RESUMO
OBJECTIVE: There is a growing demand both for respect for patient autonomy regarding the use of sophisticated technology and for consideration of health care expenditures at the end of life. The major objective of this study was to assess the relationship between the documentation of a discussion of advance directives and hospital charges for Medicare patients during the last hospitalization of the patient's life. DESIGN: Multivariate analysis of a retrospective cohort. SETTING: Large (700+ beds), private university, tertiary care hospital. PATIENTS: All 474 patients who had Medicare listed as their primary insurer and who died in the hospital between January 1 and June 30 in 1990, 1991, or 1992. MAIN OUTCOME MEASURE: Total inpatient charges. RESULTS: The mean inpatient charge for the 342 patients without documentation of a discussion of advance directives was more than three times that of the 132 patients with such documentation ($95.305 vs $30,478). This relationship remained statistically significant after controlling for severity of disease, use of an intensive care unit, and number of procedures. Demographics, length of stay, admitting service, admitting diagnosis, and previous admission to the study hospital did not contribute to the predictive model. CONCLUSIONS: During discussions of advance directives, patients often opt to limit the extent of care they desire in certain situations. Although the most appropriate setting for developing advance directives is not clear, the results of this study imply that an enormous cost savings to society may be realized if such discussions take place, while, at the same time, autonomous patient choice will be respected.
Assuntos
Diretivas Antecipadas/economia , Preços Hospitalares , Medicare/economia , Idoso , Idoso de 80 Anos ou mais , Grupos Controle , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Estudos Retrospectivos , Índice de Gravidade de Doença , Estados Unidos , Suspensão de TratamentoAssuntos
Medicina de Família e Comunidade/educação , Geriatria/educação , Serviços Hospitalares de Assistência Domiciliar , Visita Domiciliar/estatística & dados numéricos , Internato e Residência/organização & administração , Idoso , Idoso de 80 Anos ou mais , Continuidade da Assistência ao Paciente , Grupos Diagnósticos Relacionados , Feminino , Humanos , Masculino , Avaliação de Resultados em Cuidados de Saúde , Philadelphia , Padrões de Prática Médica , Desenvolvimento de Programas , Saúde da População Urbana , Recursos HumanosRESUMO
Urethral cultures were obtained from 90 adolescent youth, 16 of whom denied previous sexual activity. Among the sexually active boys was a group of 32 with clinically significant pyuria, consistent with the diagnosis of urethritis, on a first-part urinalysis (FPU) specimen. To relate differences in urethral microflora to sexual activity, 42 sexually active patients with a negative FPU were compared with the never sexually active group. The profile of anaerobic, but not aerobic, bacteria isolated from the urethra was related to the presence or absence of previous sexual activity. Mycoplasma species and Ureaplasma urealyticum were isolated from sexually active patients only, and may be markers of sexual activity in adolescent boys. Of the 32 patients with FPU evidence of urethritis, 22 (69%) had cultures positive for Chlamydia trachomatis, and an additional three (9%) had cultures positive for Neisseria gonorrhoeae. The findings in sexually active patients with a positive FPU were otherwise similar to those of sexually active patients without evidence of urethritis. C. trachomatis appears to be the most important agent of urethritis among adolescent boys with a positive FPU.