Outpatient-based bone marrow transplantation for hematologic malignancies: cost saving or cost shifting?
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PURPOSE: To determine whether a shift in care from an inpatient-based to an outpatient-based bone marrow transplantation (BMT) program decreased charges to payers without increasing clinical complications or out-of-pocket costs to patients. PATIENTS AND METHODS: This nonrandomized prospective cohort study compared clinical and economic outcomes for 132 consecutive BMT patients with hematologic malignancies who received either inpatient- or outpatient-based BMT care. RESULTS: Seventeen of 132 BMT patients underwent outpatient-based BMT. Compared with the inpatient-based group, the outpatient-based group had a markedly lower mean number of inpatient hospital days (22 v 47; P <.001) and decreased mean inpatient facility charges ($61,059 less per patient; P <.0001) but had higher mean outpatient facility charges ($49,732 higher; P <. 0001). Total professional fees were similar for the groups. The mean total charge to payers was only 7% less ($12,652; P =.21) for outpatient-based BMT than for inpatient-based BMT, but total charge was 34% less for outpatient compared with inpatient BMT ($54,240; P = 0.056) in a subset of patients who had a standard rather than high risk of treatment failure. There was no significant difference between groups in out-of-pocket costs for transportation, lodging, meals, home nursing, household assistance, child care, medication expenses, or unreimbursed medical bills. There also was no significant difference between groups in reported income lost, involuntary unemployment, or months of disability. The two groups had similar rates of major complications, including death, significant acute graft-versus-host disease, and veno-occlusive disease of the liver. CONCLUSION: Increased use of outpatient-based BMT should produce substantial cost savings for payers without adverse effects on patients for those patients who do not have a high risk of treatment failure. (+info)
A comparison of nursing and medical diagnoses in predicting hospital outcomes.
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The main premise of the Nursing Minimum Data Set (NMDS) is that nursing data should be included in the hospital discharge abstract. Yet to date, little empirical evidence has been published to measure the efficacy or usefulness of these nursing data elements. We report the results of a comparison between a daily collection of nursing assessments using nursing diagnoses (NDX) to the Diagnostic Related Group (DRG) and the All Payer Refined DRG (APR-DRG) in their ability to predict three common outcome variables: hospital days, ICU day, and total charges. A secondary data analysis was performed from a large existing data set of four years patient data from a Midwest University hospital. FINDINGS: NDX is significantly associated with hospital length of stay, ICU length of stay, and total charges. NDX also improves explanatory power when added to models with DRG or APR-DRG. This suggests that nursing data compliments existing data and is not redundant with the DRG or APR-DRG. The findings also suggest that NDX explains a different portion of the variance of the three outcome variables in this series. The results of this study support the argument that nursing data should be included in the hospital discharge abstract. (+info)
Getting data out of the electronic patient record: critical steps in building a data warehouse for decision support.
(35/2332)
Health care has taken advantage of computers to streamline many clinical and administrative processes. However, the potential of health care information technology as a source of data for clinical and administrative decision support has not been fully explored. This paper describes the process of developing on-line analytical processing (OLAP) capacity from data generated in an on-line transaction processing (OLTP) system (the electronic patient record). We discuss the steps used to evaluate the EPR system, retrieve the data, and create an analytical data warehouse accessible for analysis. We also summarize studies based on the data (lab re-engineering, practice variation in diagnostic decision-making and evaluation of a clinical alert). Besides producing a useful data warehouse, the process also increased understanding of organizational and cost considerations in purchasing OLAP tools. We discuss the limitations of our approach and ways in which these limitations can be addressed. (+info)
Building a hospital information system: design considerations based on results from a Europe-wide vendor selection process.
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A number of research and development projects in the U.S. and in Europe have shown that novel technologies can open significant perspectives for hospital information systems (HIS). The selection of software products for a HIS, however, is still nontrivial. Generalist vendors promise a broad scope of functionality and integration, while specialist vendors promise elaborated and highly adapted functionality. In 1997, the university hospital Marburg, a 1,250 bed teaching hospital, decided to introduce a new large-scale HIS. The objectives of the project included support of clinical workflows, cost effectiveness and a maximum standard of medical care. In 1997/98 a formal Europe-wide vendor contest was performed. 15 vendors, including several from the U.S., participated. Systems were checked against the hospital's objectives, functionality, and technological criteria. One of the results of both technology and market assessment was the identification of fundamental technological and design aspects strongly influencing functionality and flexibility. (+info)
Epidemiological approach to quality assessment in echocardiographic diagnosis.
