INTRODUCTION: Emergency laparotomy (EL) is associated with high morbidity and mortality, often exceeding 10%. This study evaluated the impact of the EMergency Laparotomy Audit (EMLA) interdisciplinary perioperative pathway on patient outcomes, hospital costs and length of stay (LOS) within a single centre. METHOD: A prospective cohort study was conducted from August 2020 to July 2023. The intervention team included specialist clinicians, hospital administrators and an in-hospital quality improvement team. Patients who underwent EL were divided into a pre-intervention control group (n=136) and a post-intervention group (n=293), and an 8-item bundle was implemented. Propensity scoring with a 1:1 matching method was utilised to reduce confounding and selection bias. The primary outcomes examined were LOS, hospitalis-ation costs and surgical morbidity, while secondary outcomes included 30-day mortality and adherence to the intervention protocol. RESULTS: The utilisation of the EMLA perioperative care bundle led to a significant reduction in surgical complications (34.8% to 20.6%, P<0.01), a decrease in LOS by 3.3 days (15.4 to 12.1 days, P=0.03) and lower hospitalisation costs (SGD 40,160 to 30,948, P=0.04). Compliance with key interventions also showed improvement. However, there was no difference in 30-day mortality. CONCLUSION This study offers insights on how surgical units can implement systemic perioperative changes to improve outcomes for patients undergoing emergency laparotomy.
Humans ; Laparotomy/methods* ; Propensity Score ; Female ; Male ; Prospective Studies ; Length of Stay/statistics & numerical data* ; Middle Aged ; Hospital Costs/statistics & numerical data* ; Postoperative Complications/epidemiology* ; Aged ; Emergencies ; Perioperative Care/methods* ; Critical Pathways ; Singapore ; Adult

OBJECTIVETo evaluate the effect of a clinical pathway for Crohn disease (CD) complicated with intestinal obstruction.

METHODSCD patients complicated with intestinal obstruction in Inflammatory Bowel Disease(IBD) Center of Jinling Hospital were enrolled. One hundred and nineteen CD patients from March 2014 to September 2015 received treatment with the clinical pathway (CP), which was developed based on medical evidence and experience of the IBD center in February 2014, as CP group. The other 108 CD patients from September 2012 to February 2014 received treatment according to the management strategy made by individual attending physician as non-CP group. Rate of operation, rate of stoma, morbidity of surgical complications, hospital stay, hospital cost, and 6-month unplanned re-admission were compared between two groups.

RESULTSThe baseline data were similar between the two group (all P > 0.05). No significant differences were noted between these the two groups in terms of rate of operation (73.9% vs. 77.8%, P = 0.605), rate of stoma (15.9% vs. 25.0%, P = 0.197), and morbidity of surgical complications (23.9% vs. 27.4%, P = 0.724). However, the mean postoperative hospital stay was shorter (10.9 d vs. 13.2 d, P = 0.000), the mean hospital cost was less (78 325 Yuan vs. 85 310 Yuan, P = 0.031) and the rate of 6-month unplanned re-admission was lower(3.4% vs. 11.1%, P = 0.035) in CP group.

CONCLUSIONTreatment based on this CP for CD patients complicated with intestinal obstruction can reduce the rate of 6-month unplanned re-admission, shorten the postoperative hospital stay and decrease the hospital cost in patients requiring surgery.

Critical Pathways ; Crohn Disease ; complications ; therapy ; Female ; Hospital Costs ; statistics & numerical data ; Humans ; Intestinal Obstruction ; complications ; therapy ; Intraoperative Complications ; epidemiology ; Length of Stay ; statistics & numerical data ; Male ; Patient Readmission ; statistics & numerical data ; Postoperative Complications ; epidemiology ; Surgical Stomas ; statistics & numerical data ; Treatment Outcome

OBJECTIVETo investigate the application of bundles of intervention in the treatment of esophageal carcinoma anastomotic leak.

