Potential Influence of Advance Care Planning and Palliative Care Consultation on ICU Costs for Patients With Chronic and Serious Illness.

OBJECTIVES: To estimate the potential ICU-related cost savings if in-hospital advance care planning and ICU-based palliative care consultation became standard of care for patients with chronic and serious illness. DESIGN AND SETTING: Decision analysis using literature estimates and inpatient administrative data from Premier. PATIENTS: Patients with chronic, life-limiting illness admitted to a hospital within the Premier network. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Using Premier data (2008-2012), ICU resource utilization and costs were tracked over a 1-year time horizon for 2,097,563 patients with chronic life-limiting illness. Using a Markov microsimulation model, we explored the potential cost savings from the hospital system perspective under a variety of scenarios by varying the interventions\u27 efficacies and availabilities. Of 2,097,563 patients, 657,825 (31%) used the ICU during the 1-year time horizon; mean ICU spending per patient was 11.3k (SD, 17.6k). In the base-case analysis, if in-hospital advance care planning and ICU-based palliative care consultation were systematically provided, we estimated a mean reduction in ICU costs of 2.8k (SD, 14.5k) per patient and an ICU cost saving of 25%. Among the simulated patients who used the ICU, the receipt of both interventions could have resulted in ICU cost savings of 1.9 billion, representing a 6% reduction in total hospital costs for these patients. CONCLUSIONS: In-hospital advance care planning and palliative care consultation have the potential to result in significant cost savings. Studies are needed to confirm these findings, but our results provide guidance for hospitals and policymakers

Evaluating the Economic Impact of Palliative and End-of-Life Care Interventions on Intensive Care Unit Utilization and Costs from the Hospital and Healthcare System Perspective.

Purpose of report: Understanding the impact of palliative care interventions on intensive care unit (ICU) costs and utilization is critical for demonstrating the value of palliative care. Performing these economic assessments, however, can be challenging. The purpose of this special report is to highlight and discuss important considerations when assessing ICU utilization and costs from the hospital perspective, with the goal of providing recommendations on methods to consider for future analyses. FINDINGS: ICU length of stay (LOS) and associated costs of care are common and important outcome measures, but must be analyzed properly to yield valid conclusions. There is significant variation in costs by day of stay in the ICU with only modest differences between an ICU day at the end of a stay and the first day on the acute care floor; this variation must be appropriately accounted for analytically. Furthermore, reporting direct variable costs, in addition to total ICU costs, is needed to understand short-term and long-term impact of a reduction in LOS. Importantly, incentives for the hospital to realize savings vary depending on reimbursement policies. SUMMARY: ICU utilization and costs are common outcomes in studies evaluating palliative care interventions. Accurate estimation and interpretation are key to understanding the economic implications of palliative care interventions

Patterns of Cost for Patients Dying in the Intensive Care Unit and Implications for Cost Savings of Palliative Care Interventions.

BACKGROUND: Terminal intensive care unit (ICU) stays represent an important target to increase value of care. OBJECTIVE: To characterize patterns of daily costs of ICU care at the end of life and, based on these patterns, examine the role for palliative care interventions in enhancing value. DESIGN: Secondary analysis of an intervention study to improve quality of care for critically ill patients. SETTING/PATIENTS: 572 patients who died in the ICU between 2003 and 2005 at a Level-1 trauma center. METHODS: Data were linked with hospital financial records. Costs were categorized into direct fixed, direct variable, and indirect costs. Patterns of daily costs were explored using generalized estimating equations stratified by length of stay, cause of death, ICU type, and insurance status. Estimates from the literature of effects of palliative care interventions on ICU utilization were used to simulate potential cost savings under different time horizons and reimbursement models. MAIN RESULTS: Mean cost for a terminal ICU stay was 39.3K ± 45.1K. Direct fixed costs represented 45% of total hospital costs, direct variable costs 20%, and indirect costs 34%. Day of admission was most expensive (mean 9.6K ± 7.6K); average cost for subsequent days was 4.8K ± 3.4K and stable over time and patient characteristics. CONCLUSIONS: Terminal ICU stays display consistent cost patterns across patient characteristics. Savings can be realized with interventions that align care with patient preferences, helping to prevent unwanted ICU utilization at end of life. Cost modeling suggests that implications vary depending on time horizon and reimbursement models

Estimating the Effect of Palliative Care Interventions and Advance Care Planning on ICU Utilization: A Systematic Review

OBJECTIVE: We conducted a systematic review to answer three questions: 1) Do advance care planning and palliative care interventions lead to a reduction in ICU admissions for adult patients with life-limiting illnesses? 2) Do these interventions reduce ICU length of stay? and 3) Is it possible to provide estimates of the magnitude of these effects? DATA SOURCES: We searched MEDLINE, EMBASE, Cochrane Controlled Clinical Trials, and Cumulative Index to Nursing and Allied Health Literature databases from 1995 through March 2014. STUDY SELECTION: We included studies that reported controlled trials (randomized and nonrandomized) assessing the impact of advance care planning and both primary and specialty palliative care interventions on ICU admissions and ICU length of stay for critically ill adult patients. DATA EXTRACTION: Nine randomized controlled trials and 13 nonrandomized controlled trials were selected from 216 references. DATA SYNTHESIS: Nineteen of these studies were used to provide estimates of the magnitude of effect of palliative care interventions and advance care planning on ICU admission and length of stay. Three studies reporting on ICU admissions suggest that advance care planning interventions reduce the relative risk of ICU admission for patients at high risk of death by 37% (SD, 23%). For trials evaluating palliative care interventions in the ICU setting, we found a 26% (SD, 23%) relative risk reduction in length of stay with these interventions. CONCLUSIONS: Despite wide variation in study type and quality, patients who received advance care planning or palliative care interventions consistently showed a pattern toward decreased ICU admissions and reduced ICU length of stay. Although SDs are wide and study quality varied, the magnitude of the effect is possible to estimate and provides a basis for modeling impact on healthcare costs

