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.

Automated charge processing streamlines data entry

A healthcare organization can significantly improve its billing office's performance by implementing an automated charge-processing system that integrates scanning technology with hospital and physician office billing systems. Such a system offers large healthcare organizations a means to eliminate costly and inefficient manual processing of paper charge sheets, thereby improving productivity and accuracy. An automated charge-processing system allows a billing department to automatically post, track, monitor, control, and reconcile all charges through a central database. To implement the system, a healthcare organization should assemble a project team composed of representatives from information services, the software supplier, and the organization's business offices. The team will be responsible for setting up the system; designing an easily scannable, standard charge form; establishing the rules the system will follow for posting charges; and designing billing office reports.

The impact of an inpatient physician program on quality, utilization, and satisfaction

OBJECTIVE

To evaluate an inpatient physician system initiated in June 1996 for all patients of a health maintenance organization admitted to the general medicine service of an urban teaching hospital. In the new program, attending physician duties were transferred from the patient's own general internist to another internist serving on a hospital-based rotation.

STUDY DESIGN

Cohort with historical controls.

PARTICIPANTS AND METHODS

We compared the following measures before and after the new inpatient physician program began: (1) hospital length of stay and total charges, (2) outcomes related to quality of care, (3) primary care physician satisfaction, and (4) housestaff satisfaction. Differences before and after initiation of the inpatient physician program were evaluated using multivariate analyses to adjust for patient differences and secular trends.

RESULTS

There were 2265 patients discharged from the general medical service in the year following implementation of the inpatient physician program. Postintervention average length of stay decreased from 3.5 to 3.0 days (P < .001). In multivariate analyses, average length of stay was reduced by 0.3 days (P = .008), and total hospital charges were reduced an average of $426 per admission (P = .001). In-hospital mortality rates, percentage of patients discharged home directly, and 30-day readmission rates did not change significantly in the postintervention period. Satisfaction among primary care physicians was high, with 90% of those answering a survey responding that they would recommend a similar program to other primary care groups. Medical housestaff satisfaction with their educational experience also increased.

CONCLUSIONS

Implementation of an inpatient physician program at this institution significantly decreased resource utilization while maintaining or improving quality of care. Satisfaction with the program was high among primary care internists and housestaff.

Laparoscopic versus open appendectomy

BACKGROUND

Laparoscopic appendectomy is commonly performed and has been presumed to offer economic benefits similar to those of laparoscopic cholecystectomy. This study was done to examine that premise.

METHODS

Two surgical groups contributed consecutively operated patients with a clinical diagnosis of appendicitis. One group did all appendectomies open and the other group did them laparoscopically. Hospital expenses were compared using a single billing formula. Hospital length of stay, time to return to work, and complications were analyzed.

RESULTS

Operating room times were longer for the laparoscopic group, median 80 minutes, versus median 50 minutes for the open group. Hospital length of stay and return to work were the same, median 1 day and median 10 days, respectively. Wound complications were less common in the laparoscopic group, 0 of 30, than in the open group, 3 of 18; however, there was 1 intra-abdominal abscess in the laparoscopic group. Median cost of the laparoscopic group was $2,915 versus $1,747 for the open group.

CONCLUSIONS

Laparoscopic appendectomy is more expensive than appendectomy but does not reduce hospital length of stay nor change the time to return to work; however, wound complications are less common.

Implementation of clinical guidelines via a computer charting system: effect on the care of febrile children less than three years of age

OBJECTIVE

The authors have shown that clinical guidelines embedded in an electronic medical record improved the quality, while lowering the cost, of care for health care workers who incurred occupational exposures to body fluid. They seek to determine whether this system has similar effects on the emergency department care of young children with febrile illness.

DESIGN

Off-on-off, interrupted time series with intent-to-treat analysis.

SETTING

University hospital emergency department.

SUBJECTS

830 febrile children less than 3 years of age and the physicians who treated them.

INTERVENTIONS

Implementation of an electronic medical record that provides real-time advice regarding the content of the history and physical examination and recommendations regarding laboratory testing, treatment, diagnosis, and disposition.

MEASUREMENTS

Documentation of essential items in the medical record and after-care instructions; compliance with guidelines regarding testing, treatment, and diagnosis; charges.