METHODSFrom January 2014 to May 2015, 44 cases of esophageal carcinoma anastomotic fistula were treated by bundles of intervention (through the collection of a series of evidence-based treatment and care measures for the treatment of diseases) in Department of Thoracic Surgery, Huai'an First Hospital, Nanjing Medical University (bundles of intervention group), and 68 patients with esophageal carcinoma postoperative anastomotic leak from December 2013 to January 2012 receiving traditional therapy were selected as the control group. The clinical and nutritional indexes of both groups were compared.

RESULTSThere were no significant differences in general data and proportion of anastomotic leak between the two groups. Eleven patients died during hospital stay, including 3 cases in bundles of intervention group(6.8%) and 8 cases in control group (11.8%) without significant difference(P = 0.390). In bundles of intervention group, 1 case died of type III( intrathoracic anastomotic leak, 2 died of type IIII( intrathoracic anastomotic leak. In control group, 2 cases died of type III( cervical anastomotic leak, 2 died of type III( intrathoracic anastomotic leak and 4 of type IIII( intrathoracic anastomotic leak. The mortality of bundles of intervention group was lower than that of control group. The duration of moderate fever [(4.1±2.4) days vs. (8.3±4.4) days, t=6.171, P=0.001], the time of antibiotic use [(8.2±3.8) days vs.(12.8±5.2) days, t=5.134, P = 0.001], the healing time [(21.5±12.7) days vs.(32.2±15.8) days, t=3.610, P=0.001] were shorter, and the average hospitalization expenses[(63±12) thousand yuan vs. (74±19) thansand yuan, t=3.564, P=0.001] was lower in bundles of intervention group than those in control group. Forty-eight hours after occurrence of anastomotic leak, the levels of hemoglobin, albumin and prealbumin were similar in both groups. However, at the time of fistula healing, the levels of hemoglobin [(110.6±10.5) g/L vs.(103.8±11.1) g/L, t=3.090, P=0.002], albumin [(39.2±5.2) g/L vs.(36.3±5.9) g/L, t=2.543, P=0.013] and prealbumin [(129.3±61.9) g/L vs.(94.1±66.4) g/L, t=2.688, P=0.008] were significantly higher in bundles of intervention group.

CONCLUSIONIn the treatment of postoperative esophageal carcinoma anastomotic leak, application of bundles of intervention concept can significantly improve the nutritional status and improve the clinical outcomes.

Anastomotic Leak ; mortality ; therapy ; Anti-Infective Agents ; therapeutic use ; Carcinoma ; complications ; surgery ; Esophageal Fistula ; complications ; mortality ; therapy ; Esophageal Neoplasms ; complications ; surgery ; Esophagectomy ; adverse effects ; mortality ; Female ; Fever ; epidemiology ; etiology ; Hemoglobins ; metabolism ; Hospital Costs ; statistics & numerical data ; Humans ; Male ; Middle Aged ; Nutritional Status ; Patient Care Bundles ; mortality ; statistics & numerical data ; Prealbumin ; metabolism ; Serum Albumin ; metabolism ; Treatment Outcome

OBJECTIVES: This study aimed to test our hypothesis that a raise in the emergency fee implemented on March 1, 2013 has increased the proportion of patients with emergent symptoms by discouraging non-urgent emergency department visits. METHODS: We conducted an analysis of 728 736 patients registered in the National Emergency Department Information System who visited level 1 and level 2 emergency medical institutes in the two-month time period from February 1, 2013, one month before the raise in the emergency fee, to March 31, 2013, one month after the raise. A difference-in-difference method was used to estimate the net effects of a raise in the emergency fee on the probability that an emergency visit is for urgent conditions. RESULTS: The percentage of emergency department visits in urgent or equivalent patients increased by 2.4% points, from 74.2% before to 76.6% after the policy implementation. In a group of patients transferred using public transport or ambulance, who were assumed to be least conscious of cost, the change in the proportion of urgent patients was not statistically significant. On the other hand, the probability that a group of patients directly presenting to the emergency department by private transport, assumed to be most conscious of cost, showed a 2.4% point increase in urgent conditions (p<0.001). This trend appeared to be consistent across the level 1 and level 2 emergency medical institutes. CONCLUSIONS: A raise in the emergency fee implemented on March 1, 2013 increased the proportion of urgent patients in the total emergency visits by reducing emergency department visits by non-urgent patients.
Adult ; Ambulances ; Direct Service Costs ; Emergency Service, Hospital/*economics/*statistics & numerical data ; *Fees and Charges ; Female ; Humans ; Male ; Middle Aged ; Regression Analysis ; Time Factors

