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JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS 1999年第1期189卷 11-20页

作者： Villavicencio, RT Aucar, JA Univ Pittsburgh Dept Surg Pittsburgh PA 15261 USA Baylor Coll Med Dept Surg Houston TX 77030 USA Ben Taub Gen Hosp Houston TX 77030 USA

Background: The optimum roles for laparoscopy in trauma have yet to be established. To date, reviews of laparoscopy in trauma have been primarily descriptive rather than analytic. This article analyzes the results of laparoscopy in trauma. Study Design: Outcome analysis was done by reviewing 37 studies with more than 1,900 trauma patients, and laparoscopy was analyzed as a screening, diagnostic, or therapeutic tool. Laparoscopy was regarded as a screening tool if it was used to detect or exclude a positive finding (eg, hemoperitoneum, organ injury, gastrointestinal spillage, peritoneal penetration) that required operative exploration or repair. Laparoscopy was regarded as a diagnostic tool when it was used to identify all injuries, rather than as a screening tool to identify the first indication for a laparotomy. It was regarded as a diagnostic tool only in studies that mandated a laparotomy (gold standard) after laparoscopy to confirm the diagnostic accuracy of laparoscopic findings. Costs and charges for using laparoscopy in trauma were analyzed when feasible. Results: As a screening tool, laparoscopy missed 1% of injuries and helped prevent 63% of patients from having a trauma laparotomy. When used as a diagnostic tool, laparoscopy had a 41% to 77% missed injury rate per patient. Overall, laparoscopy carried a 1% procedure-related complication rate. Cost-effectiveness has not been uniformly proved in studies comparing laparoscopy and laparotomy. Conclusions: Laparoscopy has been applied safely and effectively as a screening tool in stable patients with acute trauma. Because of the large number of missed injuries when used as a diagnostic tool, its value in this context is limited. Laparoscopy has been reported infrequently as a therapeutic tool in selected patients, and its use in this context requires further study. (J Am Cell Surg 1999;189:11-20. (C) 1999 by the American College of Surgeons).

关键词：结果评价(卫生保健)/统计学和数值数据前瞻性研究回顾性研究创伤和损伤/诊断创伤和损伤/经济学

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Cost savings associated with changes in routine laboratory tests ordered for victims of trauma

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AMERICAN SURGEON 2000年第6期66卷 579-584页

作者： Jacobs, IA Kelly, K Valenziano, C Chevinsky, AH Pawar, J Jones, C Morristown Mem Hosp Dept Surg Div Trauma Surg Morristown NJ 07962 USA

Not all trauma victims evaluated by the trauma service require a full complement of laboratory tests upon admission. This study set out to determine the cost savings and safety of limited laboratory testing of trauma victims. Before 1998, our admission trauma protocol included 11 laboratory tests for all trauma victims. In 1998, we created two categories: Trauma Blue--severe injury likely (Glasgow Coma Score <13;systolic blood pressure <100 mm Hg at any time;significant head, chest, abdominal, or proximal long bone injury;or clinical suspicion of need for operative or intensive care unit management) and Trauma Yellow--severe injury unlikely. The triage decision was made by the team leader or attending physician. Trauma Blue laboratory tests included an arterial blood gas, blood alcohol, type and screen or crossmatch, and urine dipstick. All patients who did not meet Trauma Blue criteria were entered in the Trauma Yellow group. There were only two tests for the Trauma Yellow group, a venous blood gas and blood alcohol. All arterial and venous blood gases measured pH, pO(2), pCO(2,) HCO3, base deficit, hemoglobin, sodium, potassium, and ionized calcium. Other laboratory tests were done if requested by the trauma team leader or attending physician. All trauma admissions for a S-month period were entered into this prospective study. The admitting trauma surgeon was surveyed after each admission to evaluate any problems in patient care. The test group was compared with a historical control of 100 consecutive patients under the original laboratory trauma protocol. One hundred and forty-eight (148) patients were entered into the study. Average laboratory cost per patient was $29.82 less with the study protocol. No patient care problem was identified. A cost savings of $29.82 per patient or $20,000.00 a year was realized for our institution, with no change in the quality of patient care. Trauma protocols designed to reflect a patient's potential for serious injury can resul

关键词：临床方案费用节省/统计学和数值数据诊断试验常规/经济学诊断试验常规/利用新泽西创伤诊治中心/经济学创伤严重度指数伤病员分拣/经济学伤病员分拣/方法美国创伤和损伤/分类创伤和损伤/经济学人类

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Trauma services: A profit center?

