The results of a randomized trial of a quality improvement intervention in the care of patients with heart failure. The MISCHF Study Investigators

PURPOSE

Quality improvement and disease management programs for heart failure have improved quality of care and patient outcomes at large tertiary care hospitals. The purpose of this study was to measure the effects of a regional, multihospital, collaborative quality improvement intervention on care and outcomes in heart failure in community hospitals.

PATIENTS AND METHODS

This randomized controlled study included 10 acute care community hospitals in upstate New York. After a baseline period, 5 hospitals were randomly assigned to receive a multifaceted quality improvement intervention (n = 762 patients during the baseline period; n = 840 patients postintervention), while 5 were assigned to a "usual care" control (n = 640 patients during the baseline period; n = 664 patients postintervention). Quality of care was determined using explicit criteria by reviewing the charts of consecutive patients hospitalized with the primary diagnosis of heart failure during the baseline period and again in the postintervention period. Clinical outcomes included hospital length of stay and charges, in-hospital and 6-month mortality, hospital readmission, and quality of life measured after discharge.

RESULTS

Patients had similar characteristics in the baseline and postintervention phases in the intervention and control groups. Using hospital-level analyses, the intervention had mixed effects on 5 quality-of-care markers that were not statistically significant. The mean of the average length of stay among hospitals decreased from 8.0 to 6.2 days in the intervention group, with a smaller decline in mean length of stay in the control group (7.7 to 7.0 days). The net effects of the intervention were nonsignificant changes in length of stay of -1.1 days (95% confidence interval [CI]: -2.9 to 0.7 days, P = 0.18) and in hospital charges of -$817 (95% CI: -$2560 to $926, P = 0.31). There were small and nonsignificant effects on mortality, hospital readmission, and quality of life.

CONCLUSIONS

The incremental effect of regional collaboration among peer community hospitals toward the goal of quality improvement was small and limited to a slightly, but not significantly, shorter length of stay.

Is routine use of the intensive care unit after elective infrarenal abdominal aortic aneurysm repair necessary?

INTRODUCTION

Postoperative care after infrarenal abdominal aortic aneurysm (AAA) repair has traditionally involved admission to the intensive care unit (ICU). With the advent of endovascular AAA repair, the management of open procedures has received increased scrutiny. We recently modified our AAA clinical pathway to include selective use of the ICU.

METHODS

Consecutive elective infrarenal AAA repairs performed by members of the vascular surgery division at a university medical center from 1994 to 1999 were analyzed retrospectively with a computerized database, the Medical Archival Retrieval System. Group I consisted of 245 patients who were treated in the ICU for 1 or more days, and Group II included 69 patients admitted directly to the floor. Ruptured, symptomatic, suprarenal, endovascular, and reoperative repairs were excluded. Outcome variables were compared over the 6-year period.

RESULTS

Floor admissions increased over the study period with 0%, 0%, 3.3%, 16.3%, 48.6%, and 43.6% of patients admitted directly to the surgery ward from 1994 to 1999. The average ICU length of stay declined from 4.6 to 1.2 days, whereas the hospital length of stay decreased from 12.5 to 6.8 days from 1994 to 1999. The change in ICU use had no effect on death (2.4% in Group I vs 0% in Group II). Major and minor morbidity was comparable. Hospital charges were significantly lower for patients in Group II.

CONCLUSION

A policy of selective utilization of the ICU after elective infrarenal AAA repair is safe. It can reduce resource use without a negative impact on the quality of care.

Impact of Guglielmi detachable coils on outcomes of patients with intracranial aneurysms treated by a multidisciplinary team at a single institution

OBJECT

The goal of this study was to investigate the impact of the introduction of the Guglielmi detachable coil (GDC) therapeutic option on the overall management outcome of intracranial aneurysms. The authors accomplished this by assessing patient morbidity and mortality, inflation-adjusted hospital charges, lengths of stay in the hospital and the intensive care unit (ICU), and treatment efficacy.

