Decreasing Laboratory Testing for Neonatal Jaundice Through Revision of a Clinical Practice Pathway

Author(s):  
Erin Preloger ◽  
Michael Wedoff ◽  
Jennifer T. Lemke ◽  
Amy Pan ◽  
Anika Nelson

OBJECTIVES: The purpose of this study was to minimize unnecessary laboratory services for hospitalized neonates with hyperbilirubinemia by revising a local clinical practice pathway (CPP). METHODS: A retrospective cohort study was performed to compare the number of laboratory tests and blood draws in patients hospitalized with neonatal hyperbilirubinemia before and after implementation of a revised CPP. The study included infants with neonatal hyperbilirubinemia <14 days old admitted after their birth hospitalization between April 2017 and October 2019. Primary outcome measures included the total number of blood draws and the number of laboratory tests obtained per patient and length of stay. Secondary outcome measures included 7-day readmission rate, charges, and discharge bilirubin level. RESULTS: The median number of blood draws per patient after implementation of the CPP decreased to 2 (interquartile range [IQR], 2–3) compared with 3 (IQR, 2–3) before implementation (Poisson model–based estimated mean difference, 1.1; 95% confidence interval, 1.0–1.3; P = .018). The median number of laboratory tests per patient after implementation decreased from 4 (IQR, 3–6) to 3 (IQR, 2–4; Poisson model–based estimated mean difference, 1.3; 95% confidence interval, 1.2–1.5; P < .0001). There was no significant change in length of stay, readmission rate, charges, or discharge bilirubin level. CONCLUSIONS: Implementation of a revised CPP was associated with a significant decrease in the number of blood draws and laboratory tests per patient for infants admitted to the hospital for neonatal hyperbilirubinemia.

2017 ◽  
Vol 83 (4) ◽  
pp. 414-420
Author(s):  
Jennifer A. Kaplan ◽  
Emily Finlayson ◽  
Andrew D. Auerbach

Trials of enhanced recovery programs suggest that multimodality pain regimens improve outcomes after colorectal surgery. We sought to determine whether patients receiving postoperative multimodality pain regimens would have shorter lengths of stay without an associated increase in readmission rate as compared to those receiving opioid-based pain regimens. Retrospective cohort study of adults who underwent elective colorectal surgery between January 1, 2006, and December 31, 2012, in a national hospital network participating in the Premier Perspective database. Patients were grouped into multimodality or opioid-based using postoperative medication charges. Primary outcome measures included length of stay and 30-day readmission rate. Among 91,936 patients, 38 per cent received multimodality pain regimens and 61 per cent received opioid-based regimens. After adjustment for patient and surgical characteristics, there was no difference in length of stay or cost, odds of readmission were 1.2 (95% confidence interval = 1.2–1.3, P < 0.001), and odds of mortality were 0.8 (95% confidence interval = 0.6–0.9, P < 0.001) in the multimodality group compared to nonopioid sparing. Our results were consistent in secondary analyses using propensity matching. Fewer than half of patients undergoing elective colorectal surgery in our cohort received multimodality pain regimens, and receipt of these medications was associated with mixed benefits in terms of length of stay, readmission, and mortality.


2018 ◽  
Vol 84 (9) ◽  
pp. 1429-1432 ◽  
Author(s):  
William P.L. Main ◽  
Amy E. Murphy ◽  
Lala R. Hussain ◽  
Katherine M. Meister ◽  
Kevin M. Tymitz

The objective of this study was to determine whether implementing an outpatient infusion pathway (OIP) resulted in a decreased 30-day readmission rate after laparoscopic Roux-en-Y gastric bypass (LRYGB). Data were retrospectively gathered on all patients who underwent LRYGB at our institution between April 1, 2015, and March 31, 2016, after instituting an OIP (postinfusion group). Thirty-day readmission rate, length of stay, and 30-day mortality rate were compared with patients who underwent LRYGB between January 1, 2014, and December 31, 2014, before implementing the OIP (preinfusion group). Patients not able to take 40 ounces of fluid orally at discharge after surgery were enrolled in the OIP. One OIP session would include an antiemetic, 1 liter bolus of 0.9 per cent saline, and intravenous multivitamin, thiamine, and folic acid. A total of 174 patients were included for analysis. Seventy-nine patients were in the pre-infusion group and 95 patients in the postinfusion group. Of the 95 patients in the postinfusion group, 18 patients (18.9%) met inclusion criteria for the OIP. There was a 45 per cent decrease in 30-day readmission rate after the institution of the OIP for patients who underwent LRYGB, however this was not statistically significant (11.39% vs 6.31%; OR 1.907; 95% confidence interval: 0.648–5.613, P = 0.235). There was no difference in postoperative length of hospital stay (1.65 vs 1.41 days, P = 0.114) or mortality (0.7% vs 0%, P = 0.454), in the pre- and postinfusion groups, respectively. Implementation of an OIP decreased 30-day readmission rate after LRYGB by 45 per cent; however, this was not statistically significant.


