RESUMO
OBJECTIVE: Although the lack of health insurance has been linked to poor health outcomes in several diseases, this relationship is still understudied in trauma. There exist differences between the Puerto Rico health care system and that of the United States. We therefore aimed to assess mortality disparities related to insurance coverage at the Puerto Rico Trauma Hospital (PRTH). METHODS: A retrospective cohort study of patients who sustained penetrating injuries (presenting at the PRTH from 2000 to 2014) was performed. Individuals were classified by their insurance status. Study variables comprised demographics, clinical characteristics and outcomes. A logistic regression analysis was performed to identify the association between health insurance status and risk of dying. RESULTS: Patients with public health insurance experienced more complications than did individuals who had private health insurance (PrHI) or who were uninsured. This group had longer durations of mechanical ventilation and spent more time in the hospital than did patients who had PrHI or who were uninsured. However, uninsured patients with gunshot wounds were 54% (adjusted odds ratio = 1.54; 95% CI: 1.01, 2.36) more likely to die than were their counterparts who had PrHI. CONCLUSION: Our study suggests that having health insurance could reduce a given patient mortality risk in trauma settings. More studies with larger samples are warranted to confirm these findings. If these findings hold true, then providing equitable access to health services for the entire population could prevent patients suffering trauma from having premature, preventable deaths.
Assuntos
Disparidades em Assistência à Saúde , Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Qualidade da Assistência à Saúde , Ferimentos Penetrantes/etnologia , Ferimentos Penetrantes/mortalidade , Cuidados Críticos/economia , Feminino , Hispânico ou Latino/estatística & dados numéricos , Humanos , Escala de Gravidade do Ferimento , Masculino , Porto Rico/epidemiologia , Estudos Retrospectivos , Ferimentos por Arma de Fogo/mortalidade , Ferimentos Penetrantes/diagnóstico , Ferimentos Penetrantes/terapiaRESUMO
Postoperative patients are susceptible to alterations in electrolyte homeostasis. Although electrolytes are replaced in critically ill patients, stable asymptomatic non-intensive care unit (ICU) patients often receive treatment of abnormal electrolytes. We hypothesize there is no proven benefit in asymptomatic patients. In 2016, using the electronic medical records and pharmacy database at a university academic medical center, we conducted a retrospective cost analysis of the frequency and cost of electrolyte analysis (basic metabolic panel [BMP], ionized calcium [Ca], magnesium [Mg], and phosphorus [P]) and replacement (potassium chloride [KCl], Mg, oral/iv Ca, oral/iv P) in perioperative patients. Patients without an oral diet order, with creatinine more than 1.4, age less than 16 years, admitted to the ICU, or with length of stay of more than 1 week were excluded. Nursing costs were calculated as a fraction of hourly wages per laboratory order or electrolyte replacement. One hundred thirteen patients met our criteria over 11 months. Mean length of stay was 4 days; mean age was 54 years; and creatinine was 0.67 ± 0.3. Electrolyte analysis laboratory orders (n = 1,045) totaled $6,978, and BMP was most frequently ordered accounting for 36% of laboratory costs. In total, 683 doses of electrolytes cost the pharmacy $1,780. Magnesium was most frequently replaced, followed by KCl, P, and Ca. Nursing cost associated with electrolyte analysis/replacement was $7,782. There is little evidence to support electrolyte analysis and replacement in stable asymptomatic noncritically ill patients, but their prevalence and cost ($146/case) in this study were substantial. Basic metabolic panels, pharmacy charges for potassium, and nursing staff costs accounted for the most significant portion of the total cost. Considering these data, further research should determine whether these practices are warranted.