METHODS

The authors conducted a retrospective analysis of consecutive cases of intracranial intradural aneurysms managed by a single multidisciplinary neurovascular team at a tertiary care, academic referral center during the 24 months preceding the introduction of the GDC procedure (Group I or pre-GDC era, 77 patients) and during the first 24 months after its introduction (Group II or GDC era, 99 patients). Treatment with GDCs was considered for cases of higher clinical grade or poor surgical risk, or in response to patient preference (27 [27%] of 99 patients in Group II). Host and lesion parameters in our cohort were validated against outcome parameters by using univariate and multivariate analyses. The pre-GDC and GDC subgroups of patients were comparable for major disease severity parameters (patient age, lesion location, clinical grade, and hemorrhage severity). There was no significant difference in clinical outcome at 6 months, infarcts on computerized tomography scanning, or aneurysm obliteration rates before and after introduction of GDC treatment. Decreasing trends in duration of hospital and ICU stay and in inflation-adjusted hospital charges occurred well before and thus were unrelated to the introduction of the GDC therapeutic option.

CONCLUSIONS

The results of this study do not demonstrate any significant impact of integration of the GDC modality on clinical outcome, mortality, morbidity, or effectiveness of treatment. Ongoing improvements in hospital charges and length of hospital stay appeared unrelated to the introduction of the GDC option.

Carotid endarterectomy: the financial impact of practice changes

PURPOSE

New techniques in the management of extracranial carotid occlusive disease have focused attention on the outcome and economics of carotid endarterectomy (CEA). Changing practice patterns for CEA must be assessed to allow accurate comparisons. The purpose of this study was to evaluate the effect of practice modifications related to CEA on patient outcome and cost data.

METHODS

Data on patients undergoing CEAs at a single institution from fiscal year 1992 to 1998 were prospectively collected and entered into a computerized database. Records were reviewed for patient demographics and outcome with regard to stroke and death. Selected years that corresponded to transitions in perioperative management were audited for complete hospital financial information from.

RESULTS

We performed 960 CEAs during the study period, with a combined stroke and death rate of 1.1%. Inflation-adjusted hospital costs per patient in 1998 dollars for the years 1992, 1996, and 1998 were $5494, $4476, and $3350, respectively. In 1998, costs for patients who required arteriography were $1825 greater than those operated on during duplex scan examination alone in 1998. Statistically significant differences occurred in the year-to-year comparisons in the use of arteriography, intensive care unit monitoring, same day admissions, and length of stay. There were no statistically significant differences in the stroke and death rate between years.

CONCLUSION

Practice changes related to CEA have resulted in significant savings without detriment in patient outcome. Comparisons between CEA and endovascular techniques will need to be evaluated within this context. Given these advances in perioperative management, it will be difficult to justify carotid stenting on the basis of current economic considerations.

Cervical cancer outcomes analysis: impact of age, race, and comorbid illness on hospitalizations for invasive carcinoma of the cervix

OBJECTIVE

The aim of this study was to evaluate the association of age, race, and comorbid illness with procedures and complications in hospitalized patients with invasive carcinoma of the cervix in a statewide population-based database over a 3-year period.

METHODS

Hospitalizations were classified into homogeneous subgroups based on a diagnosis of invasive cervical cancer. Cancer-related complications and comorbid diseases were evaluated. chi(2) and t tests determined differences in means or proportions. Linear regression techniques were applied to build models for hospitalization charges and lengths of stay (LOS).

RESULTS

There were 1009 admissions. The mean age was 49.5, with a median age of 46 (21-100, SD 15.4). Of the total, 606/1009 (60%) were white, 354/1009 (35%) were African-American (AA), and 5% were "other" races. AAs were more likely to have Medicaid or be uninsured (44% vs 23%, P = 0. 001) and were more likely to be admitted for an emergency (unadjusted odds ratio (OR) = 1.6; 1.2-2.2), to have a comorbid illness (P = 0.001), to be admitted for a cancer-related complication (P = 0.036), to be admitted for a transfusion (P = 0. 01), and to be admitted for radiation therapy rather than surgery (P = 0.001). The following were associated with LOS and higher hospital costs: emergency admissions for complications of cancer, comorbid illness, and older age.

CONCLUSIONS

Racial differences exist in patterns of admission, type of therapy, and severity of illness; however, there were no differences in charges or LOS for similar procedures. The large percentage of African-Americans uninsured or insured by government-supported programs indicates the potential impact of public policy on the care of these patients. Socioeconomic status rather than phenotypic appearance may be a more important determinant of outcome.

Costs, charges and revenues of elective coronary angioplasty and stenting: the public versus the private system

OBJECTIVE

To calculate the costs of elective coronary angioplasty and stenting (CAS) in the public and private healthcare systems and to compare these costs with the charges levied and the revenues obtained.

