMI >35 (odds ratio [OR]=1.78, p=.003), chronic steroid use (OR=1.73, p=.049), and operative time >197 minutes (OR=2.08, p=.005), were identified in multivariable analysis. CONCLUSIONS: Optimization of preoperative nutritional status, serum blood cell counts, and operative efficiency may lead to a reduction in SSI rates. Obese patients and patients on chronic steroid therapy should be counseled on elevated SSI risk.
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Descompresión Quirúrgica/efectos adversos , Fusión Vertebral/efectos adversos , Infección de la Herida Quirúrgica/epidemiología , Adulto , Anciano , Bases de Datos Factuales , Descompresión Quirúrgica/normas , Descompresión Quirúrgica/estadística & datos numéricos , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Obesidad/epidemiología , Tempo Operativo , Mejoramiento de la Calidad , Estudios Retrospectivos , Factores de Riesgo , Fusión Vertebral/normas , Fusión Vertebral/estadística & datos numéricosRESUMEN
BACKGROUND: A nomogram to predict disease-specific mortality (DSM) following surgery for soft tissue sarcoma (STS) has been developed by the Memorial Sloan Kettering Cancer Center (MSKCC). The goal of this study was to validate this nomogram by assessing discrimination and calibration at the population level using a national cancer database. METHODS: Retrospective review of the Surveillance, Epidemiology, and End Results cancer registries identified patients undergoing surgery for STS from 1988 to 2011. Data for patient age, tumor size, tumor grade, histologic subtype, sex, primary tumor location, and tumor depth were entered into the nomogram calculator for each patient. Discrimination was quantified using a concordance index. Calibration was assessed by comparing quintiles of nomogram-predicted probabilities of disease-specific mortality (DSM) with American Joint Committee on Cancer (AJCC) stage DSM. RESULTS: Overall, 9237 patients were identified with complete information needed for the nomogram. With a mean follow-up of 45 months, the concordance index for nomogram-predicted DSM with actual DSM was 0.74 for the entire cohort. For low- and high-grade tumors, this was 0.71 and 0.66, respectively. Kaplan-Meier curves showed better calibration for nomogram-predicted DSM when compared with AJCC staging. CONCLUSIONS: Our results validate the use of the MSKCC STS nomogram in the general population, with better predictive ability than AJCC staging. However, a concordance index of 0.74 suggests that further improvement in prognostication is needed, perhaps with biological markers or additional clinical variables.
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Nomogramas , Sistema de Registros , Sarcoma/mortalidad , Sarcoma/patología , Humanos , Estadificación de Neoplasias , Pronóstico , Tasa de SupervivenciaRESUMEN
BACKGROUND: A clinical risk score for pancreatic fistula (CRS-PF) was recently reported to predict postoperative pancreatic fistula (POPF) after pancreatoduodenectomy (PD). An independent external validation has not been performed. Our hypothesis was that CRS-PF predicts POPF after both laparoscopic and open PD. STUDY DESIGN: The CRS-PF was calculated from a retrospective review of patients undergoing PD from January 2007 to February 2014. Postoperative pancreatic fistula was graded using International Study Group of Pancreatic Fistula criteria. Grade B and C leaks were defined as clinically significant. Performance was measured based on sensitivity, specificity, positive and negative predictive value, accuracy, and R(2). RESULTS: There were 808 patients who met inclusion criteria; 539 (66.7%) had open and 269 (33.3%) had laparoscopic PD. The CRS-PF was high risk in 134 patients, intermediate in 492, low in 135, and negligible in 47. Postoperative pancreatic fistula occurred in 191 (23.6%) patients (grade A, 3.8%; B, 14.2%; and C, 5.6%), and it increased with risk category (R(2) = 0.935 all, 0.898 open, and 0.968 laparoscopic). High and intermediate risk categories were combined and classified as "test positive," and negligible and low risk categories were combined and classified "test negative," resulting in a CRS-PF with a sensitivity of 95% and a negative predictive value of 96% for predicting POPF. Contrary to previous studies, grade A POPF increased with increasing CRS-PF and POPF did not correlate with estimated blood loss (R(2) = 0.04). CONCLUSIONS: The CRS-PF was validated independently by predicting POPF for both laparoscopic and open PD. Predictive performance was at least as good for laparoscopic PD as for open PD. Lack of correlation with estimated blood loss suggests CRS-PF might be tailored for improved performance. The CRS-PF is a clinically useful tool for POPF risk stratification after PD and allows for targeted intra- and postoperative measures to address patients at increased risk.