RESULTS

The computer was used in 64 percent of eligible cases. Mean percentage documentation of 21 essential history and physical examination items increased from 80 percent during the baseline period to 92 percent in the intervention phase (13 percent increase; 95 percent CI, 10-15 percent). Mean percentage documentation of ten items in the after-care instructions increased from 48 percent at baseline to 81 percent during the intervention phase (33 percent increase; 95 percent confidence interval, 28-38 percent). All documentation decreased to baseline when the computer system was removed. There were no demonstrable improvements in appropriateness of care, nor was there evidence that appropriateness worsened. Mean charges were not changed by the intervention.

CONCLUSION

The intervention markedly improved documentation, had little effect on the appropriateness of the process of care, and had no effect on charges. Results for the febrile child module differ from those for the module for occupational blood and body fluid exposure (a more focused and straightforward medical condition), underscoring the need for implementation methods to be tailored to specific clinical complaints.

Inadequate hospital reimbursement for victims of motor vehicle crashes due to health reform legislation

STUDY OBJECTIVE

Effective for 1997, health reform legislation in New York resulted in a change in hospital reimbursement for victims of motor vehicle crashes. We evaluated the impact of this change from no-fault to Medicaid rates on the financial viability of a regional trauma center within an academic medical center.

METHODS

This study represents a retrospective review of the trauma registry for all motor vehicle-related injuries (meeting the statewide definition of trauma) admitted to a regional trauma center for a 9-month period just before the legislation implementation date. Charges, costs, and projected reimbursement were calculated by standard hospital accounting methods. Profit or loss (reimbursement minus costs) was calculated by standard hospital accounting methods for each admission using no-fault and Medicaid reimbursement rates.

RESULTS

One hundred seventy-three cases during the 9-month period generated total charges of $4,112,174, total costs of $3,447,110, and estimated total profit of $800,084 ($4,625 per case) using no-fault reimbursement and a total loss of $184,154 ($1,064 per case) using Medicaid reimbursement. For the 31 patients with diagnosis-related groups (DRGs) that were specifically created in New York to ensure adequate reimbursement for multiple significant trauma (730 through 734 and 792 through 794), no-fault reimbursement resulted in an average profit of $371 per case and Medicaid generated a loss of $6,118 per case. Actual payments for the study population were almost $500,000 less than estimated.

CONCLUSION

Changes in rates of no-fault insurance payments to hospitals will result in inadequate reimbursement for motor vehicle crash victims admitted to a regional trauma center, undermining the viability of the regional trauma system.

Pharmacoeconomic evaluation of flumazenil for routine outpatient EGD

BACKGROUND

Flumazenil is a benzodiazepine antagonist indicated for reversal of the sedative effects of benzodiazepines. Previous studies suggest that flumazenil may shorten recovery time after endoscopy, but there are few data on actual recovery room times and charges.

METHODS

Fifty patients undergoing routine upper endoscopy were sedated with midazolam alone in the usual titrated manner. Patients were randomized in a double-blind fashion to receive either flumazenil or saline immediately after procedure. Assessments of responsiveness, speech, facial expression, and ptosis (Observer's Assessment of Alertness/Sedation [OAA/S] scale) were made before procedure, immediately after procedure and every 15 minutes thereafter. The patient was discharged from the recovery room when vital signs and OAA/S scale reached preprocedure levels. Recovery room times and charges were recorded.

RESULTS

The flumazenil group demonstrated shorter recovery room times and recovery room charges than the placebo group (p < 0.001). The difference in recovery room charges was not statistically different when flumazenil charges were included (p = 0.09).

CONCLUSIONS

The routine use of flumazenil after midazolam sedation for upper endoscopy significantly shortened recovery time and charges but did not statistically reduce overall charges.

Transcatheter coil occlusion of the small patent ductus arteriosus (<4 mm): improved results with a "multiple coil-no residual shunt" strategy

We report our experience with transcatheter occlusion of the small PDA using Gianturco coils comparing a single coil strategy to a "multiple coil-no residual shunt strategy". Fifteen patients (Group I) had a single coil only placed irrespective of residual shunting and 20 (Group II) were treated using the no residual shunt strategy. Age, minimal PDA diameter, PDA length and PDA types were similar between groups. Closure rates in Group I patients were 60%, 80% and 87% at <1 month, 6 months and 1 year, respectively. In Group II, the <1 month and 6 month closure rates were 100%. The costs and hospital charges for coil closure were comparable to a concurrent surgical group; the total charges (hospital plus physician) were less for Group I, but similar between Group II and the surgical group. The complication rate for coil closure was significantly less than surgical closure. From these data, transcatheter closure with multiple coils can achieve the same closure rate as surgery at similar hospital charges with fewer complications.