DESIGN

A prospective health economics study.

SETTING

A tertiary care public hospital and a co-located tertiary care private hospital in the 12 months from February 1998.

STUDY POPULATION

186 consecutive patients (124 public, 62 private) undergoing elective CAS.

MAIN OUTCOME MEASURES

Outcome of CAS; exact costs of CAS in the two hospitals; exact charges to private patients; estimated charges in a typical, not co-located, "industry standard private hospital"; estimated costs to the Federal Government of CAS in the public and private system.

RESULTS

The immediate and six-month outcomes in the two groups were similar. The average cost of CAS in public patients was $5,516, compared with $5,844 in private patients. The length of stay, number of stents per case and use of nonstent consumables was similar for both groups. Average charges for CAS in patients in the co-located private hospital were $13,347, and estimated average charges for CAS in an industry standard private hospital were $14,978. Estimated current costs to the government for CAS in a public hospital, a co-located private hospital, and an industry standard private hospital were $5664, $5,394 and $6,201, respectively.

CONCLUSIONS

Despite similar treatments and similar treatment costs, CAS in the private system, as a consequence of the charges levied, is more than twice as expensive as in the public system, with government costs similar for both systems. These data (together with data from other studies showing that CAS is performed more frequently in private patients) suggest that encouraging more people to take out private health insurance will, paradoxically, increase government costs for CAS as well as increasing overall health expenditure.

The cost value of medical versus surgical hormonal therapy for metastatic prostate cancer

PURPOSE

The cost of luteinizing hormone releasing hormone analogue and antiandrogen for prostate cancer is being scrutinized by the Health Care Finance Administration and other insurers. We compared the discounted present value cost of medical hormonal therapy to that of orchiectomy as well as the value created by these treatments from the insurer and patient perspectives.

MATERIALS AND METHODS

We performed a telephone survey of 42 patients receiving hormonal therapy to estimate the value created by medical versus surgical castration from the patient perspective. The cost of medical hormonal therapy was discounted back to the present value and compared with the cost of bilateral orchiectomy.

RESULTS

The total cost of bilateral orchiectomy was $2,022, while the discounted present value cost using the average wholesale price for 30 months of medical hormonal therapy was $13,620. Therefore, medical hormonal therapy costs $11,598 more than orchiectomy ($13,620 - $2,022). A discounted payment of $386 per month for 30 months is necessary to recoup the $11,598 difference. All surveyed patients on medical hormonal therapy stated that avoiding orchiectomy was worth $386 per month and it was an appropriate insurer expense. If patients paid $386 per month out-of-pocket, 22 of the 42 (52%) would pay the additional monthly expense, while 20 (48%) indicated that they could not afford the additional expense.

CONCLUSIONS

These results indicate that medical hormonal therapy costs significantly more than bilateral orchiectomy but creates positive value for men with prostate cancer by enabling them to avoid orchiectomy.

Prospective evaluation of early versus delayed laparoscopic cholecystectomy for treatment of acute cholecystitis

Although laparoscopic cholecystectomy (LC) is known to be safe in the treatment of acute cholecystitis (AC), the optimal timing of laparoscopic intervention remains controversial. The objective of this study is to prospectively compare the safety and cost effectiveness of early versus delayed LC in AC. Our study population consisted of 43 patients presenting with AC (localized tenderness, white blood cell count >10.0 or temperature >38.0 degrees C, and ultrasound confirmation) who were prospectively randomized to early versus delayed LC during their first admission. Exclusion criteria included a history of peptic ulcer disease or evidence of gallbladder perforation. All patients were treated with bowel rest and antibiotics (piperacillin 2 g intravenous piggyback every 6 hours). Early treatment patients underwent LC as soon as the operating schedule allowed. Delayed treatment patients received anti-inflammatory medication (indomethacin 50 mg per rectum every 12 hours) in addition to bowel rest and antibiotics and underwent operation after resolution of symptoms or within 5 days if symptoms failed to resolve. Early LC was performed in 21 patients, whereas 22 patients underwent delayed LC. There was no difference in age, temperature, or white blood cell count on admission between groups. Early LC slightly reduced operative time and conversion rate. There was no difference in complications. Estimated blood loss was significantly lower in those receiving early LC. There was also a significant reduction in total hospital stay and hospital charges with early LC. We conclude that delay in operation combined with anti-inflammatory medication showed no advantage with regard to operative time, conversion, or complication rate. Furthermore, early laparoscopic intervention significantly reduced operative blood loss, hospital days, and hospital charges.