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Fístula Pancreática/etiología , Pancreaticoduodenectomía/efectos adversos , Medición de Riesgo , Anciano , Femenino , Humanos , Laparoscopía , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Sensibilidad y EspecificidadRESUMEN
OBJECTIVE: To characterize the evolving management of vestibular schwannoma (VS) in the United States. STUDY DESIGN: Retrospective analysis of the Surveillance, Epidemiology, and End Results (SEER) database. SETTING: SEER database. SUBJECTS AND METHODS: All patients with a diagnosis of VS were analyzed. Data were described and compared using trend analyses and univariate and multivariable logistic regression. RESULTS: A total of 8330 patients (average age 54.7 years, 51.9% female) were analyzed. The mean incidence was approximately 1.1 per 100,000 per year and did not vary significantly across time; however, from 2004 to 2011, there was a statistically significant decrease in tumor size category at time of diagnosis (P < .01). Overall, 3982 patients (48%) received primary microsurgery, 1978 (24%) radiation therapy alone, and 2370 (29%) observation. Within the microsurgical cohort, 732 (18%) underwent subtotal resection, and of those, 98 (13.4%) received postoperative radiation therapy. Multivariable regression revealed that surgical treatment was more common in younger patients and larger tumor size categories (P < .05). Management trend analysis revealed that microsurgery was used less frequently over time (P < .0001), observation was used more frequently (P < .0001), and the pattern of radiation therapy remained unchanged. Linear regression was used to create an equation that was applied to predict future management practices. These data predict that by 2026, half of all cases of VS will be managed initially with observation. CONCLUSION: While the incidence of VS has remained steady, tumor size at time of diagnosis has decreased over time. Within the United States there has been a clear, recent evolution in management toward observation.
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Neuroma Acústico/radioterapia , Neuroma Acústico/cirugía , Femenino , Humanos , Incidencia , Masculino , Microcirugia , Persona de Mediana Edad , Neuroma Acústico/epidemiología , Neuroma Acústico/patología , Estudios Retrospectivos , Programa de VERF , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND/PURPOSE: Identifying quality in pediatric surgery can be difficult given the low frequency of postoperative complications. We compared postoperative events following pediatric surgical procedures at a single institution identified by ACS-NSQIP Pediatric (ACS NSQIP-P) methodology and AHRQ Pediatric Quality Indicators (AHRQ PDIs), an administrative tool. METHODS: AHRQ PDI algorithms were run on inpatient hospital discharge abstracts for 1257 children in the 2010 to 2013 ACS NSQIP-P at our institution. Four events-pulmonary complications, postoperative sepsis, wound dehiscence and bleeding-were matched between ACS NSQIP-P and AHRQ PDI. RESULTS: Events were identified by ACS NSQIP-P in 7.9% of children and by AHRQ PDI in 8.0%. The four matched events were identified in 5.5% and 3.7%, respectively. Specificities of AHRQ PDI ranged from 97% to 100% and sensitivities from 0 to 2%. The largest discrepancy was in bleeding, where AHRQ PDI captured 1 of the 54 events identified by ACS NSQIP-P. None of the 41 pulmonary, sepsis, and wound dehiscence events identified by AHRQ PDI were clinically relevant according to ACS NSQIP-P. CONCLUSIONS: Adverse events following pediatric surgery are infrequent; thus, additional measures of quality to supplement postoperative adverse events are needed. AHRQ PDIs are inadequate for assessing quality in pediatric surgery.
