Stephen Stemkowski

BACKGROUND: Postoperative ileus, a transient impairment of gastrointestinal motility, is a common cause of delay in return to normal bowel function after abdominal surgery. Colectomy surgery patients who develop postoperative ileus could have greater health care resource utilization, including prolonged hospitalization, compared with those who do not develop postoperative ileus. Very few studies have assessed the impact of postoperative ileus on resource utilization and costs using retrospective analysis of administrative databases. OBJECTIVE: To assess health care utilization and costs in colectomy surgery patients who developed postoperative ileus versus those who did not. METHODS: A retrospective cohort study design was used. Adult patients with a principal procedure code for colectomy (ICD-9-CM procedure codes 45.71-45.79), discharged between January 1, 2004, and December 31, 2004, were identified from the Premier Perspective database of inpatient records from more than 500 hospitals in the United States. The colectomy patients were further classified for the presence of postoperative ileus, identified by the presence, in any diagnosis field on the administrative patient records, of a code for paralytic ileus (ICD-9-CM code 560.1) and/or digestive system complications (ICD-9-CM code 997.4) during the inpatient stay. Code 997.4 was used to account for cases in which postoperative ileus would be reported as a complication of anastomosis, as could be the case in colectomy surgeries. Hospital length of stay (LOS) and hospitalization costs were compared using t-tests. Multivariate analyses were performed with log-transformed LOS and log-transformed cost as the dependent variables. Patient demographics, mortality risk, disease severity, admission source, payment type (retrospective/prospective), and hospital characteristics were used as covariates. RESULTS: A total of 17,876 patients with primary procedure code for colectomy were identified, of whom 3115 (17.4%) patients were classified for presence of postoperative ileus (including paralytic ileus only [n=1216; 6.8%], digestive system complications only [n=383; 2.1%], or both [n=1516; 8.5%]). A majority of the colectomy patients with and without postoperative ileus, respectively, were male (54.1% vs. 50.3%, P < 0.001), Caucasian (70.5% vs. 69.3%, P = 0.170), and aged 51-64 years (51.1% vs. 49.7%, P = 0.143). The mean [SD] hospital LOS was significantly longer in patients with postoperative ileus (13.8 [13.3] days) compared with patients without postoperative ileus (8.9 [9.5] days; P < 0.001). Presence of postoperative ileus was found to be a significant predictor of LOS (P < 0.001) in the regression model, controlling for covariates. Female gender (P = 0.002), greater severity level (P < 0.001), and hospital bed size of more than 500 (P = 0.013) were other significant predictors of hospital LOS. Presence of postoperative ileus was found to be a significant predictor of hospitalization costs (P < 0.001), controlling for covariates. CONCLUSION: Postoperative ileus in colectomy patients is a significant predictor of hospital resource utilization.

Abstract BACKGROUND: The clinical venous thromboembolism (VTE) burden remains high in the United States, despite guidelines recommending that safe and effective VTE prophylaxis be available. This study assesses the real‐world rate of appropriate inpatient VTE prophylaxis in hospitalized U.S. medical and surgical patients at risk of VTE, in accordance with the seventh American College of Chest Physicians, (ACCP) guidelines. METHODS: Medical and surgical discharges from Premier's Perspective™ database between January 1, 2005 and December 31, 2006 were considered. Discharges aged ≥40 years, with a length of stay ≥6 days, at risk of VTE due to the presence of ≥1 VTE risk factors identified by the seventh ACCP guidelines, and without contraindications for anticoagulation, were included in the analysis. Appropriate prophylaxis was determined by comparing the daily use, dosage, and duration of anticoagulants and compression devices with the seventh ACCP recommendations for each medical condition or surgical procedure. RESULTS: A total of 390,024 discharges met the inclusion criteria, of which 201,224 (51.6%) were medical discharges and 188,800 (48.4%) were surgical discharges. Overall, 65.9% of medical discharges and 77.7% of surgical discharges received at least 1 order for VTE prophylaxis during hospitalization. However, only 12.7% of medical discharges and 16.4% of surgical discharges received appropriate prophylaxis when the recommended prophylaxis type, dose, and duration from the seventh ACCP guidelines were taken into account. CONCLUSIONS: Few medical and surgical patients at high risk of VTE receive appropriate inpatient prophylaxis in accordance with guideline recommendations. It is important for individual hospitals to improve VTE prophylaxis practices to meet national performance initiatives. Journal of Hospital Medicine 2009;4:E15–E21. © 2009 Society of Hospital Medicine.