Author(s):  
Michelle B. Leavy ◽  
Claudia Schur ◽  
Ferhat Q. Kassamali ◽  
Margaret Edder Johnson ◽  
Raj Sabharwal ◽  
...  

2019 ◽  
Vol 144 (3) ◽  
pp. 671-681.e1 ◽  
Author(s):  
Richard E. Gliklich ◽  
Mario Castro ◽  
Michelle B. Leavy ◽  
Valerie G. Press ◽  
Amisha Barochia ◽  
...  

Author(s):  
A. M. Snedden ◽  
J. B. Lilleker ◽  
H. Chinoy

Abstract Purpose of review No clinical trial in sporadic inclusion body myositis (IBM) thus far has shown a clear and sustained therapeutic effect. We review previous trial methodology, explore why results have not translated into clinical practice, and suggest improvements for future IBM trials. Recent findings Early trials primarily assessed immunosuppressive medications, with no significant clinical responses observed. Many of these studies had methodological issues, including small participant numbers, nonspecific diagnostic criteria, short treatment and/or assessment periods and insensitive outcome measures. Most recent IBM trials have instead focused on nonimmunosuppressive therapies, but there is mounting evidence supporting a primary autoimmune aetiology, including the discovery of immunosuppression-resistant clones of cytotoxic T cells and anti-CN-1A autoantibodies which could potentially be used to stratify patients into different cohorts. The latest trials have had mixed results. For example, bimagrumab, a myostatin blocker, did not affect the 6-min timed walk distance, whereas sirolimus, a promotor of autophagy, did. Larger studies are planned to evaluate the efficacy of sirolimus and arimoclomol. Summary Thus far, no treatment for IBM has demonstrated a definite therapeutic effect, and effective treatment options in clinical practice are lacking. Trial design and ineffective therapies are likely to have contributed to these failures. Identification of potential therapeutic targets should be followed by future studies using a stratified approach and sensitive and relevant outcome measures.


2019 ◽  
Vol 26 (4) ◽  
pp. 401-407
Author(s):  
Tak Kyu Oh ◽  
Ah-Young Oh ◽  
Jung-Won Hwang

Perioperative positive fluid balance (FB) increases postoperative complication and length of hospital stay. We aimed to investigate 30-day unplanned readmission after major abdominal surgery based on perioperative FB (%) on postoperative days (POD) 0 to 3. This retrospective cohort study analyzed medical records of patients who underwent elective major abdominal surgery (surgery time >2 hours, estimated blood loss >500 mL) at a single tertiary academic hospital from January 2010 to December 2017. Cumulative FB was calculated by total input fluid − output fluid in liters × weight (kg)−1 on admission × 100 during POD 0 (24 hours), 0 to 1 (48 hours), 0 to 2 (72 hours), and 0 to 3 (96 hours). Of the 3650 patients in the final analysis, 503 (13.8%) had unplanned readmission within 30 days. In the multivariable logistic regression analysis, FB on POD 0 (24 hours), 0 to 1 (48 hours), 0 to 2 (72 hours), and 0 to 3 (96 hours) showed no significant association with 30-day unplanned readmission (all P > .05). However, an increase of 10 000 points in the total relative value unit scores was associated with 5% increase in 30-day unplanned readmission (odds ratio = 1.05, 95% confidence interval = 1.02-1.07; P = .001), and 1-hour increase in surgery time was associated with 10% increase in 30-day unplanned readmission (odds ratio = 1.10, 95% confidence interval = 1.05-1.15; P < .001). This study showed that perioperative FB is not associated with 30-day unplanned readmission rate after a major abdominal surgery. Total relative value unit scores and duration of surgery were significantly associated with 30-day unplanned readmission rate after major abdominal surgery in a single tertiary academic hospital.


2002 ◽  
Vol 9 (3) ◽  
pp. 255-261 ◽  
Author(s):  
Bradley B. Hill ◽  
Yehuda G. Wolf ◽  
W. Anthony Lee ◽  
Frank R. Arko ◽  
Cornelius Olcott ◽  
...  