Impact of sentinel lymph node mapping on relative charges in patients with early-stage breast cancer

BACKGROUND

The introduction of SLNB has allowed accurate staging in early-stage breast carcinomas and has minimized the number of unnecessary ALNDs. Intraoperative frozen-section analysis is a fundamental component of the sentinel lymph node biopsy (SLNB) procedure. Some patients have positive nodes on frozen-section analysis and thus undergo a conventional axillary lymph node dissection (ALND) at the time of the SLNB. A few patients have negative nodes on frozen-section analysis but have subsequent evidence of metastases on final pathologic examination. The purpose of our study was 2-fold: to compare the hospital-related charges of patients undergoing staging by SLNB with those of patients undergoing conventional ALND and to assess whether the different outcomes associated with SLNB adversely affect the charges incurred with this procedure.

METHODS

Our study group consisted of 100 patients with T1 breast cancer and breast conservation therapy who underwent either SLNB or ALND from July 1, 1997, to June 30, 1998. We identified the first 50 consecutive patients to undergo SLNB during this period. We chose a similar cohort of 50 patients for ALND. Mean hospital-related charges for the SLNB patients were categorized and compared with those for the ALND patients.

RESULTS

Results for the two groups were analyzed using a two-sample Wilcoxon rank-sum test. Charges for the OR and hospital stay were less for the SLNB group (P < .05). Frozen-section analysis in the SLNB group contributed to the significant difference in charges for pathologic evaluation. Overall, the two groups showed no significant difference in total hospital-related charges.

CONCLUSIONS

When SLNB is used for T1 tumors, a small percentage of patients (10% in our study) will return to the operating room for an ALND. This small percentage does not increase the charges related to SLNB, however, as the reduced stay for most patients offsets this subgroup's contribution to the total hospital-related charges. Thus, in patients with clinical stage I breast cancer, SLNB does not cause significantly higher hospital-related charges compared with conventional ALND.

Respiratory syncytial virus in patients with congenital heart disease: a contemporary look at epidemiology and success of preoperative screening

Awareness of respiratory syncytial virus (RSV) as a serious pathogen in the child with congenital heart disease is increasing. We studied the impact of RSV lower respiratory tract disease on patients in a large academic pediatric cardiology practice. We found that RSV disease necessitating hospitalization occurs in congenital heart disease patients well into the second year of life. Although pulmonary hypertension remains a significant risk factor for morbidity in these patients, it does not appear to be as much of a factor as in the past. By implementing a nasopharyngeal RSV enzyme-linked immunoassay screening of young patients prior to cardiac surgery we found a reduction in community-acquired postoperative RSV disease. We postulate this will lead to a reduction in nosocomial disease in the postoperative care unit.

The process of charging medical tests, drugs and materials in an integrated H.I.S.: problems and challenges

The purpose of this paper is to present in brief the billing procedures related to Medical Tests, drugs and supplies in H.I.S. and to discuss the problems and the challenges to the user.

Hospital charges following simultaneous kidney--pancreas transplantation: enteric drainage versus bladder drainage

BACKGROUND

Enteric drainage (ED) is associated with reduced morbidity compared with bladder drainage (BD) after simultaneous kidney-pancreas transplantation (SKPT) and is becoming increasingly common (more than 50% of SKPTs done in the US in 1998 were performed with enteric drainage). Although several studies have reported the morbidity and graft survival of ED compared with BD previously, there are limited data available comparing the length of stay and hospital charges between these two drainage procedures.

METHODS

Fourteen SKPTs were performed during the period January 1995 May 1998 using BD and 20 during June 1998-August 1999 using ED. Hospital charges analyzed included the following categories: pharmacy, inpatient room, laboratory, operating room, medical surgical supply, radiology/nuclear medicine, and miscellaneous. Organ acquisition charges and professional fees were not included in this analysis.

RESULTS

The mean hospital stay for patients with ED was 7.8+/-2.2 d (range 5-12 d; median 7.5 d) compared with 15.9+/-7 d (range 8-38 d; median 15 d) for patients with BD (p = 0.002). The mean hospital charges during initial hospitalization for the ED group were $36 582+/-11 424 compared with $64 555+/-29 054 for the BD group (p = 0.005). There was a significant decrease in the charges relating to pharmacy, inpatient room, laboratory, radiology/nuclear medicine, and miscellaneous category in the ED group compared with the BD group, while the charges relating to operating room and medical-surgical supply were no different between the two groups. One-year actuarial kidney and pancreas graft survival rates were 83% and 93%, respectively, for the BD group and 90% and 80%, respectively, for the ED group (p = NS).