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Pediatría/normas , Complicaciones Posoperatorias/epidemiología , Garantía de la Calidad de Atención de Salud/métodos , Mejoramiento de la Calidad , Indicadores de Calidad de la Atención de Salud/estadística & datos numéricos , Especialidades Quirúrgicas/normas , Adolescente , Niño , Preescolar , Femenino , Humanos , Lactante , Recién Nacido , Masculino , Estados Unidos , United States Agency for Healthcare Research and QualityRESUMEN
OBJECTIVE: To assess the impact of wellness center attendance on weight loss and costs. METHODS: A retrospective analysis was conducted using employee data, administrative claims, and electronic health records. A total of 3199 employees enrolled for 4 years (2007 to 2010) were included. Attendance was categorized as follows: 1 to 60, 61 to 180, 181 to 360, and more than 360 visits. Weight loss was defined as moving to a lower body mass index category. Total costs included paid amounts for both medical and pharmacy services. RESULTS: Subjects with 181 to 360 and more than 360 visits were 46% (P = 0.05) and 72% (P = 0.01) more likely to have body mass index improvement compared with those with 1 to 60 visits. Compared with the mean annual cost of $13,267 for 1 to 60 visits, the mean for subjects with 61 to 180, 181 to 360, and more than 360 visits had significantly lower costs at $9538, $9332 and $8293, respectively (all P < 0.01). Higher attendance was associated with weight loss and significantly lower annual costs.
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Centros de Acondicionamiento , Costos de la Atención en Salud , Servicios de Salud del Trabajador , Pérdida de Peso , Adulto , Índice de Masa Corporal , Ahorro de Costo , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Lugar de TrabajoRESUMEN
BACKGROUND/PURPOSE: Following publication of American Pediatric Surgical Association (APSA) hospital benchmarks for the operative management of blunt splenic trauma in specialized centers, it was found that most hospitals exceeded these benchmarks. We sought to determine if benchmarks were being met a decade later and to identify factors associated with splenectomy in injured children. METHODS: Rates of splenic procedures were calculated for children≤19 with a blunt splenic injury (ICD-9 865) using the 2010-2011 National Trauma Data Bank. Multivariable analysis was performed to determine independent predictors of splenectomy. RESULTS: Of 8597 children, 24.3% received care at pediatric trauma centers (PTC), 34.6% at adult trauma centers (ATC), and the remaining 41.2% at other centers (OTC). The overall operative rate was 9.2% (3.9% if age≤14, 6.7% if ≤17). Operative rates were higher in children treated at ATC and OTC when compared to PTC. On multivariable analysis, age>14, coexisting injuries, severity of splenic injury, and care at ATC or OTC were predictive of undergoing operative treatment. CONCLUSIONS: Operative rates for splenic injuries meet APSA benchmarks at PTC yet remain high at other centers. Care at an ATC or OTC is associated with greater odds of operative management after adjustment for age and injury severity.
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Traumatismos Abdominales/cirugía , Benchmarking/métodos , Manejo de la Enfermedad , Bazo/lesiones , Esplenectomía/métodos , Centros Traumatológicos , Heridas no Penetrantes/cirugía , Adolescente , Niño , Preescolar , Femenino , Humanos , Masculino , Bazo/cirugía , Adulto JovenRESUMEN
BACKGROUND: Patients undergoing surgical treatment of chronic ulcerative colitis usually undergo a staged approach to IPAA. OBJECTIVE: The purpose of this work was to identify the national trends in approach to IPAA for chronic ulcerative colitis and to evaluate 30-day outcomes using the American College of Surgeons National Surgical Quality Improvement Program. DESIGN: This was a retrospective review study SETTINGS: : This study was conducted at a tertiary care cancer center. PATIENTS: Patients with chronic ulcerative colitis who underwent IPAA from 2005 to 2011 were identified. Those who underwent colectomy with pouch procedure were placed in a 2-stage cohort, and those without simultaneous colectomy were part of a 3-stage cohort. Emergent operations were excluded. MAIN OUTCOME MEASURES: Trends in procedure mix, preoperative characteristics, and postoperative 30-day outcomes were compared. Multivariate analysis was used to identify independent risk factors for postoperative infection. RESULTS: Of 2002 patients who underwent IPAA, 1452 (72.5%) underwent 2-stage and 550 (27.5%) underwent 3-stage surgery. Since 2007, the distribution of 2- versus 3-stage procedures has not changed (p = 0.66). At the time of pouch surgery, patients who had undergone 3-stage surgery were less likely to have preoperative corticosteroid therapy, albumin <3 mg/dL, preoperative sepsis, and weight loss (all p < 0.05). Superficial surgical site infection was more common after 3-stage surgery (11.5% vs 7.3%; p < 0.01). After controlling for preoperative factors, wound classification was the only independent predictor of deep incisional or organ space infection (p < 0.01; OR, 1.76; 95% CI, 1.23-2.53). LIMITATIONS: This was a retrospective study. CONCLUSIONS: National trends of 2- versus 3-stage IPAA have remained stable over the last 5 years. Patients who underwent a 3-stage approach were healthier at the time of pouch surgery, with decreased corticosteroid use, hypoalbuminemia, and weight loss. Mixed results were seen for infectious complications with either approach. Prospective research is needed to determine the best approach to IPAA for chronic ulcerative colitis.
