Effect of Solvent Drag

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definitive diagnosis and bleeding may occur during the procedure. definitive diagnosis and bleeding may occur during the procedure. Only farther experience will the precise precise role biopsy in will define de&ne the role ofofbiopsy In the the Only further experience evaluation of suspected suspected Kaposi’s sarcoma involving the tratraKaposi's sarcoma involving the evaluation of cheobronchial tree. cheobronchial tree. Kam-Yung M.D.; Janet Av, M.D.; Kam-Yung Lau, Lau, M.D.;}anet Av, M.D.; Alan Rubin, M.D.; Michael Littner, M.D., FC.C.P; Alan Rubin, M.D.; Michael UHner, M.D., F.C.C.P.;

and Marcel KrautIatJmmer, Krauthaminer, M.D., FC.C.P.; and Marcel M.D., F.C.C.P.; Veterans Administration Medical Center, VetmJns AtlmiraimrJcion Medical Center, Sepulveda, Sepulo«la,

and UCLA School School of Medicine, and the the UCLA oj'MedidRIJ, Los Angeles LoIAngelu

To the Editor: To the EdUor:

Although of Kaposi's Kaposi’s sarcoma sarcoma of the tracheobronchial tracheobronchial ofthe Although the the diagnosis diagnosis of tree can sometimes sometimes be made histologically histologically by biopsy at at &beroptic fiberoptic tree can be made by biopsy

bronchoscopic in the the setting setting of the acquired acquired immune bronchoscopic examination eumlnation In of the immune deficiency syndrome, these tracheobronchial tracheobronchial de&ciency syndrome, we we feel feel that that biopsy biopsy of of these lesions is usually usually unnecessary; the diagnosis Kaposi’s unnecessary; the diagnosis of of widespread widespread Kaposi! lesions is sarcoma is frequently frequently already histologically (ie, by or sarcomais already established established histologically (fe, by skin skin or lymph node biopsy). The tracheal tracheal and bronchial bronchial lesions are are highly highly biopsy). The and lesions lymph node characteristic in appearance and may bleed bleed when when biopsied. biopsied. characteristic In appearance and they they may Further, the diagnostic diagnostic yield ofbiopsy of biopsy samples may be Further, the yield samples may be low. low. We now perfimned peribrmed fiberoptic bronchoscopic examination on We have have now &beroptic bronchoscopic examination on nine who bad had endobronchial lesions which endobronchial and/or and/or tracheal tracheal lesions which nine patients patients who appeared characteristic of Kaposi! Kaposi’s sarcoma sarcoma (ie, brightly brightly red to to appeared characteristic of (fe, red violaceous vascular lesions). As In in the the case case reported reported by Lau and lesions). As by Lau and violaceous vascular colleagues, all nine patients had Kaposi! Kaposi’s sarcoma sarcoma extensively extensively involvcolleagues, all nine patients bad involving the the skin, skin, proven biopsy prior to the the fiberoptic bronchoscopic ing proven by by biopsy prior to &beroptic bronchoscopic examinations examinations (which (which were were performed pertOnned to to diagnose diagnose unexplained unexplained pulpulmonary infiltrates). The diagnosis of Kaposi! Kaposis sarcoma monary in<rates). The diagnosis of sarcoma ofof the the tratracheobronchial tree from bronchial samples in in only only cheobronchial tree was was made made from bronchial biopsy biopsy samples one of these these nine nine patients, patients, but confirmed at autopsy autopsy one (11 (11 percent) percent) of but was con&nned at in additional five patients. Three (33 percent) percent) of of the the nine patients in an an additional ave patients. Three (33 nine patients had self-limited 20 to to 50 ml mucosal mucosal bleeds following the the bronchial bad self-limited 20 50 ml bleeds fOllowing bronchial

was

biopsy procedure. biopsy procedure.