CONCLUSIONS

SKPT patients with ED had a 43% reduction in hospital charges and equivalent pancreas and kidney graft survival rates compared with SKPT patients with BD. A shorter hospital stay and a reduction in pharmacy, radiology/nuclear medicine, and laboratory charges contributed to the decreased hospital charges in SKPT patients with ED.

Rational treatment of empyema in children

HYPOTHESIS

Efficacious and cost-effective treatment of pediatric empyema can be accomplished following a protocol based on its radiographic appearance. Therapeutic modalities include thoracostomy tube drainage (TTD) with or without fibrinolytic therapy (FT) and video-assisted thoracoscopic debridement (VATD).

DESIGN

Retrospective case series.

SETTING

Tertiary referral center.

RESULTS

From 1995 through 1999, 31 children were treated ranging in age from 11 months to 18 years (mean age, 5.1 years). Twenty-seven (87.1%) underwent TTD; of these, 22 (81.5%) received FT with urokinase. The TTD failed in 4 children (14.8%) who required salvage VATD. Primary VATD was performed in another 4 children (12.9%). The mean length of stay was 14.6 days (TTD, 14.1 days; salvage VATD, 20. 0 days; primary VATD, 11.5 days), ranging from 8.0 to 30.0 days. Complications included readmission for fever (2 patients [6.5%]) and gastrointestinal bleeding (1 patient [3.2%]). There were no anaphylactic reactions or bleeding episodes due to urokinase. Two patients (7.4%) treated with TTD and FT developed an air leak that resolved spontaneously. The mean hospital charges were $78,832 (TTD with or without FT, $75,450; salvage VATD, $107,476; primary VATD, $69,634). The procedural charges were highest for salvage VATD.

CONCLUSIONS

Most cases of pediatric empyema can be treated by TTD with or without FT. This therapy is safe and effective for children with nascent disease. Primary VATD is preferred in children with advanced disease. Cost-effectiveness could be further improved through better prediction of those patients likely to fail TTD and require salvage VATD. An algorithmic approach based on findings from computed tomography or (better) ultrasonography of the chest may be the best way to make this distinction and rationalize care.

Respiratory syncytial virus pneumonia in the hospital setting: length of stay, charges, and mortality

BACKGROUND

Respiratory syncytial virus (RSV) is the most important viral cause of lower respiratory tract infection in infants and young children worldwide. No vaccine against RSV is available, but prophylactic interventions have been shown to be safe and effective in clinical trials.

OBJECTIVES

This retrospective analysis was conducted to examine the health and economic burden of hospitalization for RSV pneumonia.

METHODS

Nationally weighted hospital discharges for RSV pneumonia among children 4 years old and younger were analyzed by using the Healthcare Cost and Utilization Project National Inpatient Sample.

RESULTS

In 1993, there were estimated to be 16,500 hospital discharges with RSV pneumonia, which increased to 19,700 and 20,800 in 1994 and 1995, respectively. Children less than 1 year of age accounted for over 70% of these discharges. Hospital charges (in 1998 dollars) for RSV pneumonia-associated episodes were $295,100,000 in 1993; $392,300,000 in 1994; and $295,800,000 in 1995.

CONCLUSIONS

With inpatient charges of $300 to $400 million per year in the United States, the disease burden of RSV pneumonia is very high in terms of both morbidity and economic costs. Emerging prophylactic interventions should have an impact on the high burden of RSV pneumonia.

The costs of disease

BACKGROUND

To date there have been no studies identifying and comparing the component costs to treat a large number of diseases for hospitalized inpatients.

METHODS

Hospital costs were analyzed for 486 diagnosis-related groups (DRGs) relating to >1.3 million patient discharges from 60 University Hospital members of the University HealthSystems Consortium. For each DRG, length of stay, total cost, and key cost components were analyzed, including accommodation, intensive care, and surgery.