Purpose: To compare the outcomes of open versus endovascular repair of abdominal aortic aneurysm (AAA) in a cohort of patients who fulfill morphological criteria for endovascular repair. Methods: A retrospective review of 229 consecutive AAA patients treated over a 3-year period identified 149 patients who were candidates for endovascular repair based on preoperative computed tomography and angiography. Of the 149 patients, 79 (68 men; mean age 74 ± 8 years) underwent endovascular repair with the AneuRx stent-graft; the remaining 70 (56 men; mean age 72 ± 8 years) had open repair. Short-term outcome measures were 30-day mortality and procedure-related morbidity, length of stay in the intensive care unit and hospital, intraoperative blood loss, interval to oral diet, and time to ambulation. Long-term outcome measures included death and secondary procedures. Results: There was no difference in the 30-day mortality between endovascular repair (2, 2.5%) and open repair (2, 2.9%), even though endovascular patients had more comorbidities (p<0.05). Overall length of stay was reduced for endovascular patients (3.9 ± 2.4 days versus 7.7 ± 3.1 days for surgical patients, p<0.0001). Fewer endograft patients had complications (24% versus 40% for open repair, p<0.05), and the severity of these complications was less, as evidenced by the shorter hospital stays for endovascular patients with complications compared to conventionally treated patients with complications (6.7 ± 2.4 days versus 22.5 ± 35.2 days, p<0.05). There were no aneurysm ruptures or late surgical conversions in either group. Conclusions: Patients with AAA who were endograft candidates but who were treated with open repair experienced more morbidity and had more complications than patients treated with stent-grafts. Despite increased comorbidities in the endograft patients, there was no increase in mortality compared to open repair. Both treatments required secondary procedures and appeared to be equally effective in preventing aneurysm rupture up to 3 years.


Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Jayme Strauss ◽  
Andrew Waisbrot ◽  
Daniel D'Amour ◽  
Amy K Starosciak

Introduction: Acute stroke is a major contributor to healthcare costs. In 2012, estimated direct costs associated with stroke was $71B, which is projected to double to $184B by 2030. As healthcare evolves and reimbursements decrease, cost control in disease specific populations is critical. In November 2017, length of stay (LOS) peaked at 5.78 days, as did variable and total cost/case (Table). In fiscal year 2017 the 30-d readmission rate was 9% and the mortality rate was 12%. Compliance with stroke admission order sets was at 55%. Methods: A multidisciplinary committee was formed in February 2017 to develop standardized, evidence-based clinical pathways for three populations: Ischemic stroke (IS) treated with IV tPA, TIA/IS without IV tPA, and intracerebral hemorrhage. The team met biweekly to standardize clinical pathways, decrease time to follow-up imaging, focus on physician order set utilization, and control costs. A comprehensive education program for all clinical staff was completed; official implementation of the pathways was in November 2017. A stroke financials team meets monthly to continue to look at opportunities and transitions of care. We reviewed a retrospective financial report of all in-hospital cases coded as MS-DRG 61-69 from 12/2017 through 7/31/2019 and compared it the 11/2017 report. Results: A total of 83 cases were available for 12/2017 and 2192 for 1/2018 through 7/2019. There was a reduced LOS by 26% (4.34 days), reduced variable cost/case by 24% ($5,958), reduced total cost/case by 23% ($13,790), reduced the 30-d readmission rate to 6%, and reduced the mortality rate to 4%. Case mix index was 12% higher at 1.3272 (vs. 1.2055 previously). Order set compliance improved to 94% (Table). A total cost saving dollar realization of $4.5 million. Discussion: Standardization of stroke clinical pathways led to improved order set compliance, almost 1/4 reduction in variable and total costs per case, shortened LOS, and reduced mortality and readmission rates.


2021 ◽  
Author(s):  
Nianyue Wu ◽  
Siru Liu ◽  
Haotian Zhang ◽  
Xiaomin Hou ◽  
Ping Zhang ◽  
...  

BACKGROUND The intensive care unit (ICU) length of stay is significant to evaluate the effect of cardiac surgical treatment inpatient. OBJECTIVE This research aims to accurately predict the ICU length of stay in patients with cardiac surgery. Methods: We used machine learning methods to construct the model, and the medical information mart for intensive care (MIMIC IV) database was used as the data source. A total of 7,567 patients were enrolled and the mean length of stay in the ICU was 3.12 days. A total of 126 predictors were included, and 44 important predictors were screened by least absolute shrinkage and selection operator (Lasso) regression. METHODS We used machine learning methods to construct the model, and the medical information mart for intensive care (MIMIC IV) database was used as the data source. A total of 7,567 patients were enrolled and the mean length of stay in the ICU was 3.12 days. A total of 126 predictors were included, and 44 important predictors were screened by least absolute shrinkage and selection operator (Lasso) regression. RESULTS The mean accuracy are 0.603 (95% confidence interval (CI): [0.602-0.604]), 0.687 (95% confidence interval (CI): [0.687-0.688]) and 0.688 (95% confidence interval (CI): [0.687-0.689]) for the logistic regression (LR) with all variables, the gradient boosted decision tree (GBDT) with important variables and the GBDT with all variables respectively. CONCLUSIONS The GBDT model with important predictors partly overestimated patients whose length of stay was less than 3 days and underestimated patients whose length of stay was longer than 3 days. But the better prediction performance of GBDT facilitates early intervention of ICU patients with a long period of hospitalization.


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