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OBJECTIVES: This study sought to determine whether statistical analysis of a computerized clinical diagnostic database can be used as a tool for quality assessment by determining the contribution of reader bias to variance in diagnostic output. BACKGROUND: In industry, measurement of product uniformity is a key component of quality assessment. In echocardiography, quality assessment has focused on review of small numbers of cases, or prospective determination of reader variability in selected and relatively small subsets. However, diagnostic biases in clinical practice might be discerned utilizing large computerized databases to determine interreader differences in diagnostic prevalence and, with use of appropriate statistical methods, to determine the association of reader selection with diagnostic prevalence independently of other covariates. METHODS: We analyzed 6,026 echocardiograms in a computerized database, read by one of three level 3 (American Society of Echocardiography) readers, for differences in frequency among four coded echocardiographic diagnoses: mitral valve prolapse, valvular vegetations, left ventricular (LV) thrombus, and LV regional wall-motion abnormality. RESULTS: Significant differences (up to fourfold) were found between readers, which persisted after statistical adjustment for those population characteristics, which differed slightly between readers. The low population prevalence of these conditions would have made it unlikely that these interreader differences could be detected by nonstatistical methods. Additionally, chamber dimensions differed between readers and were not normally distributed. CONCLUSIONS: Statistically based quality assessment analysis of computerized clinical databases facilitates ongoing monitoring of interreader bias despite low diagnostic prevalence, and targets opportunities for subsequent quality improvement. (+info)
Control of a prolonged outbreak of extended-spectrum beta-lactamase-producing enterobacteriaceae in a university hospital.
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Extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBLPE) were isolated from clinical specimens from 130 to 140 patients/year in 1989-1991 in our hospital. In February 1992, a control program was initiated: screening tests in 3 intensive care units (ICUs) and contact-isolation precautions in all units. The septic surgical unit served as an isolation ward for surgical patients from whom ESBLPE was isolated. In 1992, the incidence of ESBLPE acquisition failed to decrease, and most acquisitions occurred in 3 ICUs. Critical evaluation of implementation of isolation procedures in these ICUs prompted corrective measures for barrier precautions. The incidence of acquired cases subsequently decreased, and a second evaluation determined that these measures had been correctly applied. The incidence of acquired cases in the septic surgical unit was lower than those in the other units. Decreases were also found in the incidence of acquisition of other hand-transmitted multidrug-resistant organisms. Barrier precautions, screening tests for ICU patients, and grouping of cohorts after ICU discharge are effective in controlling the spread of multidrug-resistant microorganisms by cross-contamination. The outbreak was effectively controlled without restricting antimicrobial use. (+info)
Four years of experience with silver-copper ionization for control of legionella in a german university hospital hot water plumbing system.
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Silver-copper ionization was used for controlling Legionella distribution in a German university hospital hot water plumbing system for 4 years. In the beginning, silver concentrations were not allowed to exceed 10 microg/L because of drinking water regulation limits in Germany. Water samples were monitored for Legionella counts, temperature, and silver and copper concentrations. A significant (P<.001) 3.8-log reduction of Legionella counts, from 40, 000 cfu/L to 7 cfu/L, was found during the first year with silver-copper ionization. Nevertheless, the long-term efficacy of silver concentrations <10 ,++microg/L was not sufficient. Legionella counts increased to 10,000 cfu/L during the third year. During the fourth year, we studied the influence of higher silver concentrations on Legionella distribution. With an average silver level of 30 microg/L, only a 1.3-log reduction in Legionella, to 500 cfu/L, was achieved. The effect was not significant (P=.071); therefore, it must be considered that Legionella developed a tolerance to silver ions. (+info)
Unusual spread of a penicillin-susceptible methicillin-resistant Staphylococcus aureus clone in a geographic area of low incidence.
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We describe the unusual spread of a penicillin-susceptible methicillin-resistant Staphylococcus aureus (MRSA) clone in hospitals in western Switzerland, where the incidence of MRSA is usually low. During a 2-year period, this clone had been responsible for several outbreaks and had been isolated from >156 persons in 21 institutions. Molecular typing by pulsed-field gel electrophoresis (PFGE) demonstrated that all of these isolates belonged to the same clone. In 1 of the outbreaks, involving 30 cases, the clone was responsible for at least 17 secondary cases. In contrast, during the period of the latter outbreak, 9 other patients harboring different MRSA strains, as assessed by PFGE, were hospitalized in the same wards, but no secondary cases occurred. These observations suggest that this clone, compared with other MRSA strains, had some intrinsic factor(s) that contributed to its ability to disseminate and could thus be considered epidemic. (+info)