Arthur E. Pitchenik, PUchenilc, M.D., F.C.C.P.; ArthurE. M.D., F.C.C.P; Margaret A. Fischl, M.D.; and MargtJret A FUchl, M.D.; and Mariof Mario

of

Saldana, M.D., J. StJlclana, M.D.,

University Florida Univerlity of Miami, Mi4mi, Miami, Mi4mi, FloriJa

Costs Costs In in the the leu ICU To the To the Editor: EdUor:

In the the recent recent study, Butler et et al al (Chut (Chest 1985; 1985; 82:229-33) 82:229-33) evaluated evaluated In study, Butler the care to to seriously seriously ill the relative relative profitability pro&tability of of providing providing critical critical care ilII elderly patients in relation relation to cost cost and and reimbursement reimbursement under the elderly patients in to under the present system adopted adopted by Based on on their present DRG DRG payment payment system by Medicare. Medicare. Based their finding of of aa 4.7 4.7 million revenue loss 446 patients, the &nding million dollar dollar revenue loss treating treating 446 patients, the authors that "this “this should send a a clear clear message message to to hospitals hospitals authors concluded concluded that should send concerning the care to these these patients.” are concerned concerned about concerning the care given given to patients." We We are about the potential negative impact impact on on health health care care fOr for the the elderly elderly resultiog resulting the potential negative from aa study study such such as as this. this. With this in in mind, mind, we to note note the the from With this we would would like like to following significant omissions from of cost fOllowing significant omissions from their their analysis analysis of cost data. data. The study to to detennine determine costs were not wellThe methods methods used used inin this this study costs were not wellplanned. The cost cost generated generated by these these 446 446 patients million, patients was was $11.1 $11.1 million, planned. The by or $1,200 per $50 per for every every hour hour the the patients or $1,200 per day, day, $50 per hour hour fOr patients were were in In the ICU and The authors authors stated that costs the hospital, hospital, ICU and non-ICU. non-ICU. The stated that costs were were calculated by multiplying multiplying patient charges by cost-to-charge cost-to-charge calculated by patient billed billed charges by ratios. This method represents the accounting accounting ratios. This method of of determining determining costs costs represents the cost fur the the patient and not not the the true cost of of providing providing care cost fOr patient and true economic economic cost care to these these patients.’ If the authors’ purpose purpose was to to determine determine how to patients. I If the authors' was how many more more dollars dollars were were spent spent on on the the use use of of intensive care over over many Intensive care routine care, economic been more more appropriate. appropriate.’ routine care, economic costs costs would would have have been I