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Anastomosis Quirúrgica/métodos , Colitis Ulcerosa/cirugía , Complicaciones Posoperatorias , Proctocolectomía Restauradora/métodos , Adulto , Anastomosis Quirúrgica/tendencias , Estudios de Cohortes , Reservorios Cólicos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Proctocolectomía Restauradora/tendencias , Estudios Retrospectivos , Infección de la Herida Quirúrgica , Resultado del TratamientoRESUMEN
OBJECTIVES: To examine multiple chronic conditions and related health care expenditures in children. METHODS: Retrospective cohort study of all dependents of Mayo Clinic employees aged 0-17 on Jan 1, 2004 with continuous health benefits coverage for 4 years (N=14,727). Chronic conditions, health care utilization, and associated expenditures were obtained from medical and pharmacy claims. RESULTS: The most prevalent chronic conditions were asthma/chronic obstructive pulmonary disease (12%), allergic rhinitis (11%), and behavior problems (9%). The most costly conditions were congenital anomalies, asthma/chronic obstructive pulmonary disease, and behavior problems ($9602, $4335, and $5378 annual cost per child, respectively). Annual health care expenditures increased substantially with the number of chronic conditions, and a small proportion of children with multiple chronic conditions accounted for a large proportion of health care costs. In addition, those with multiple chronic conditions were more likely to persist in the top 10th percentile spender group in year-to-year spending. CONCLUSION: Children with multiple chronic conditions accounted for a large proportion of health care expenditures. These children were also likely to persist as high spenders in the 4-year time frame. Further research into effective ways to manage the health care delivery for children with multiple chronic conditions is needed.
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Enfermedad Crónica/economía , Comorbilidad , Atención a la Salud/economía , Costos de la Atención en Salud , Gastos en Salud , Adolescente , Asma/economía , Niño , Trastornos de la Conducta Infantil/economía , Preescolar , Estudios de Cohortes , Anomalías Congénitas/economía , Femenino , Humanos , Lactante , Recién Nacido , Masculino , Enfermedad Pulmonar Obstructiva Crónica/economía , Estudios Retrospectivos , Rinitis Alérgica/economíaRESUMEN
OBJECTIVES: The aim of this study was to determine the utility of intraoperative cystoscopy in detecting and managing ureteral injury among women undergoing vaginal hysterectomy. METHODS: We performed a secondary analysis of a retrospective cohort study of 593 patients who underwent vaginal hysterectomy for benign indications, with or without additional pelvic floor reconstructive surgery, from January 2, 2004, through December 30, 2005. A logistic regression model determining the propensity to undergo intraoperative cystoscopy was constructed. Comparisons of ureteral injury and cost between patients with and without cystoscopy were adjusted for the cystoscopy propensity score. We further explored the feasibility of using perioperative change in creatinine level to detect ureteral injury. RESULTS: In total, 230 (38.8%) of 593 patients underwent cystoscopy. Six patients (2.6%) in the cystoscopy group and 5 (1.4%) in the no-cystoscopy group had ureteral injuries (odds ratio, 1.92; 95% confidence interval [CI], 0.58-6.36). This association was further attenuated after adjusting for the propensity to undergo cystoscopy (odds ratio, 1.31; 95% CI, 0.19-9.09). Four injuries detected cystoscopically were managed intraoperatively. Adjusted mean-predicted costs for patients undergoing cystoscopy were $10,686 (95% CI, $7500-$13,872) versus $10,217 (95% CI, $6894-$13,540). In the no-cystoscopy group, patients with ureteral injury had a median increase in creatinine level of 0.2 mg/dL, whereas patients without injury had a median decrease of 0.1 mg/dL (P < 0.001). CONCLUSIONS: The level of selection for cystoscopy did not significantly increase the mean predicted costs for patients. Reliance on postoperative creatinine level to detect ureteral injury, while highly sensitive, is limited by a low positive predictive value and variable range.