Screening for oropharyngeal dysphagia in stroke: insufficient evidence for guidelines

There is no evaluation of the evidence for the screening of oropharyngeal dysphagia in stroke. We reviewed the literature on clinical screening for oropharyngeal dysphagia in adults with stroke to determine (a) the accuracy of different screening tests used to detect dysphagia defined by abnormal oropharyngeal physiology on videofluoroscopy and (b) the health outcomes reported and whether screening alters those outcomes. Peer-reviewed English-language and human studies were sought through Medline (from 1966 to July 1997) by using the key words cerebrovascular disorders and deglutition disorders, relevant Internet addresses, and extensive hand searching of bibliographies of identified articles. Of the 154 sources identified, 89 articles were original, peer-reviewed, and focused on oropharyngeal dysphagia in stroke patients. To evaluate the evidence, the next selection identified 10 articles on the comparison of screening and videofluoroscopic findings and three articles on screening and health outcomes. Evidence was rated according to the level of study design by using the values of the Canadian Task Force on Periodic Health Examination. From the identified screening tests, most of the screenings were related to laryngeal signs (63%) and most of the outcomes were related to physiology (74%). Evidence for screening accuracy was limited because of poor study design and the predominant use of aspiration as the diagnostic reference. Only two screening tests were identified as accurate: failure on the 50-ml water test (likelihood ratio = 5.7, 95% confidence interval = 2.5-12.9) and impaired pharyngeal sensation (likelihood ratio = 2.5, 95% confidence interval = 1.7-3.7). Limited evidence for screening benefit suggested a reduction in pneumonia, length of hospital stay, personnel costs, and patient charges. In conclusion, screening accuracy needs to be assessed by using both abnormal physiology and aspiration as diagnostic markers for dysphagia. Large well-designed trials are needed for more conclusive evidence of screening benefit.

Outpatient management of malignant pleural effusion by a chronic indwelling pleural catheter

BACKGROUND

Previous studies have shown that a chronic indwelling pleural catheter (PC) safely and effectively relieved dyspnea, maintained quality of life, and reduced hospitalization in patients with malignant pleural effusions. Outpatient management of malignant pleural effusion with a PC may reduce length of stay and early (7-day) charges compared with inpatient management with chest tube and sclerosis.

METHODS

A retrospective review of consecutive PC patients (n = 100; 60 outpatient, 40 inpatient) were treated from July 1, 1994 to September 2, 1998 and compared with 68 consecutive inpatients treated with chest tube and sclerosis between January 1, 1994 and December 31, 1997. Hospital charges were obtained from date of insertion (day 0) through day 7.

RESULTS

Demographics were similar in both groups. Pretreatment cytology was positive in 126 of 168 patients (75%), negative in 21 (12.5%), and unknown in 21 (12.5%). Primary histology included lung (n = 61, 36%), breast (n = 39, 23%), lymphoma (n = 12, 7%), or other (n = 56, 34%). Median survival was 3.4 months and did not differ significantly between treatment groups. Overall median length of stay was 7.0 days for inpatient chest tube and inpatient PC versus 0.0 days for outpatient Pleurx. No mortality occurred related to the PC. Eighty-one percent (81/100) of PC patients had no complications. One or more complications occurred in 19 patients (19%). Patients treated with outpatient PC (n = 60) had early (7-day) mean charges of $3,391 +/- $1,753 compared with inpatient PC (n = 40, $11,188 +/- $7,964) or inpatient chest tube (n = 68, $7,830 +/- $4,497, SD) (p < 0.001).

CONCLUSIONS

Outpatient PC may be used effectively and safely to treat malignant pleural effusions. Hospitalization is not required in selected patients. Early (7-day) charges for malignant pleural effusion are reduced in outpatient PC patients compared with inpatient PC patients or chest tube plus sclerosis patients.

Intensive care unit use and mortality in the elderly

OBJECTIVE

To examine utilization and outcomes of intensive care unit (ICU) use for the elderly in the United States.

DESIGN

We used 1992 data from the Health Care Financing Administration to examine ICU utilization and mortality by age and admission reason for hospitalizations of elderly Medicare beneficiaries.