Definitions and potential health benefits of the Mediterranean diet: views from experts around the world

The Mediterranean diet has been linked to a number of health benefits, including reduced mortality risk and lower incidence of cardiovascular disease. Definitions of the Mediterranean diet vary across some settings, and scores are increasingly being employed to define Mediterranean diet adherence in epidemiological studies. Some components of the Mediterranean diet overlap with other healthy dietary patterns, whereas other aspects are unique to the Mediterranean diet. In this forum article, we asked clinicians and researchers with an interest in the effect of diet on health to describe what constitutes a Mediterranean diet in different geographical settings, and how we can study the health benefits of this dietary pattern

Conceptual design of a winged hybrid airship

The present study focuses on the sizing and aerodynamic contour design of a two-seater 1000 kg gross take-off mass winged hybrid airship. Unlike the conventional hybrid airships, which stay aloft and takeoff with the help of VTOL propulsion systems, a winged hybrid airship requires a certain speed to takeoff by utilizing lift coming from its aerodynamic surfaces. Heaviness fraction and takeoff ground roll are considered as measure of merit in initial sizing. Based on the design requirement of Malaysian inter-island tourism and transportation of agricultural products, range is set to 450 km and ground roll for take-off about 150 m. For the airship to be heavy enough for ground handling, the ratio of hydrostatic to hydrodynamic lift is set equal to 49:51. Summary of the results to be obtained in early design phase will give a baseline start to study the aerodynamics and stability characteristics of such airships in future

Long-term Survival in Patients with Severe Acute Respiratory Distress Syndrome and Rescue Therapies for Refractory Hypoxemia

Thesis (Master's)--University of Washington, 2013Objective: To assess survival up to 5 years in patients who develop severe acute respiratory distress syndrome (ARDS) and evaluate differences in characteristics and outcomes for patients selected for treatment with a rescue therapy (inhaled nitric oxide, inhaled epoprostenol or prone position ventilation) versus conventional treatment. Design and Setting: Retrospective cohort study of patients admitted to the intensive care unit (ICU) at a 413-bed Level 1 trauma university hospital. Patients: Patients diagnosed with severe ARDS, according to the Berlin definition, within 72 hours of ICU admission between 1/1/2008 and 12/31/2011. Methods: Data were abstracted from the electronic medical record and included demographic and clinical variables, hospital and ICU length of stay, discharge disposition, and hospital costs. We compared patients placed on inhaled nitric oxide, inhaled epoprostenol or ventilated in the prone position with patients treated conventionally. To determine survival beyond hospital discharge, patient-level data were linked to the Washington State Death Registry. Kaplan-Meir survival analysis methods were used to assess survival. Cox's proportional hazards models were used to compare differences in outcomes between patients treated with a rescue therapy and those treated conventionally. Costs were analyzed using the Lin method to estimate mean total costs in the presence of censoring. Main Results: 428 patients meeting the inclusion criteria were identified, of whom 62 (14%) were placed on a rescue therapy. Five-year survival for all patients was 54.9% (95% CI: 50.2%, 60.1%). For patients who were discharged from the hospital alive, 5-year survival was 84.5% (95% CI: 79.8%, 89.4%). Mean hospital cost was $701 K (95$97K, $846 K). Admission PaO2/FIO2 ratios were similar between patients treated with a rescue therapy and those treated conventionally. However, prior to initiation of rescue therapy, patients treated with a rescue therapy had substantially lower PaO2/FIO2 ratios by 72 hours (54 mm Hg ± 17 versus 69 mm Hg ± 17; p=Conclusions: Severe ARDS patients surviving to hospital discharge have relatively good long-term survival. Patients with worsening hypoxemia are selected to receive a rescue therapy. Future prospective studies should investigate the impact of the timing of initiation of a rescue therapy prior to the development of life-threatening critical hypoxemia on long-term outcomes

Serum HSV-1 and 2 IgM in sexually transmitted diseases - more for screening less for diagnosis: An evaluation of clinical manifestation

Background: Herpes simplex virus type 2 (HSV-2) is the cause of most genital herpes. Now, HSV-1 has become an important cause and represents even about 30% of genital herpes in some countries. So, study related to genital herpes should consider both HSV-1 and HSV-2. Aim: To examine trends in HSV-1 and 2 seroprevalence by Serum HSV-1 and 2 IgM in all type of sexually transmitted disease (STD) patients and also to evaluate correlation of serum HSV-1 and 2 IgM in STD. Materials and Methods: 150 patients attending the STD clinic attached to a tertiary care hospital of Ahmedabad were included in the study. Serum HSV-1 and 2 IgM correlations with clinical manifestations of recurrent and non-recurrent type of genital herpes patients and other non-herpetic STD patients were studied. Results: The overall serum HSV-1 and 2 IgM in STD seroprevalence were 15.66%. Female has significant higher prevalence (P < 0.05). STD cases and HSV seroprevalence were specially concentrated in persons aged 21 to 30 years. Among those positive with HSV, the distribution of STD are wide spread and found in non-herpetic group at high frequency. Out of total 23 serum HSV-1 and 2 IgM positive, 12 and 11 are distributed in herpetic and non-herpetic STDs, respectively. Discussion and Conclusion: Though serum HSV-1 and 2 IgM in STDs are less diagnostic, they help to see the iceberg part of the infection among the population concerned in recent scenario or in another words, it provides recent infective burden