OBJECTIVE: The cost of treating complex traumatic wounds is substantial because of trauma severity, potential for infection, and delayed closure. Negative pressure wound therapy using reticulated open cell foam (NPWT/ROCF) as delivered by Vacuum-Assisted Closure* (KCI Licensing, Inc, San Antonio, Texas) is an established, viable option for treating traumatic wounds. The authors used retrospective data to study the clinical and cost-effective benefits of using NPWT/ROCF early on day 1 or day 2 of treatment for traumatic wounds as compared with using it late (on day 3 or later). METHODS: Hospital data records from trauma wound patients treated with NPWT/ROCF were retrospectively analyzed. Data were subdivided into 2 groups based on start of treatment. The group of patients treated on day 1 or 2 of their hospital stay was referred to as the early group, and that composed of patients treated on day 3 or later as the late group. Clinical and cost-effective metrics were compared between the 2 groups. RESULTS: For the early group, 518 patient records were included; 1000 records were reviewed for the late group. Early-group patients had fewer hospital inpatient days (10.6 vs 20.6 days; P < .0001), fewer treatment days (5.1 vs 6.0 days; P = .0498), shorter intensive care unit (ICU) stays (5.3 vs 12.4 days; P < .0001), and higher ICU admission rates (51.5 vs 44.5%; P = .0091) than the late group. Compared with late-group patients, early-group patients had lower total and variable costs per patient discharge ($43,956 vs $32,175; P < .0001 and $22,891 vs $15,805; P < .0001, respectively). CONCLUSION: Acute-care trauma wound patients receiving early NPWT/ROCF demonstrated significant reductions in length of stay, treatment days, and ICU stay, which resulted in significant reduced patient treatment costs. These results indicate that early intervention with NPWT/ROCF has potential clinical and cost-effective benefits for the treatment of traumatic wounds.

Preventing venous thromboembolism in US hospitals: Are surgical patients receiving appropriate prophylaxis? -

BACKGROUND AND AIMS: Pulmonary arterial hypertension (PAH) is a rare medical disease in which patients experience increased pulmonary vascular resistance (PVR) and pulmonary arterial pressure that can result in remodeling of the pulmonary vasculature and heart, and eventually lead to right heart failure and death. As PAH progresses, patients become unable to perform even routine daily tasks without severe shortness of breath (dyspnea), fatigue, dizziness, and fainting (syncope). Treatment strategies largely depend on assessment of an individual patient's WHO Functional Class. The aim of the present study was to determine whether PAH functional decline, as described by the WHO Functional class (FC), is associated with increased healthcare costs for patients. METHODS: Patients with a prescription for a FDA-approved treatment for PAH and a medical claim indicating chronic pulmonary heart disease or right heart catheterization were identified from an administrative claims database. Provider-reported data from prior authorization forms required for advanced PAH therapies and medical charts were examined for reported FC. Healthcare resource utilization and costs were the primary outcomes of interest. Costs were accounted in 2014 US dollars ($) from a healthcare payer perspective. RESULTS: Patients with a reported FC-IV were observed to have the worst outcomes; averaging significantly more inpatient admissions, longer average lengths of stay, and more emergency department visits than the other FC sub-groups, resulting in higher medical costs. CONCLUSIONS: Using administrative data to document disease severity, this study replicates and expands on findings obtained from the registry study; disease severity was associated with higher healthcare resource utilization and costs. Stakeholders' implications for patient management are discussed.