- Email: [email protected]
39 National Cost Savings from Observation Unit Management of Syncope
Research Forum Abstracts should consider patient position as a best practice strategy for airway management. Further long term out-of-hospital studies are warranted to evaluate airway management techniques, training regimens, and patient positions.
39
National Cost Savings from Observation Unit Management of Syncope
Baugh CW, Liang L-J, Sun BC/Brigham and Women’s Hospital, Boston, MA; David Geffen School of Medicine at UCLA, Los Angeles, CA; Oregon Health & Sciences University, Portland, OR
Study Objectives: Syncope is a common presenting emergency department complaint resulting in a disproportionate rate of subsequent hospitalization. Recent evidence suggests protocolized care in a dedicated observation unit is a cost effective alternative to inpatient care. We seek to estimate the annual national cost savings, reduction in inpatient hospitalizations, and reduction in hospital bed hours from widespread implementation of this management strategy. Methods: We conducted a Monte Carlo simulation by building a robust model that best reflects current clinical practice in the United States and uses inputs gathered from the most recent available peer-reviewed literature and national survey data (eg, the National Hospital Ambulatory Care Survey and National Emergency Department Sample). We adjusted for hospitals too small to likely operate a dedicated observation unit and the portion of observation visits requiring subsequent inpatient care. The key variables of cost savings and length of stay reduction per observation unit stay were informed by a recent multicenter randomized controlled study, which was the first to report cost data comparing observation to inpatient care for patients with syncope. Our study population was patients aged 50 and above with syncope deemed intermediate risk for serious 30-day cardiovascular outcomes. Results: We estimate that the average annual cost savings resulting from maximum use of a syncope protocol in a dedicated observation unit in appropriate patients is $169 million (SD $89 million). The average annual number of avoided inpatient admissions is 263,098 (SD 18,870) and the number of avoided hospital bed hours is 4,679,000 (SD 1,360,000). Conclusion: The potential national cost savings for managing selected patients with syncope in a dedicated observation unit is $169 million (SD $89 million). Syncope is one of many conditions suitable for care in an observation unit as an alternative to an inpatient setting. As pressure to decrease hospital length of stay and bill short-stay hospitalizations as observation increases, syncope illustrates the value of observation unit care, especially as health care in the United States moves towards capitated payments and hospitals must focus on cost reduction as their main tool to improve financial performance.
40
Detection and Evaluation of Major Bleeding in Atrial Fibrillation or Total Hip or Knee Replacement Patients Treated with Rivaroxaban
Tamayo S, Hopf K, Fields LE, Sarich T, Wu S, Yannicelli D, Yuan Z/Naval Medical Center Portsmouth, Portsmouth, VA; Health Research Tx, Trevose, PA; Janssen Scientific Affairs, LLC, Raritan, NJ; Janssen Research & Development, LLC, Raritan, NJ
Study Objective: Rivaroxaban is a novel direct factor Xa inhibitor that is approved for multiple indications in the US. As part of an FDA postmarketing safety requirement that was initially communicated for the indication of prophylaxis of deep venous thrombosis in patients following total hip (THR) or total knee replacement (TKR) surgery, this 5-year study was designed to evaluate major bleeding (MB) associated with the use of rivaroxaban for prophylaxis of deep venous thrombosis in THR and TKR and for the additional indication of the prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation (NVAF). Methods: The Department of Defense (DoD) electronic health care records were queried using the Cunningham Algorithm (a validated database method) to identify MB in rivaroxaban users in the NVAF and THR/TKR cohorts. Incidence rates of MB were examined. Descriptive statistics were used to evaluate patient characteristics including demographics, comorbidities, bleeding risk factors and concomitant medications as well as clinical outcomes and management of MB. Results: From January 1, 2013 to December 31, 2013 (first year of the study), 346/23,248 rivaroxaban patients in the NVAF cohort experienced MB, yielding an incidence rate of 2.83 [95% CI 2.55, 3.15] per 100 person-years. The average age of the MB patients was 78.6 years (SD¼7.3) versus 75.7 years (SD¼9.5) for non-bleeders with approximately 73% of MB patients 75 years of age; 52.4% were men, and 55.4% received blood transfusions. The most common bleeding site was