This study aims to estimate the volume of unnecessarily utilized hospital outpatient services in Korea and quantify the total cost resulting from the inappropriate utilization. The analysis included a sample of 27,320,505 outpatient claims from the 2009 National Inpatient Sample database. Using the Charlson Comorbidity Index (CCI), patients were considered to have received 'unnecessary hospital outpatient utilization' if they had a CCI score of 0 and were concurrently admitted to hospital for treatment of a single chronic disease - hypertension (HTN), diabetes mellitus (DM), or hyperlipidemia (HL) - without complication. Overall, 85% of patients received unnecessary hospital services. Also hospitals were taking away 18.7% of HTN patients, 18.6% of DM and 31.6% of HL from clinics. Healthcare expenditures from unnecessary hospital outpatient utilization were estimated at: HTN (94,058 thousands USD, 38.6% of total expenditure); DM (17,795 thousands USD, 40.6%) and HL (62,876 thousands USD, 49.1%). If 100% of patients who received unnecessary hospital outpatient services were redirected to clinics, the estimated savings would be 104,226 thousands USD. This research proves that approximately 85% of hospital outpatient utilizations are unnecessary and that a significant amount of money is wasted on unnecessary healthcare services; thus burdening the National Health Insurance Service (NHIS) and patients.
Chronic Disease/*economics/*epidemiology/therapy ; Comorbidity ; Delivery of Health Care/economics/utilization ; Health Care Costs/*statistics & numerical data ; Humans ; Outpatient Clinics, Hospital/*economics/*utilization ; Patient Admission/economics/statistics & numerical data ; Prevalence ; Republic of Korea/epidemiology ; Unnecessary Procedures/*economics/*utilization ; Utilization Review

PURPOSE: Under the proper program, day-case laparoscopic cholecystectomy is feasible in the aspect of postoperative recovery consisting of patient's satisfaction and postoperative complication. In this study, we plan a new protocol for laparoscopic cholecystectomy by analyzing factors that can reduce hospital days. METHODS: A total of 175 patients who underwent three-day laparoscopic cholecystectomy were initially selected. Out of 175 patients, secondary selection was executed using inclusion criteria. The selected patients were scheduled for new two-day laparoscopic cholecystectomy, and 89 patients were included in the data analysis. This study elucidated the comparative analysis between the discharged in the postoperative day 0 group and the postoperative day 1 group. RESULTS: The clinical characteristics were not significantly different between discharged in the postoperative day 0 group and the postoperative day 1 group. The combined diseases were not significantly different between the two groups. Post-operative complications in both groups were analyzed on the seventh day after the operation. No significant difference was observed between the two groups. Members of the patient group who were discharged on postoperative day 0 were given a survey regarding post-operative pain, desirability of discharge, and the level of satisfaction with patient education. The average score was 8.3 out of 10 points. In comparison of the total hospital cost between the two groups, the group discharged on postoperative day 0 had lower cost in all factors. CONCLUSION: We conclude that day-case laparoscopic cholecystectomy is as safe and effective as routine clinical pathway applied laparoscopic cholecystectomy in stable cardiovascular disease, uncomplicated pulmonary disease, and controlled DM patients.
Cardiovascular Diseases ; Cholecystectomy, Laparoscopic* ; Critical Pathways ; Hospital Costs ; Humans ; Lung Diseases ; Patient Education as Topic ; Postoperative Complications ; Statistics as Topic

INTRODUCTIONIn end-stage heart failure (HF) that is not eligible for mechanical assist device or heart transplant, palliative care serves to maximise symptom control and quality of life. We sought to evaluate the impact of home-based advance care programme (ACP) on healthcare utilisation in end-stage HF patients.

