Bottom line: Ultrasound imaging likely reduces the failure of lumbar puncture and epidural catheterization, but future research will be necessary to evaluate the cost-effectiveness of ultrasound use for these procedures.
Citation: Shaikh F, Brzezinski J, Alexander S, et al. Ultrasound imaging for lumbar punctures and epidural catheterisations: systematic review and meta-analysis. BMJ. 2013;346:f1720.
Surgical Complications might Be Financially Advantageous for Hospitals
Clinical question: What is the impact of surgical complications on hospital finances?
Background: Surgical complications are common and lead to longer lengths of stay and higher costs. Strategies are available to reduce postsurgical complications but have not been universally adopted.
Study design: Observational study.
Setting: Twelve hospitals in one nonprofit Southern hospital system, which includes academic, nonacademic, and rural settings.
Synopsis: Researchers identified 34,526 patients who underwent surgery in 2010, excluding patients undergoing Caesarean section. Of those, 1,820 procedures (5.3%) were associated with at least one complication. The most frequent complications were surgical-site infection, other infections, pneumonia, and thromboembolic disease. The mortality rate for patients with complications was 12.3% compared with 0.6% for those without. Length of stay was four times longer for patients with complications.
Complications were associated with a higher total cost of hospitalization, with a differential of $37,917. This translated into a higher contribution to the margin. The cost differential varied by insurance type, with higher contributions under Medicare and private insurance but not with Medicaid.
The study had the benefit of using a large administrative database; however, this may have underestimated the actual rate of postoperative complications. The study supports the paradox in which quality-improvement (QI) programs that reduce surgical complications and improve postoperative mortality may negatively affect a hospital’s financial performance.
Bottom line: Surgical complications lead to higher mortality for patients but a financial benefit for hospitals.
Citation: Eappen S, Lane BH, Rosenberg B, et al. Relationship between occurrence of surgical complications and hospital finances. JAMA. 2013;309(5):1509-1606.
Showing Lab Test Fees May Decrease Frequency Of Test Ordering
Clinical question: Does information on the cost of a lab test lead to lowered ordering frequency among internal-medicine residents?
Background: Lab test overuse is common; some studies estimate that 70% of lab tests do not affect care. Strategies to reduce frequency of unnecessary lab tests are needed.
Study design: Randomized controlled trial.
Setting: Johns Hopkins Hospital, a 1,051-bed academic medical center in Baltimore.
Synopsis: Researchers used an administrative database to identify the 35 most frequently ordered and the 35 most expensive tests (each ordered at least 50 times). They randomized tests to an active arm, which displayed the Medicare allowable fee at the time of order entry within the computerized physician order entry, and a control arm. A total of 1,166,753 tests were ordered during the baseline and intervention period. Many more tests were ordered in the active group relative to the control group, a consequence of the randomization process. Relative to a six-month baseline period, tests in the active group were ordered 9.1% less frequently; control-group tests were ordered 5.1% more frequently. Charges decreased by $3.79 per patient-day in the active group and increased by $0.52 per patient-day in the control group.
This study reflects a low-cost strategy to reduce lab testing and associated costs. It is unknown whether only unnecessary tests were averted, or if there was any effect on the quality of care. The durability of the intervention and its applicability to other settings and with other types of providers is unclear.
Bottom line: Showing the fee associated with lab tests may decrease the frequency of ordering these tests and the resultant costs.