Assuntos
Cuidados Críticos/economia , Eletrólitos/economia , Hidratação/economia , Magnésio/economia , Cuidados Pós-Operatórios/economia , Potássio/economia , Enfermagem em Ortopedia e Traumatologia/economia , Adulto , Idoso , Idoso de 80 Anos ou mais , Cuidados Críticos/estatística & dados numéricos , Feminino , Hidratação/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Cuidados Pós-Operatórios/estatística & dados numéricos , Estudos Retrospectivos , Enfermagem em Ortopedia e Traumatologia/estatística & dados numéricosRESUMO
Tropical diseases are those that occur primarily or solely in the tropics, and as such include infectious diseases that are particularly prevalent in hot, humid conditions. The incidence of encephalitis in tropical countries is reported to be as high as 6.34/100,000/year. The term encephalitis implies inflammation of the brain and includes the presence of encephalopathy with two and more of the following features: fever, seizures and/or focal neurological findings; a cerebrospinal fluid pleocytosis; electroencephalographic findings or abnormal neuroimaging suggestive of encephalitis. Transverse myelitis (TM) is an inflammation of the spinal cord which has a wide variety of clinical presentations depending on the degree (severity of myelin and neuronal injury) and site of spinal cord involvement. In the present article we discuss the various forms of tropical, viral encephalitides and myelitis and the diagnosis and management.
Assuntos
Cuidados Críticos/normas , Encefalite/diagnóstico , Unidades de Terapia Intensiva/normas , Mielite Transversa/diagnóstico , Avaliação de Resultados em Cuidados de Saúde , Comitês Consultivos , Cuidados Críticos/economia , Países em Desenvolvimento , Encefalite/terapia , Humanos , Unidades de Terapia Intensiva/economia , Área Carente de Assistência Médica , Mielite Transversa/terapia , Convulsões , Sociedades Médicas , Medicina TropicalRESUMO
OBJECTIVES: This study sought to analyze the clinical and epidemiologic characteristics of critically ill patients who were denied intensive care unit admission due to the unavailability of beds and to estimate the direct costs of treatment. METHODS: A prospective cohort study was performed with critically ill patients treated in a university hospital. All consecutive patients denied intensive care unit beds due to a full unit from February 2012 to February 2013 were included. The data collected included clinical data, calculation of costs, prognostic scores, and outcomes. The patients were followed for data collection until intensive care unit admission or cancellation of the request for the intensive care unit bed. Vital status at hospital discharge was noted, and patients were classified as survivors or non-survivors considering this endpoint. RESULTS: Four hundred and fifty-four patients were analyzed. Patients were predominantly male (54.6%), and the median age was 62 (interquartile range (ITQ): 47 - 73) years. The median APACHE II score was 22.5 (ITQ: 16 - 29). Invasive mechanical ventilation was used in 298 patients (65.6%), and vasoactive drugs were used in 44.9% of patients. The median time of follow-up was 3 days (ITQ: 2 - 6); after this time, 204 patients were admitted to the intensive care unit and 250 had the intensive care unit bed request canceled. The median total cost per patient was US$ 5,945.98. CONCLUSIONS: Patients presented a high severity in terms of disease scores, had multiple organ dysfunction and needed multiple invasive therapeutic interventions. The study patients received intensive care with specialized consultation during their stay in the hospital wards and presented high costs of treatment.
