Economic impact of ventilator-associated pneumonia in a large matched cohort.
ABSTRACT To evaluate the economic impact of ventilator-associated pneumonia (VAP) on length of stay and hospital costs. Design. Retrospective matched cohort study.
Premier database of hospitals in the United States.
Eligible patients were admitted to intensive care units (ICUs), received mechanical ventilation for ≥2 calendar-days, and were discharged between October 1, 2008, and December 31, 2009.
VAP was defined by International Classification of Diseases, Ninth Revision (ICD-9), code 997.31 and ventilation charges for ≥2 calendar-days. We matched patients with VAP to patients without VAP by propensity score on the basis of demographics, administrative data, and severity of illness. Cost was based on provider perspective and procedural cost accounting methods.
Of 88,689 eligible patients, 2,238 (2.5%) had VAP; the incidence rate was 1.27 per 1,000 ventilation-days. In the matched cohort, patients with VAP ([Formula: see text]) had longer mean durations of mechanical ventilation (21.8 vs 10.3 days), ICU stay (20.5 vs 11.6 days), and hospitalization (32.6 vs 19.5 days; all [Formula: see text]) than patients without VAP ([Formula: see text]). Mean hospitalization costs were $99,598 for patients with VAP and $59,770 for patients without VAP ([Formula: see text]), resulting in an absolute difference of $39,828. Patients with VAP had a lower in-hospital mortality rate than patients without VAP (482/2,144 [22.5%] vs 630/2,144 [29.4%]; [Formula: see text]).
Our findings suggest that VAP continues to occur as defined by the new specific ICD-9 code and is associated with a statistically significant resource utilization burden, which underscores the need for cost-effective interventions to minimize the occurrence of this complication.
- Critical care medicine. 01/2015; 43(1):227-9.
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ABSTRACT: To perform a population-based analysis to compare the complications and cost of laparoscopic and robotically assisted adnexal surgery. A nationwide database was used to analyze the use and outcomes of robotically assisted adnexal surgery from 2009 to 2012. Multivariable mixed effects regression models were developed to examine predictors of use of robotic surgery. After propensity score matching, complications and cost were compared between robotically assisted and laparoscopic surgery. Eighty-seven thousand five hundred fourteen women were identified. From 2009 to 2012, performance of robotic-assisted oophorectomy increased from 3.5% (95% confidence interval [CI] 3.2-3.8%) to 15.0% (95% CI 14.4-15.6%), whereas robotically assisted cystectomy rose from 2.4% (95% CI 2.0-2.7%) to 12.9% (95% CI 12.2-13.5%). The overall complication rate was 7.1% (95% CI 4.0-10.2%) for robotically assisted compared with 6.0% (95% CI 2.9-9.1%) for laparoscopic oophorectomy (odds ratio [OR] 1.20, 95% CI 1.00-1.45; P=.052). Robotic-assisted oophorectomy was associated with a higher rate of intraoperative complications (3.4% compared with 2.1%, OR 1.60, 95% CI 1.21-2.13). The overall complication rate was 3.7% (95% CI -0.8 to 8.2%) after robotically assisted compared with 2.7% (95% CI -1.8 to 7.2%) for laparoscopic cystectomy (OR 1.38, 95% CI 0.95-1.99). The intraoperative complication rate was higher for robotically assisted cystectomy (2.0% compared with 0.9%, OR 2.40, 95% CI 1.31-4.38). Compared with laparoscopy, robotically assisted oophorectomy was associated with $2,504 (95% CI $2,356-2,652) increased total costs and robotically assisted cystectomy $3,310 (95% CI $3,082-3,581) higher costs. Use of robotically assisted adnexal surgery increased rapidly. Compared with laparoscopic surgery, robotically assisted adnexal surgery is associated with substantially greater costs and a small, but statistically significant, increase in intraoperative complications. : II.Obstetrics and Gynecology 11/2014; 124(5):886-96. · 4.37 Impact Factor
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ABSTRACT: Microaspiration of subglottic secretions through channels formed by folds in high volume-low pressure poly-vinyl chloride cuffs of endotracheal tubes is considered a significant pathogenic mechanism of ventilator-associated pneumonia (VAP). Therefore a series of prevention measures target the avoidance of microaspiration. However, although some of these can minimize microaspiration, benefits in terms of VAP prevention are not always obvious. Polyurethane-cuffed endotracheal tubes successfully reduce microaspiration but high quality data demonstrating VAP rate reduction are lacking. An analogous conclusion can be made regarding taper-shaped cuffs compared with classic barrel-shaped cuffs. More clinical data regarding these endotracheal tube designs are needed to demonstrate clinical value in addition to in vitro-based evidence. The clinical usefulness of endotracheal tubes developed for subglottic secretions drainage is established in multiple studies and confirmed by meta-analysis. Any change in cuff design will fail to prevent microaspiration if the cuff is insufficiently inflated. At least one well-designed trial demonstrated that continuous cuff pressure monitoring and control decrease the risk of VAP. Gel lubrication of the cuff prior to intubation temporarily hampers microaspiration through sludging the channels formed by folds in high volume-low pressure cuffs. As the beneficial effect of gel lubrication is temporarily, its potential to reduce VAP risk is probably nonsignificant. A minimum positive end-expiratory pressure of at least 5 cmH2O can be recommended as it reduces the risk of microaspiration in vitro and in vivo. One randomized controlled study demonstrated a reduced risk of VAP in patients ventilated with PEEP (5-8 cmH2O). Regarding head-of-bed elevation, it can be recommended to avoid supine positioning. Whether a 45° head-of-bed elevation is to be preferred above 25-30° head-of-bed elevation remains unproven. Finally, the routine monitoring of gastric residual volumes in mechanically ventilated patients receiving enteral nutrition cannot be recommended.BMC Infectious Diseases 01/2014; 14(1):119. · 2.56 Impact Factor