RESULTS

In general, total costs of diseases classified as surgical exceeded those classified as medical. Diseases involving organ transplantation typically cost more than other diseases. However, within the studied population, the two DRGs accounting for most total healthcare dollars were percutaneous cardiovascular procedures and management of neonates with immaturity or respiratory failure.

CONCLUSIONS

Considering six key cost components, as well as disease complexity and length of stay, the best predictors of total costs for medical conditions were the length of stay and accommodation (housing, meals, nursing services) costs, whereas for surgical conditions, the best predictor of total costs was laboratory costs. This analysis may be used within an individual institution to identify surgical or medical diagnoses with total or component costs at variance with the group mean. A hospital may focus its cost reduction efforts to make decisions to expand, alter, or eliminate particular clinical programs based on comparison of its own total and component costs with those from other hospitals in the database.

Holmium:YAG laser and pulsed dye laser: a cost comparison

BACKGROUND AND OBJECTIVE

This study was designed to evaluate the relative cost effectiveness of the Holmium:YAG laser and the pulsed dye laser for the treatment of ureteral calculi. Cost containment is a priority for every health care facility. As a result, the staff of the Lutheran Medical Center (Wheat Ridge, CO) looked at alternative ways to provide quality laser treatment of ureteral stones. As part of our study, the laser committee offered the Holmium:YAG laser to urologists for ureteral lithotripsy. Previously, the pulsed dye laser was rented for ureteral calculi on a per case basis at $1,500. A hospital processing fee was added to this cost, resulting in a total charge of $1,638 to the patient. Our organization owns a Holmium:YAG laser and uses it primarily in orthopedics.

STUDY DESIGN/MATERIALS AND METHODS

Two ureteral lithotripsy cases were performed and compared. One case used the Holmium:YAG for ureteral lithotripsy; the other procedure used the pulsed dye laser. A cost analysis was performed after the procedures.

RESULTS

The data indicated a significant difference in cost between the two lasers. Approximately $1,000 was eliminated when using the Holmium:YAG laser.

CONCLUSION

A cost savings of $15,000 per year would be realized if 15 cases were performed. The Holmium:YAG laser also can be used on cystine calculi, a procedure for which the pulsed dye laser is ineffective. The potential for ureteral injury exists. When using the Holmium:YAG laser, appropriate training is required. Due to this risk, not all urologists will use the Holmium:YAG laser. We also found a positive correlation between the proficiency of the urologists' laser skills and overall cost effectiveness.

The do-not-resuscitate decision: the context, process, and consequences of DNR orders

This study examines the process and consequences of an increasingly important element of the dying experience in American hospitals: the writing of a Do-Not-Resuscitate (DNR) order. The focus of the study is on the decision-making process and timing of the DNR decision, the impact of the DNR order on the dying experience, and the consequences of the DNR order for length of hospital stay and accrued medical charges. Patients with a DNR order are compared to those who were unsuccessfully coded. Data are obtained from a review and analysis of the medical charts and death monitor sheets of a sample of 249 persons who died in 1994 in a single teaching hospital. The study found physicians routinely discuss the DNR decision with patients and/or their surrogates (though patients are involved in the decision in only about one-third of cases) and that the decision is often made relatively early in the hospital stay. The dying experience of patients with a written DNR was different in significant ways from the experience of unsuccessfully-coded patients. Those with a DNR were more likely to remain in a single unit in the hospital and less likely to die in an intensive care unit or while connected to a ventilator. Consistent with other studies, however, average length of hospital stay and average medical charges were actually higher for the DNR patients. Implications of these differences between DNR and unsuccessfully-coded patients are discussed.

Ischemic heart disease. Hospitalization, length of stay and expenses in Brazil from 1993 to 1997

OBJECTIVE

To identify characteristics of the hospitalizations due to ischemic heart disease (IHD) made by the Single Health System--"Sistema Unico de Saúde (SUS) in Brazil from 1993 to 1997.

METHODS

The information used came from records of permissions for hospitalization due to IHD (diseases codified from 410 to 414 by the International Disease Classification--9th Revision) furnished by the data bank DATA-SUS. The material studied was classified according to age, sex and length of hospitalization of the patients, and expenses to the system for IHD.

RESULTS

IHD represents 1.0% of total hospitalizations. Angina pectoris was the most frequent type, occurring in 53.3% of the cases, followed by acute myocardial infarct (26.6%). This later was more frequent in men and angina in women. The majority of patients with IHD stayed hospitalized from 5 to 8 days. In the years of 1997 the expenses due to hospital treatment for IHD reach to 0.01% of Brazil's Gross Internal Product. In the studied period (1993-1997), IHD was responsible by 1.0% of hospitalizations, however it was 3.3% of the expenses of SUS.