Assuntos
Ocupação de Leitos/estatística & dados numéricos , Cuidados Críticos/economia , Cuidados Críticos/estatística & dados numéricos , Estado Terminal/economia , Estado Terminal/terapia , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Unidades de Terapia Intensiva/estatística & dados numéricos , APACHE , Adulto , Idoso , Brasil/epidemiologia , Estado Terminal/mortalidade , Feminino , Custos de Cuidados de Saúde , Acessibilidade aos Serviços de Saúde/economia , Necessidades e Demandas de Serviços de Saúde/economia , Necessidades e Demandas de Serviços de Saúde/estatística & dados numéricos , Humanos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Índice de Gravidade de Doença , Estatísticas não Paramétricas , Fatores de TempoRESUMO
OBJECTIVES: This study sought to analyze the clinical and epidemiologic characteristics of critically ill patients who were denied intensive care unit admission due to the unavailability of beds and to estimate the direct costs of treatment. METHODS: A prospective cohort study was performed with critically ill patients treated in a university hospital. All consecutive patients denied intensive care unit beds due to a full unit from February 2012 to February 2013 were included. The data collected included clinical data, calculation of costs, prognostic scores, and outcomes. The patients were followed for data collection until intensive care unit admission or cancellation of the request for the intensive care unit bed. Vital status at hospital discharge was noted, and patients were classified as survivors or non-survivors considering this endpoint. RESULTS: Four hundred and fifty-four patients were analyzed. Patients were predominantly male (54.6%), and the median age was 62 (interquartile range (ITQ): 47 - 73) years. The median APACHE II score was 22.5 (ITQ: 16 - 29). Invasive mechanical ventilation was used in 298 patients (65.6%), and vasoactive drugs were used in 44.9% of patients. The median time of follow-up was 3 days (ITQ: 2 - 6); after this time, 204 patients were admitted to the intensive care unit and 250 had the intensive care unit bed request canceled. The median total cost per patient was US$ 5,945.98. CONCLUSIONS: Patients presented a high severity in terms of disease scores, had multiple organ dysfunction and needed multiple invasive therapeutic interventions. The study patients received intensive care with specialized consultation during their stay in the hospital wards and presented high costs of treatment.
Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Idoso , Ocupação de Leitos/estatística & dados numéricos , Cuidados Críticos/economia , Cuidados Críticos/estatística & dados numéricos , Estado Terminal/economia , Estado Terminal/terapia , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Unidades de Terapia Intensiva/estatística & dados numéricos , APACHE , Brasil/epidemiologia , Estado Terminal/mortalidade , Custos de Cuidados de Saúde , Acessibilidade aos Serviços de Saúde/economia , Necessidades e Demandas de Serviços de Saúde/economia , Necessidades e Demandas de Serviços de Saúde/estatística & dados numéricos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Estudos Prospectivos , Índice de Gravidade de Doença , Estatísticas não Paramétricas , Fatores de TempoRESUMO
OBJECTIVE: With increasing emphasis on high "value" care, we designed this study to evaluate the relationship between hospital costs and patient outcomes in pediatric critical care. DESIGN: Post hoc analysis of data from an existing administrative national database, Pediatric Health Information Systems. Multivariable mixed effects logistic regression models were fitted to evaluate association of hospital cost tertiles with odds of mortality after adjusting for patient and center characteristics. SETTING: Forty-seven children's hospitals across the United States. PATIENTS: Patients 18 years old or younger admitted to a PICU at a Pediatric Health Information Systems participating hospital were included (2004-2015). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 917,663 patients from 47 hospitals were included. Median cost per patient was $42,181 in the low-cost hospitals (341,689 patients, 16 hospitals), $56,806 in the middle-cost hospitals (310,293 patients, 16 hospitals), and $82,588 in the high-cost hospitals (265,681 patients, 15 hospitals). In unadjusted analysis, patients cared for in the high-cost tertile hospitals were younger in age, associated with more comorbidities, had higher resource utilization (including extracorporeal membrane oxygenation and nitric oxide), had higher prevalence of cardiac arrest, and were associated with worse outcomes (including mortality). In adjusted analysis, high-cost tertile hospitals were not associated with improved mortality, when compared with low- and medium-cost tertile hospitals (low cost vs high cost: odds ratio, 0.99; 95% CI, 0.79-1.25 and middle cost vs high cost: odds ratio, 1.10; 95% CI, 0.86-1.41). When stratified by diagnoses category, we noted similar trends among cardiac and noncardiac patients. CONCLUSIONS: This large observational study did not demonstrate any relationship between hospital costs and patient outcomes in children with critical illness. Further efforts are needed to evaluate quality-cost relationship and high value care in critically ill children across centers of varying volume by linking data from clinical and administrative databases.