Volume 64, no. 4s : October 2014
gastrointestinal (89.4%, n¼321), followed by intracranial (7.2%, n¼26). Ten of the 346 patients died during hospitalization for MB at an average age of 84.7 years (SD¼5.4 years), yielding a fatal bleeding rate of 0.08 [95% CI 0.04, 0.15] per 100 person years in the entire cohort. Statins and proton pump inhibitors were the most frequently used concomitant medications of interest and the most frequent comorbid conditions of interest were hypertension followed by coronary heart disease. Two MB events were identified in the THR/TKR cohort (0.04%, n¼5,428). Conclusions: The MB incidence rate during this observational period appears generally consistent with the phase 3 results in the NVAF cohort in ROCKET AF (3.6/100 person years) and lower than expected in the THR/TKR cohort relative to the RECORD program (0.3%), although caution is due for any direct comparisons because of differences in study design, patient population, data collection and ascertainment methods. These initial findings will be supplemented over the next several years. Disclaimer: Research data derived from an approved Naval Medical Center, Portsmouth, VA IRB protocol. The views expressed in this abstract are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense or the United States Government. Dr. Sally Tamayo is a member of the U.S. Military. This work was prepared as part of her official duties. Title 17 U.S.C. 105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17 U.S.C. 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person’s official duties.
41
Early Mortality in Acute Heart Failure in Spanish Emergency Departments: An Analysis from the “Epidemiology of Acute Heart Failure in Emergency” Project
Ferre C, Jacob J, Llopis F, Bardes I, Corbella X, Salazar A/Bellvitge Universitary Hospital, L’Hospitalet de Llobregat, Spain
Study Objective: To identify the predicting variables of early mortality in patients with acute heart failure (AHF) presenting to the emergency department (ED). Methods: Design: The “Epidemiology of Acute Heart Failure in Emergency” project (EAHFE) is a non-interventional, multicentric and prospective study. Setting: ED of 34 Spanish hospitals. Period: A total of four months: May 2007, June 2009, and November to December 2012. Patients: All consecutive patients with AHF according to Framingham diagnostic criteria presenting to the ED. Data were collected for demographic variables, comorbidities, NYHA and Barthel functional classification, clinical signs and laboratory results, treatment in the ED and outcome. Early mortality (study group) was considered when occurring within 3 days from ED visit. Differences between variables were considered statistically significant for P values <0.05. Results: From a total of 5,845 patients with AHF presenting to the different ED during the study period, data regarding mortality was available in 5,555 cases and therefore included for analysis. Age on average was 79.3 (range 40-102) with female predominance (56.5%). 141 patients (2.5%) died within 3 days. In the univariate analysis age > 80 years, chronic renal failure, worse baseline functional status (Barthel < 60, NYHA III-IV), dementia, systolic blood pressure < 110, heart rate > 100, oxygen saturation < 90%, NT-proBNP > 5000 pg/mL, positive troponin and hyponatremia were significantly related to early mortality. Regarding treatment administered in the ED, patients in the study group needed more inotropic agents and non-invasive mechanical ventilation. In the multivariate analysis, variables still related to mortality within 3 days were: age > 80 y (OR 2.4; CI 95%: 1.3-4.3; P¼0.004), dementia (OR 1.8; CI 95% 1-3.2; P¼ 0.046), oxygen saturation < 90% (OR 4.1; CI 95% 2.5-6.7; P<0.001) and hyponatremia < 135 mmol/L (OR 1.9; CI 95% 1.2-3.3; P¼0.011). Conclusions: According to the results of our study, age above 80, dementia, low oxygen saturation, and hyponatremia may predict early mortality in patients with AHF presenting to the ED.