MATERIALS AND METHODSProspectively collected registry data on all end-stage HF recruited into ACP between July 2008 and July 2010 were analysed. Chart reviews were conducted on HF database and hospital electronic records. Phone interview and home visit details by ACP team were extracted to complete data entry. HF and all-cause hospitalisations 1 year before, and any time after ACP inception were defined as events. For the latter analysis, follow-up duration adjustment to event episodes was performed to account for death less than a year.

RESULTSForty-four patients (mean age 79 years, 39% men) were followed up for 15±8 months. Fifty-seven percent had diabetes, 80% ischaemic heart disease, and 60% chronic kidney disease. All reported functional class III/IV at enrolment. Mean serum sodium was 136±6 mmol/L, and creatinine 186±126 mmol/L. Thirty (68%) died within the programme. Mean time to death was 5.5 months. Mean all-cause and HF hospitalisations were 3.6 and 2.0 per patient before enrolment, but improved to 1.0 and 0.6 respectively after ACP. Thirty-six (71%) patients had fewer HF hospitalisations. When only those who survived more than a year were considered (n = 14), 10 (71%) and 9 (64%) experienced reduced HF (mean: 1.4 episodes per patient) and all-cause hospitalisations (mean: 2.2 episodes per patient) respectively.

CONCLUSIONHome-based advance care programme is potentially effective in reducing healthcare utilisation of end-stage HF patients, primarily by reducing HF rehospitalisations, and in probably saving costs as well.

Aged ; Aged, 80 and over ; Diabetes Mellitus ; Female ; Health Care Costs ; Health Services ; economics ; utilization ; Heart Failure ; complications ; economics ; therapy ; Home Care Services, Hospital-Based ; economics ; Hospitalization ; economics ; statistics & numerical data ; Humans ; Male ; Myocardial Ischemia ; complications ; Palliative Care ; economics ; methods ; Prospective Studies ; Registries ; Renal Insufficiency, Chronic ; complications ; Tertiary Care Centers

INTRODUCTIONHip fractures in the elderly are associated with multiple comorbidities.

MATERIALS AND METHODSWe prospectively surveyed and went through all relevant medical records of 70 consecutive patients admitted to Singapore General Hospital following either a cervical or intertrochanteric femoral fracture from late February to May 2004. The total hospitalisation cost for each patient was calculated based on the costs of inpatient care up to the point of discharge. Regression modeling was performed on the 7 commonest age-related conditions (based on our data), to determine the impact of each comorbidity on total costs.

RESULTSThe average age of the cohort was 77.24 years. The median length of stay was 13.6 days. In patients without comorbidities, the mean hospitalisation cost was S$9,347.5 +/- 1719.6. With the presence of comorbidities, the mean cost increased to S$11,502.3 +/- 6024.3. In univariate modeling, dementia added the largest amount to total costs [S$5,398; 95% confidence interval (CI), S$1273 to S$9523; P <0.05]. The presence of diabetes (S$758; 95% CI, S$2,051 to S$3,566), hypertension (S$644; 95% CI, S$1,986 to S$3,274) and osteoarthritis (S$915; 95% CI, S$3,721 to S$1,891) did not significantly add to total costs. When controlled for multiple comorbidities, dementia retained its significance in adding to total costs (S$6,178; 95% CI, S$1,795 to S$10,562; P = 0.006).

CONCLUSION AND DISCUSSIONHip fracture patients with comorbidities incurred higher hospitalisation costs. Cost-containment strategies in hip fracture patients should not only examine the number of comorbidities but also the type of disease.

Aged ; Comorbidity ; Confidence Intervals ; Female ; Follow-Up Studies ; Hip Fractures ; economics ; epidemiology ; Hospital Costs ; statistics & numerical data ; Hospitalization ; economics ; Humans ; Male ; Prospective Studies ; Singapore ; epidemiology