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Cistoscopía/métodos , Histerectomía Vaginal/efectos adversos , Uréter/lesiones , Vejiga Urinaria/lesiones , Heridas y Lesiones/diagnóstico , Adulto , Cistoscopía/economía , Femenino , Humanos , Cuidados Intraoperatorios , Modelos Logísticos , Persona de Mediana Edad , Estudios Retrospectivos , Heridas y Lesiones/etiologíaRESUMEN
BACKGROUND: Stoma reversals (SRs) are commonly performed with potentially significant postoperative complications including surgical site infections (SSIs). Our aim was to determine the incidence and risk factors for SSIs in a large cohort of SR patients. DESIGN: We reviewed our institutional 2006-2011 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database for 30-day SSIs in patients undergoing SR. Records were additionally reviewed for 10 non-ACS-NSQIP variables. The primary outcome was SSI after SR. Secondary outcomes were additional 30-day postoperative complications and length-of-stay. Predictors of SSIs were identified using multivariable logistic regression. RESULTS: From 528 SR patients, 36 patients developed a SSI (6.8 %). Most patients underwent SR for loop ileostomies (76.5 %) after index operations for ulcerative colitis (38.6 %) and colorectal cancer (27.8 %). SSI patients had fewer subcutaneous drains compared to patients with no SSI and had significantly higher rates of smoking, ASA 3-4 classification and laparotomies at SR (p < 0.05). Patients with SSI had increased length-of-stay and 30-day morbidities including sepsis and returns to the operating room (p < 0.05) compared to no-SSI patients. On multivariable analysis, subcutaneous drain placement was suggestive of SSI protection (odds ratio [OR] 0.52, 95 % confidence interval [CI] 0.2-1.1), but only smoking was significantly associated with an increased risk for SSI (OR 2.4, 95 % CI 1.1-5.4). CONCLUSIONS: Smoking increased the risk of SR SSIs in patients by over twofold, and SR SSIs are associated with additional significant morbidities. Smoking cessation should be an important part of any SSI risk-reduction strategy.
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Drenaje/métodos , Ileostomía , Fumar/epidemiología , Infección de la Herida Quirúrgica/epidemiología , Infección de la Herida Quirúrgica/prevención & control , Drenaje/efectos adversos , Femenino , Humanos , Incidencia , Tiempo de Internación , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Reoperación , Factores de Riesgo , Sepsis/etiología , Infección de la Herida Quirúrgica/complicacionesRESUMEN
Computer-based clinical decision-support systems are effective interventions to improve compliance with guidelines and quality measures. However, understanding of their long-term impact, including unintended consequences, is limited. The authors assessed the clinical impact of the sequential implementation of 2 such systems to improve the use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEIs/ARBs) in inpatients with heart failure. Compliance with the core measure improved from 91.0% at baseline to 93.6% with the Pharmacy Care (P-Care) Rule and to 96.4% with the Centricity-Blaze (CE-Blaze) Rule. At the same time, prescriptions for ACEIs/ARBs documented in the hospital discharge summary decreased from 83.2% at baseline to 75.8% with the P-Care rule and to 64.1% with the CE-Blaze Rule. The inpatient mortality rate and the 30-day readmission rate did not change significantly. Better documentation of contraindications in the electronic medical record seems to account for the core measure improvement, even as ACEI/ARB therapy has unexpectedly declined.
