ECONOMIC EVALUATION

Economic evaluation of alternative hospital discharge policies of hernia



Economic evaluation of alternative hospital discharge policies of hernia

Introduction

There is little evidence to justify the widespread adoption of hospital at home on the basis of cost. A review of the subject identified only one randomised controlled trial that compared the cost of hospital at home with inpatient hospital care. This trial, based in the United States, recruited patients with a terminal illness and found no difference in overall healthcare costs. There is conflicting evidence from non-randomised studies.

We report the results of a prospective economic evaluation, in the context of a randomised controlled trial, of the cost of providing hospital at home as a substitute for some forms of inpatient hospital care(Adler, et al., 2007). The three questions addressed by the economic evaluation were

•Does substituting hospital at home care for hospital care result in a lower cost to the health service?

•Does hospital at home care, compared to hospital care, increase the cost to general practitioners?

•Does hospital at home care increase the cost borne by the patients and their families compared with hospital care?

Patients and Methods

Fast-track Endoscopy Unit (FTEU)

A specialized system for rapid endoscopy of inpatients was designed to perform triage procedures and enable quick discharge in low-risk patients at the University of Virginia. Procedures were performed by ward attending gastroenterologists and GI fellows with support staffing and portable equipment from the Digestive Health Endoscopy Center(Kemp, 2005). Physician and nursing charges were included in the billed costs for the procedure, and no extra room charges were included in the patients' hospital bills.

A vacant double patient room located on the inpatient ward, previously unused, was reserved for these procedures using the hospital's wall suction and oxygen supplies. All patients admitted on the previous night requiring endoscopic procedures were considered for the FTEU, Monday through Friday. As determined by the GI/Hepatology attending faculty on the day of the patient's admission, only patients that would be eligible for discharge on the same day as the procedure or would have considerable treatment plan changes if there were unexpected endoscopy findings underwent procedures in the FTEU(Gohgher, 2008).

Patients must have completed a rapid bowel lavage for colonoscopic procedures and be completely cleansed prior to 10 AM. The bowel lavage most often consisted of 1 gallon of polyethylene glycol (GoLYTELY) administered orally or via nasogastric tube when not tolerated orally.

Alternatively, unless contraindicated, oral phosphosoda (Fleets) was administered for bowel prep, at the discretion of the physicians caring for the patient after admission. Conscious sedation with midazolam and fentanyl as per institutional standards, unless contraindicated, was performed by the endoscopy center nurse at the bedside under direction of the attending and fellow physicians.

Patients requiring ERCP, fluoroscopy, PEG, stenting, argon plasma coagulation, general anesthesia, or advanced interventional procedures were not eligible for FTEU treatment(Cochrane, 2007). Patients with hemodynamic or respiratory compromise, ASA class IV or greater, or requiring ICU care for another reason were also ...