CONCLUSION

IHD is an important cause of hospitalization by the SUS; it has a rather high cost, indicating the need for preventive measures aimed at reducing exposure to risk factors and to decrease the incidence of this group of diseases in the nation.

Changing patterns of treatment for blunt splenic injuries: an 11-year experience in a rural state

PURPOSE

The aim of this study was to perform a population-based study evaluating the trend in management of pediatric blunt splenic injuries in a rural state and assess differences in the management of those injuries at a level I pediatric trauma center (PTC) and regional hospitals (RH) from 1985 through 1995.

METHODS

ICD-9-CM diagnosis and procedure codes for children (age less than 19) discharged from all hospitals in a rural state with splenic injuries from 1985 through 1995 were reviewed. Hospital charges, age, and nonoperative management (NOM) rates were calculated for PTC and RH and compared using chi2 and linear regression. (P < .05 is statistically significant.) Patients were divided into 2 groups; G1, 1985 through 1989 (127 children); G2, 1990 through 1995 (140 children).

RESULTS

The overall NOM rate increased from 21% (G1) to 64.2% (G2), P < .001. A total of 114 patients were treated at PTC and 153 patients received care at RH. PTC had a NOM rate of 54.3% versus 35.9% at RH (P = .003). There was no statistical difference in ages or ISS within the groups or between PTC and RH. NOM in RH rose from 7.7% in G1 to 56.9% in G2 (P < .000), and from 35.5% in G1 to 76.9% in G2 (P < .001) for PTC. Hospital charges were lower for patients receiving NOM versus those with surgical treatment of their injury, $8,094 versus $10,862 (P = .018). However, a higher percentage of children were treated at RH than PTC in G2 versus G1 (68.2% v 51.2%, P = .0541).

CONCLUSIONS

Over the 10-year period studied, the NOM rate for splenic injuries significantly decreased. This trend was seen at both the PTC and RH, but the PTC maintained a higher rate of NOM. Unfortunately, more children were treated at RH in G2. Educational programs increased NOM in RH but not to a level equal to PTC. These programs had the negative effect of allowing more children to be treated at RH, actually increasing the splenic operation rate for this population.

Perforated appendicitis: prospective outcome analysis for 150 children

BACKGROUND/PURPOSE

Controversy persists in the management of perforated appendicitis with regard to antibiotic choice and duration, operative timing, drain utilization, and wound closure. For 2 decades at the authors' institution, patients were treated with ampicillin, gentamicin, and clindamycin for 10 inpatient days, with drains in the abdomen, resulting in lower complication rates than most other published series. Managed care pressures have led to less aggressive medical management regimens with length of stay and financial factors viewed as principal outcome measures with little emphasis on clinical outcomes. In addition, there are little prospective data on clinical outcomes. The authors sought to determine whether our previously documented excellent quality outcomes could be maintained when modifications aimed at decreasing cost and length of stay in our protocol were instituted.

METHODS

The authors monitored prospectively clinical outcomes in patients with perforated appendicitis treated according to their clinical practice guidelines over a 43-month period. Patients received a single antibiotic, piperacillin-tazobactam, intravenously for 10 days. They were permitted to go home with a percutaneous intravenous catheter for the final 5 days if medical and social criteria were met. Other practices from our earlier protocol were continued, including immediate operation, placement of Penrose drains, and primary wound closure.

RESULTS

Of 150 patients treated on our protocol, major complications included intraabdominal abscess in 5 (3.3%), cecal fistula in 2 (1.3%), phlegmon in 3 (2.0%), wound infection in 4 (2.7%), and no small bowel obstructions requiring operation. None of these complications, nor their aggregate, were significantly more common than those reported in 373 patients treated over 11 years on the authors' prior protocol (chi2, P > .05).

CONCLUSIONS

Prospective outcome analysis of our protocol shows that a single broad-spectrum antibiotic (allowing portions of therapy to be delivered less expensively on an outpatient basis) effectively can treat postoperative appendicitis with very few infectious complications. These outcome data provide baseline against which future protocols can be compared. All treatment modifications aimed at decreasing costs must be analyzed to ensure quality of care is not unduly compromised.