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Antagonistas de Receptores de Angiotensina/uso terapéutico , Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Sistemas de Apoyo a Decisiones Clínicas , Insuficiencia Cardíaca/tratamiento farmacológico , Anciano , Femenino , Adhesión a Directriz , Humanos , Masculino , Alta del Paciente/estadística & datos numéricos , Pautas de la Práctica en Medicina , Mejoramiento de la Calidad , Disfunción Ventricular Izquierda/tratamiento farmacológicoRESUMEN
BACKGROUND: Policy makers are interested in aggregating fee-for-service reimbursement into episode-based bundle payments, hoping it will lead to greater efficiency in the provision of care. The focus of bundled payment initiatives has been upon surgical or discrete procedures. Relatively little is known about calculating and implementing episode-based payments for chronic conditions. OBJECTIVE: Compare the differences in two different episode-creation algorithms for two common chronic conditions: diabetes and coronary artery disease (CAD). STUDY DESIGN: We conducted a retrospective evaluation using enrollees with continuous coverage in a self-funded plan from 2003 to 2006, meeting Healthcare Effectiveness Data and Information Set (HEDIS) criteria for diabetes or CAD. For each condition, an annual episode-based payment was assessed using two algorithms: Episode Treatment Groups (ETGs) and the Prometheus model. PRINCIPAL FINDINGS: We began with 1,580 diabetes patients with a 4-year total payment mean of $67,280. ETGs identified 1,447 (92%) as having diabetes with 4-year episode-based mean payments of $12,731; while the Prometheus model identified 1,512 (96%) as having diabetes, but included only 1,195 of them in the Prometheus model with mean diabetes payments of $23,250. Beginning with 1,644 CAD patients with a 4-year total payment mean of $65,661, ETGs identified 983 patients (60%) with a 4-year episode-based mean of $24,362. The Prometheus model identified 1,135 (69%) as CAD patients with 948 CAD patients having a mean of $26,536. CONCLUSIONS: The two episode-based methods identify different patients with these two chronic conditions. In addition, there are significant differences in the episode-based payment estimates for diabetes, but similar estimates for CAD. Implementing episode-based payments for chronic conditions is challenging, and thoughtful discussions are needed to determine appropriate payments.
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Enfermedad Crónica/economía , Planes de Aranceles por Servicios/economía , Adolescente , Adulto , Anciano , Algoritmos , Enfermedad Crónica/epidemiología , Enfermedad de la Arteria Coronaria/economía , Enfermedad de la Arteria Coronaria/epidemiología , Diabetes Mellitus/economía , Diabetes Mellitus/epidemiología , Planes de Aranceles por Servicios/estadística & datos numéricos , Costos de la Atención en Salud/estadística & datos numéricos , Humanos , Persona de Mediana Edad , Modelos Estadísticos , Estudios Retrospectivos , Estados Unidos/epidemiología , Adulto JovenRESUMEN
OBJECTIVE: To provide the simultaneous 7-year estimates of incremental costs of smoking and obesity among employees and dependents in a large health care system. METHODS: We used a retrospective cohort aged 18 years or older with continuous enrollment during the study period. Longitudinal multivariate cost analyses were performed using generalized estimating equations with demographic adjustments. RESULTS: The annual incremental mean costs of smoking by age group ranged from $1274 to $1401. The incremental costs of morbid obesity II by age group ranged from $5467 to $5530. These incremental costs drop substantially when comorbidities are included. CONCLUSIONS: Obesity and smoking have large long-term impacts on health care costs of working-age adults. Controlling comorbidities impacted incremental costs of obesity but may lead to underestimation of the true incremental costs because obesity is a risk factor for developing chronic conditions.