Assuntos
Cuidados Críticos/economia , Estado Terminal/mortalidade , Custos Hospitalares/estatística & dados numéricos , Mortalidade Hospitalar , Hospitais Pediátricos/economia , Unidades de Terapia Intensiva Pediátrica/economia , Indicadores de Qualidade em Assistência à Saúde/economia , Adolescente , Criança , Pré-Escolar , Cuidados Críticos/estatística & dados numéricos , Estado Terminal/economia , Estado Terminal/terapia , Bases de Dados Factuais , Feminino , Hospitais Pediátricos/estatística & dados numéricos , Humanos , Lactente , Recém-Nascido , Unidades de Terapia Intensiva Pediátrica/estatística & dados numéricos , Modelos Logísticos , Masculino , Avaliação de Resultados em Cuidados de Saúde , Risco Ajustado , Estados UnidosRESUMO
OBJECTIVES: To analyze the direct costs of treating critically ill patients in the intensive care unit of a center specializing in treating burns. METHODS: This is a prospective cohort study of 180 patients from May 2011 to May 2013. Clinical and demographic data were collected in addition to data for the calculation of severity scores. The costs related to daily clinical and surgical treatment were evaluated until hospital outcome. The costs were grouped into five blocks: Clinical support, Drugs and blood products, Medical procedures, Specific burn procedures and Hospital fees. The level of significance was set at 5%. RESULTS: There was a predominance of males, 131 (72.8%). The mean age of the patients was 42.0±15.3years and the mean burned body surface area was 27.9±17%. The median length of stay in intensive care beds was 15.0 (interquartile range IQR: 7.0-24.8) days and the median hospital stay was 23.0 (IQR: 14.0-34.0) days. The mean daily cost was US$ 1330.48 (standard error of the mean SE=38.36) and the mean total cost of hospitalization was US$ 39,594.90 (SE: 2813.11). The drugs and blood products block accounted for the largest fraction of the total costs (US$ 18,086.09; SE 1444.55). There was a difference in the daily costs of survivors and non survivors (US$ 1012.89; SE: 29.38 and US$ 1866.11, SE: 36.43, respectively, P<0.001). CONCLUSION: The direct costs of the treatment of burn patients at the study center were high. The drugs and blood products block presented the highest mean total and daily costs. Non surviving patients presented higher costs.
Assuntos
Unidades de Queimados/economia , Queimaduras/economia , Custos Hospitalares/estatística & dados numéricos , Hospitais Universitários/economia , Adulto , Distribuição por Idade , Idoso , Queimaduras/terapia , Custos e Análise de Custo , Cuidados Críticos/economia , Feminino , Humanos , Tempo de Internação/economia , Masculino , Pessoa de Meia-Idade , Estudos ProspectivosRESUMO
OBJECTIVES: Critical care is an expensive and limited resource, and short-stay critical care admissions may be treated in alternate, less costly settings. This study objective was to determine the proportion of critical care admissions with a short critical care length of stay (LOS) and identify the clinical characteristics and diagnoses associated with high and low rates of short-stay critical care admissions. METHODS: This study was a secondary analysis of the 2011 Maryland State Inpatient Database. The study included adult emergency department (ED) visits admitted to a critical care unit. We compared clinical data and discharge diagnoses for short- (≤1 day) versus longer- (≥2 days) stay critical care admissions. RESULTS: A total of 30,212 critical care admissions were eligible, of which 11,494 (38.0%) were short stay. There were significant differences in age, insurance, and comorbidities between the short-stay and the longer-stay critical care admissions. Of short-stay critical care admissions, 3,404 (29.6%) also had a 1-day overall hospital LOS. The diagnoses with the highest proportion of short-stay critical care admissions were nonspecific chest pain (87.9%), syncope (70.6%), and transient cerebral ischemia (67.6%) and the lowest proportion were respiratory failure (17.9%), sepsis (19.4%), and aspiration pneumonitis (19.8%). CONCLUSIONS: Over one-third of critical care admissions were short stay. Alternate strategies to manage these patients, including ED-based critical care units or other venues of inpatient care, may be more cost-efficient for selected patients.