42
Predictors for Hospital Admission After Emergency Department Visits for Syncope
Baugh CW, Bernard KR, Sun BC, Ma J, Schuur JD/Brigham and Womens Hospital, Boston, MA; Brigham and Women’s Hospital, Boston, MA; Oregon Health & Sciences University, Portland, OR
Study Objectives: Outpatient management can be a safe alternative to hospital admission for selected patients with syncope. The patient and hospital characteristics
Annals of Emergency Medicine S15
39
National Cost Savings from Observation Unit Management of Syncope
Baugh CW, Liang L-J, Sun BC/Brigham and Women’s Hospital, Boston, MA; David Geffen School of Medicine at UCLA, Los Angeles, CA; Oregon Health & Sciences University, Portland, OR
Study Objectives: Syncope is a common presenting emergency department complaint resulting in a disproportionate rate of subsequent hospitalization. Recent evidence suggests protocolized care in a dedicated observation unit is a cost effective alternative to inpatient care. We seek to estimate the annual national cost savings, reduction in inpatient hospitalizations, and reduction in hospital bed hours from widespread implementation of this management strategy. Methods: We conducted a Monte Carlo simulation by building a robust model that best reflects current clinical practice in the United States and uses inputs gathered from the most recent available peer-reviewed literature and national survey data (eg, the National Hospital Ambulatory Care Survey and National Emergency Department Sample). We adjusted for hospitals too small to likely operate a dedicated observation unit and the portion of observation visits requiring subsequent inpatient care. The key variables of cost savings and length of stay reduction per observation unit stay were informed by a recent multicenter randomized controlled study, which was the first to report cost data comparing observation to inpatient care for patients with syncope. Our study population was patients aged 50 and above with syncope deemed intermediate risk for serious 30-day cardiovascular outcomes. Results: We estimate that the average annual cost savings resulting from maximum use of a syncope protocol in a dedicated observation unit in appropriate patients is $169 million (SD $89 million). The average annual number of avoided inpatient admissions is 263,098 (SD 18,870) and the number of avoided hospital bed hours is 4,679,000 (SD 1,360,000). Conclusion: The potential national cost savings for managing selected patients with syncope in a dedicated observation unit is $169 million (SD $89 million). Syncope is one of many conditions suitable for care in an observation unit as an alternative to an inpatient setting. As pressure to decrease hospital length of stay and bill short-stay hospitalizations as observation increases, syncope illustrates the value of observation unit care, especially as health care in the United States moves towards capitated payments and hospitals must focus on cost reduction as their main tool to improve financial performance.
40
Detection and Evaluation of Major Bleeding in Atrial Fibrillation or Total Hip or Knee Replacement Patients Treated with Rivaroxaban
Tamayo S, Hopf K, Fields LE, Sarich T, Wu S, Yannicelli D, Yuan Z/Naval Medical Center Portsmouth, Portsmouth, VA; Health Research Tx, Trevose, PA; Janssen Scientific Affairs, LLC, Raritan, NJ; Janssen Research & Development, LLC, Raritan, NJ
Study Objective: Rivaroxaban is a novel direct factor Xa inhibitor that is approved for multiple indications in the US. As part of an FDA postmarketing safety requirement that was initially communicated for the indication of prophylaxis of deep venous thrombosis in patients following total hip (THR) or total knee replacement (TKR) surgery, this 5-year study was designed to evaluate major bleeding (MB) associated with the use of rivaroxaban for prophylaxis of deep venous thrombosis in THR and TKR and for the additional indication of the prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation (NVAF). Methods: The Department of Defense (DoD) electronic health care records were queried using the Cunningham Algorithm (a validated database method) to identify MB in rivaroxaban users in the NVAF and THR/TKR cohorts. Incidence rates of MB were examined. Descriptive statistics were used to evaluate patient characteristics including demographics, comorbidities, bleeding risk factors and concomitant medications as well as clinical outcomes and management of MB. Results: From January 1, 2013 to December 31, 2013 (first year of the study), 346/23,248 rivaroxaban patients in the NVAF cohort experienced MB, yielding an incidence rate of 2.83 [95% CI 2.55, 3.15] per 100 person-years. The average age of the MB patients was 78.6 years (SD¼7.3) versus 75.7 years (SD¼9.5) for non-bleeders with approximately 73% of MB patients 75 years of age; 52.4% were men, and 55.4% received blood transfusions. The most common bleeding site was