MAIN RESULTS

Use of the ICU was least likely for the oldest elderly overall (85+ years, 21.1% of admissions involved ICU; 75-84 years, 27.9%; 65-74 years, 29.7%), but more likely during surgical admissions. Eighty-three percent of the Medicare patients who received intensive care survived at least 90 days. Of the oldest elderly, 74% survived. Even among the 10% most expensive ICU hospitalizations, 77% of all patients and 62% of those 85 years and older survived at least 90 days.

CONCLUSIONS

The likelihood of ICU use among these elderly decreased with age, especially among those 85 years or older. Diagnostic mix importantly influenced ICU use by age. The great majority of the elderly, including those 85 years and older and those receiving the most expensive ICU care, survived at least 90 days.

The cost of hospitalization in Crohn's disease

OBJECTIVE

The aim of this study was to evaluate the demographics, resource use, and costs associated with hospitalization of Crohn's disease patients.

METHODS

All patients hospitalized at our institution from 7/1/96 to 6/30/97 with a primary diagnosis of "Crohn's Disease" were analyzed using a computerized database. Data are presented "per hospitalization."

RESULTS

A total of 175 hospitalizations (147 patients) were identified. Mean patient age was 36.5 yr; 61% were female; 82% Caucasian. Payer mix was most commonly contracted (57%), commercial (21%), or Medicare (13%). 57% of hospitalizations had a primary surgical procedure; the remainder were medical. Average length of stay was 8.7 days (surgical, 9.6 days; medical, 7.5 days). The average cost of hospitalization, excluding physician fees, was $12,528 (surgical, $14,409; medical, $10,020), whereas average charges were $35,378 (surgical, $46,354; medical, $20,744), including physician fees, which averaged $7,249 (surgical, $11,217; medical, $1,959). Mean reimbursements were $21,968 (surgical, $28,946; medical, $12,666) with average weighted reimbursement rates of 60.17% of hospital charges, 69.57% of physician fees. The distribution of costs across subcategories was: Surgery (39.6%), Pharmacy (18.6%), Laboratory (3.8%), Radiology (2.1%), Pathology (0.8%), Endoscopy (0.3%), and Other Hospital Costs (34.9%). Of the hospitalizations, 87% included treatment with steroids, 23% with immunomodulators, and 14% with aminosalicylates; 27% included the administration of total parenteral nutrition, which accounted for 63% of the total pharmacy costs.

CONCLUSIONS

Surgery accounts for the majority of hospitalizations, nearly 40% of their total costs, and 75% of overall charges and reimbursements. Therapy that decreases the number of surgical hospitalizations should substantially reduce inpatient Crohn's disease costs, as well as overall costs.

The impact of leaving against medical advice on hospital resource utilization

OBJECTIVE

To assess the effect of hospital discharge against medical advice (AMA) on the interpretation of charges and length of stay attributable to alcoholism.

DESIGN

Retrospective cohort. Three analytic strategies assessed the effect of having an alcohol-related diagnosis (ARD) on risk-adjusted utilization in multivariate regressions. Strategy 1 did not adjust for leaving AMA, strategy 2 adjusted for leaving AMA, and strategy 3 restricted the sample by excluding AMA discharges.

SETTING

Acute care hospitals.

PATIENTS

We studied 23,198 pneumonia hospitalizations in a statewide administrative database.

MEASUREMENTS AND MAIN RESULTS

Among these admissions, 3.6% had an ARD, and 1.2% left AMA. In strategy 1 an ARD accounted for a $1,293 increase in risk-adjusted charges for a hospitalization compared with cases without an ARD ( p =.012). ARD-attributable increases of $1,659 ( p =.002) and $1,664 ( p =. 002) in strategies 2 and 3 respectively, represent significant 28% and 29% increases compared with strategy 1. Similarly, using strategy 1 an ARD accounted for a 0.6-day increase in risk-adjusted length of stay over cases without an ARD ( p =.188). An increase of 1 day was seen using both strategies 2 and 3 ( p =.044 and p =.027, respectively), representing significant 67% increases attributable to ARDs compared with strategy 1.

CONCLUSIONS

Discharge AMA affects the interpretation of the relation between alcoholism and utilization. The ARD-attributable utilization was greater when analyses adjusted for or excluded AMA cases. Not accounting for leaving AMA resulted in an underestimation of the impact of alcoholism on resource utilization.