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Costos de la Atención en Salud/estadística & datos numéricos , Obesidad/economía , Fumar/economía , Adulto , Anciano , Índice de Masa Corporal , Comorbilidad , Costos y Análisis de Costo , Femenino , Humanos , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Análisis Multivariante , Obesidad Mórbida/economía , Sobrepeso/economía , Jubilación/economía , Estudios RetrospectivosRESUMEN
OBJECTIVE: This study tested the ability of an electronic prompt to promote an asthma assessment during primary care visits. METHODS: We performed a prospective study of all eligible adult patients with previously diagnosed asthma in three geographically distinct ambulatory family medicine clinics within a 4-month period. The usual clinic visit process was performed at two geographically distinct control sites (n = 75 and n = 55 patients, respectively). The intervention group site (n = 64) had an electronic flag embedded in the Patient Check-in Locator field which prompted the distribution of a self-administered Asthma Management Questionnaire (AMQ) in the waiting room. The primary outcome measure was a documented asthma severity assessment. RESULTS: The front desk distributed the AMQ successfully in 100% of possible opportunities and the AMQ was completed by 84% of patients. Providers in the intervention group were significantly more likely than providers in the two non-intervention groups to document asthma severity in the medical record during a non-asthma ambulatory clinic visit (63.3% vs. 18.7% vs. 3.6%; p < .001). CONCLUSION: The provision of standardized asthma information triggered by an electronic prompt at the time of check-in effectively initiates an asthma assessment during the primary care visits.
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Asma/terapia , Adulto , Enfermedad Crónica , Femenino , Humanos , Modelos Logísticos , Masculino , Estudios Prospectivos , Encuestas y CuestionariosRESUMEN
Some health plans have experimented with increasing consumer cost sharing, on the theory that consumers will use less unnecessary health care if they are expected to bear some of the financial responsibility for it. However, it is unclear whether the resulting decrease in use is sustained beyond one or two years. In 2004 Mayo Clinic's self-funded health plan increased cost sharing for its employees and their dependents for specialty care visits (adding a $25 copayment to the high-premium option) and other services such as imaging, testing, and outpatient procedures (adding 10 or 20 percent coinsurance, depending on the option). The plan also removed all cost sharing for visits to primary care providers and for preventive services such as colorectal screening and mammography. The result was large decreases in the use of diagnostic testing and outpatient procedures that were sustained for four years, and an immediate decrease in the use of imaging that later rebounded (possibly to levels below the expected trend). Beneficiaries decreased visits to specialists but did not make greater use of primary care services. These results suggest that implementing relatively low levels of cost sharing can lead to a long-term decrease in utilization.
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Instituciones de Atención Ambulatoria , Seguro de Costos Compartidos/métodos , Planes de Asistencia Médica para Empleados/economía , Servicios de Salud/estadística & datos numéricos , Procedimientos Innecesarios/economía , Adulto , Femenino , Planes de Asistencia Médica para Empleados/organización & administración , Humanos , Masculino , Persona de Mediana Edad , Minnesota , Estudios de Casos OrganizacionalesRESUMEN
OBJECTIVE: This study was a retrospective data-based analysis of health care utilization and costs for patients diagnosed as having bipolar disorder compared with patients with diagnoses of depression, diabetes, coronary artery disease, or asthma. METHODS: Data were from an employer-based health plan. Consistent diagnosis and continuous enrollment from 2004 to 2007 were used to identify the study population (total N = 7,511), including those with bipolar disorder (N = 122), depression (N = 1,290), asthma (N = 2,770), coronary artery disease (N = 1,759), diabetes (N = 1,418), and diabetes with coronary artery disease (N = 455). Resource utilization quantified as cost (total, specialty care, psychiatric outpatient) and number of visits (specialty care and outpatient psychiatric care) was compared across groups. RESULTS: Patients with bipolar disorder had higher adjusted mean per member per month (PMPM) costs than any other comparison group except for those with both diabetes and coronary artery disease. The cost was predominantly related to pharmacy costs and both inpatient and outpatient psychiatric care. A subset of 20% of patients with bipolar disorder accounted for 64% of the total costs. This subgroup of patients was more likely to be female, to have frequent hospital stays, and to have a higher number of comorbidities. Depressed patients, in contrast to bipolar disorder patients, had higher adjusted mean PMPM costs in primary care and nonpsychiatric inpatient costs. CONCLUSIONS: Health care costs for bipolar disorder exceeded those for several common chronic illnesses. These data provide further evidence for employers, insurers, and providers to seek innovative models to deliver effective and efficient care to individuals with bipolar illness.