Instead, the authors, authors, concerned with break-even and/or profitability Instead, the concerned with break-even and/or pro&tability of patient chose to accounting cost, which may of patient care, care, chose to use use accounting cost, aa process process which may grossly distort economic costs. In In so so doing, they were grossly distort true true economic costs. doing, they were able able toto avoid investigating investigating the true costs costs of these patients avoid the true of these patients to to the the health health care care facility. Had these these been determined, the authors have comcomfacility. Had been determined, the authors could could have pared them them to to the of providing to these these patients under pared the exact exact cost cost of providing care care to patients under an alternative alternative system of care. By this this method, method, the authors would By the authors would an system of care. have fOund fuund the difference’ l of of the patients to the health health have the marginal marginal cost cost clifJerence the patients to the care facility, facility, thereby the economic economic efficiency, rather than thereby measuring measuring the efficiency, rather than care profitability, of not not providing fur medicare medicare patients. pro&tability, of providing intensive intensive care care fOr patients. Having chosen chosen to examine only accounting accounting costs, with Having to examine only costs, with aa resultant resultant four-million dollar loss loss to the health health care care facility, the authors then fOur-million dollar to the facility, the authors then suggest that that a a "responsible “responsible management response” to this this loss loss might management response" to might suggest require the the reduction reduction or elimination of health care care fOr for these patients. require or elimination ofhealth these patients. Whether or not this this is is a a viable viable alternative, one would have have to to assume assume alternative, one would Whether or not that care care fur these patients would be non-critical care that fOr these patients would be provided provided in in non-critical care areas. Would Would the fact, realize realize any savings? areas. the institution, institution, in in fact, any savings? Resources consumed by patients would remain remain almost ununResources consumed by the the patients would almost changed, merely transferred to different cost cost center where a a higher higher changed, merely transferred to aa different center where volume of patients patients would be costs. At volume of would be reflected reflected inin lower lower accounting accounting costs. At the same same time, not subject subject to DRG reimbursethe time, unless unless new new patients patients not to DRG reimbursement structure to replace in the the Intensive Intensive Care ment structure were were to replace these these patients patients in Care Unit, the &xed fixed costs of the the Intensive Intensive Care Unit Unit would remain costs of Care would remain Unit, the unchanged. The hospital still has fur the the space, space, as well as as has toto pay pay fOr as well unchanged. The hospital still maintenance of high technology. technology. Labor costs of the the Intensive Intensive maintenance of the the high Labor costs of Care Unit would not not change. change. Presumably, the hospital would Care Unit would Presumably, the hospital would increase billing to the non-DRG patients maintain profitability. increase billing to the non-DRG patients toto maintain pro&tability. Furthermore, the authors authors chose chose to to increase increase all all costs costs by by 16 16 percent percent Furthermore, the to reftect reflect "estimated “estimated increases in discharge between 1983 to increases in cost cost per per discharge between 1983 and 1985': 1985’ Once again, we we are are not not provided with adequate and Once again, provided with adequate justificajusti&cation. Theoretically, Theoretically, as we become more familiar familiar with with our our technology, technology, tion. as we become more the cost cost of of technology should drop. has certainly certainly drop. This This has the technology application application should been true in In areas areas such dialysis and cardiac bypass, bypass, where where been true such as as renal renal dialysis and cardiac the cost patient has decreased significantly since their introducthe cost per per patient has decreased signi&cantly since their introduction, Without Without major breakthroughs breakthroughs in intensive care technology, tion. major In intensive care technology, itit isis difficult to comprehend comprehend an increase increase of approximately approximately $4,000 difficult to an of $4,000 per per patient in two A more detailed analysis of of the inflation factor factor two years. years. A more detailed analysis the inftation patient in would in holding holding down down costs. costs. would help help the the industry Industry In Finally, one must must examine examine the ethical ethical issues involved. In an Finally, one the issues involved. In an accompanying (Chest 1985; 1985; 82:141), implies that that accompanying editorial editorial (Chut 82:141), Weinberg Weinberg implies huge amounts of money money are spent futilely on the the terminally huge amounts of are spent futilely on tenninally ill ill and and patients who cannot well. Yet, Yet, in in practice, clinicians are often patients who cannot get get well. practice, clinicians are often faced utilizing high high technology in situations situations where an an elderly elderly faced with with utilizing technology in where patient’s outcome remains remains uncertain. Despite extensive extensive work during work during patient's outcome uncertain. Despite the ten years, years, early predictive indices of of patient outcome remain early predictive indices patient outcome remain the past past ten unreliable. An error error factor of even even 5 5 percent, percent, when applied applied to factor of when to 446 446 unreliable. An patients, would result in an erroneous erroneous prediction in 25 or patients, would result In an prediction in 25 patients, patients, or more than two weeks. weeks. Since there is more than one one patient patient every every two Since there is aa significant signi&cant potential for negative negative outcome, ie, preventable morbidity or morpotential fOr outcome, fe, preventable morbidity or mo~ tality, are we we justified restricting care on the the basis tality, are justi&ed in In restricting care on basis of of uncertain uncertain financial considerations? considerations? &nancial We agree agree with The Presidents Commission on Life Life Support Support that it it We with The Presidents Commission on that would desirable to cut cut costs costs in areas where where outcome is would be be more more desirable to In areas outcome is unlikely to be be aft'ected, affected, rather than discontinue discontinue intensive care unlikely to rather than intensive care services fOr for the the elderly and severely services elderly and severely ill ill patients.2 patients. I B. Mamdani, M.D., Franklin, M.D.; K. WIriu, Weiss, M.D.; B. Mtamtlanl, M.D.; C. C. FrankUn, M.D.; K. M.D.;

and C. Burke, M.D., Cook County and C. Burke, M.D., Cook County Hospital, H08pitIIl, Chicago Chicago REFERENCES REFERENCES 1 Finkler Finlder SA. SA. The The distinction distinction between cost and and charges. Ann Intern 1 between cost charges. Ann Intern

Med 1982; 1982; 96:102-09 96:102-09 Med Deciding to sustaining treatment: on the 22 Deciding to furego fOrego life life sustaining lPeatment: aa report report on the ethical, medical and in treatment decisions. Publicaethical, medical and legal legal issues issues in treatment decisions. Publication No. No. 0-402-884. Washington, DC: Government Printing Office Office tion 0402-884. Washington, DC: Government Printing 1983; 95-100 95-100 1983;

CHEST /I 88 89 1 I/ JANUARY, JANUARY. 1986 CHEST I/ 1 1888

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