Volume 64, no. 4s : October 2014
gastrointestinal (89.4%, n¼321), followed by intracranial (7.2%, n¼26). Ten of the 346 patients died during hospitalization for MB at an average age of 84.7 years (SD¼5.4 years), yielding a fatal bleeding rate of 0.08 [95% CI 0.04, 0.15] per 100 person years in the entire cohort. Statins and proton pump inhibitors were the most frequently used concomitant medications of interest and the most frequent comorbid conditions of interest were hypertension followed by coronary heart disease. Two MB events were identified in the THR/TKR cohort (0.04%, n¼5,428). Conclusions: The MB incidence rate during this observational period appears generally consistent with the phase 3 results in the NVAF cohort in ROCKET AF (3.6/100 person years) and lower than expected in the THR/TKR cohort relative to the RECORD program (0.3%), although caution is due for any direct comparisons because of differences in study design, patient population, data collection and ascertainment methods. These initial findings will be supplemented over the next several years. Disclaimer: Research data derived from an approved Naval Medical Center, Portsmouth, VA IRB protocol. The views expressed in this abstract are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense or the United States Government. Dr. Sally Tamayo is a member of the U.S. Military. This work was prepared as part of her official duties. Title 17 U.S.C. 105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17 U.S.C. 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person’s official duties.
41
Early Mortality in Acute Heart Failure in Spanish Emergency Departments: An Analysis from the “Epidemiology of Acute Heart Failure in Emergency” Project
Ferre C, Jacob J, Llopis F, Bardes I, Corbella X, Salazar A/Bellvitge Universitary Hospital, L’Hospitalet de Llobregat, Spain
Study Objective: To identify the predicting variables of early mortality in patients with acute heart failure (AHF) presenting to the emergency department (ED). Methods: Design: The “Epidemiology of Acute Heart Failure in Emergency” project (EAHFE) is a non-interventional, multicentric and prospective study. Setting: ED of 34 Spanish hospitals. Period: A total of four months: May 2007, June 2009, and November to December 2012. Patients: All consecutive patients with AHF according to Framingham diagnostic criteria presenting to the ED. Data were collected for demographic variables, comorbidities, NYHA and Barthel functional classification, clinical signs and laboratory results, treatment in the ED and outcome. Early mortality (study group) was considered when occurring within 3 days from ED visit. Differences between variables were considered statistically significant for P values <0.05. Results: From a total of 5,845 patients with AHF presenting to the different ED during the study period, data regarding mortality was available in 5,555 cases and therefore included for analysis. Age on average was 79.3 (range 40-102) with female predominance (56.5%). 141 patients (2.5%) died within 3 days. In the univariate analysis age > 80 years, chronic renal failure, worse baseline functional status (Barthel < 60, NYHA III-IV), dementia, systolic blood pressure < 110, heart rate > 100, oxygen saturation < 90%, NT-proBNP > 5000 pg/mL, positive troponin and hyponatremia were significantly related to early mortality. Regarding treatment administered in the ED, patients in the study group needed more inotropic agents and non-invasive mechanical ventilation. In the multivariate analysis, variables still related to mortality within 3 days were: age > 80 y (OR 2.4; CI 95%: 1.3-4.3; P¼0.004), dementia (OR 1.8; CI 95% 1-3.2; P¼ 0.046), oxygen saturation < 90% (OR 4.1; CI 95% 2.5-6.7; P<0.001) and hyponatremia < 135 mmol/L (OR 1.9; CI 95% 1.2-3.3; P¼0.011). Conclusions: According to the results of our study, age above 80, dementia, low oxygen saturation, and hyponatremia may predict early mortality in patients with AHF presenting to the ED.
42
Predictors for Hospital Admission After Emergency Department Visits for Syncope
Baugh CW, Bernard KR, Sun BC, Ma J, Schuur JD/Brigham and Womens Hospital, Boston, MA; Brigham and Women’s Hospital, Boston, MA; Oregon Health & Sciences University, Portland, OR
Study Objectives: Outpatient management can be a safe alternative to hospital admission for selected patients with syncope. The patient and hospital characteristics
Annals of Emergency Medicine S15