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JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS 1999年第4期188卷 349-354页

作者： Taheri, PA Butz, DA Watts, CM Griffes, LC Greenfield, LJ Univ Michigan Med Ctr Div Trauma Burn & Emergency Surg Dept Surg Ann Arbor MI 48109 USA Univ Michigan Dept Pulm Med Ann Arbor MI 48109 USA Univ Michigan Sch Business Div Business Econ Ann Arbor MI 48109 USA Univ Michigan Hosp Hosp Finance Ann Arbor MI 48109 USA

Background: Previous studies have demonstrated inadequate reimbursement for severely injured patients with a resultant negative economic impact for the trauma service and hospital. The purpose of this study was to assess the total cost of care for all injured patients discharged from the trauma service in fiscal year 1997, and to determine the proportion of costs for the most severely injured on total cost. In addition, we assessed the total service costs and the revenue for treatment of the most severely ill. The final result nas the determination of the profit (loss) margin for the entire service. Study Design: All patients discharged from our Level I Trauma Center in fiscal year 1997 were included (n = 696). The population was then stratified into 2 subgroups using the Injury Severity Score (ISS). Patient grouping was facilitated by integration of the trauma registry with the hospital cost accounting system. The population was sub-divided into 2 distinct groups. Group A represented all patients with an ISS > 15 (n = 192). Group B contained all patients with an ISS < 15 (n = 504). Length of stay and mortality of each group was recorded. Cost of care was determined by the hospital cost accounting system TSI (Transition System Incorporated, Boston, MA), which is designed to generate cost center data on a cost per patient basis. Total costs were determined for the entire population and Groups A and B. The proportion of costs consumed by each group was then calculated. Reimbursement was determined by calculating expected payments for each patient. These calculations are based on previously agreed upon allowances from each insurer and are reconciled at the end of each fiscal year to ensure accuracy. Results: The average length of stay for the population and Groups A and B were 7.5, 9.8, and 6.7 days respectively. Mortality in each group was 9.7%, 19.3%, and 6%. Over 92% of the population sustained blunt mechanism injury and only 8% were penetrating. When controlled for

关键词：费用分配诊断相关患者组/分类诊断相关患者组/经济学医院费用/统计学和数值数据医院大学/经济学损伤严重度评分保险住院密执安创伤诊治中心/经济学美国创伤和损伤/分类创伤和损伤/经济学人类

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Injuries in Pakistan: directions for future health policy

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HEALTH POLICY AND PLANNING 1999年第1期14卷 11-17页

作者： Ghaffar, A Hyder, AA Mastoor, MI Shaikh, I Johns Hopkins Univ Sch Hyg & Publ Hlth Div Hlth Syst Baltimore MD 21205 USA Hlth Serv Acad Islamabad Pakistan Washington Hosp Ctr Washington DC 20010 USA Bur Hlth Chester PA USA

Injuries result in major financial and productivity losses to nations while inflicting tremendous personal burden on the injured and their families. Two-thirds of the global deaths from injuries occur in the developing world, consuming substantial health sector resources. Pakistan is a developing country with a population of 136 million and no reported estimate of the national impact of injuries. This study presents a profile of injuries in Pakistan, estimates the impact on the country and recommends strategies to further delineate this important public health problem. A methodical review of published, unpublished and government literature was undertaken and data collected for all types of injuries principally over the 1982-1994 period. Motor vehicle injuries, homicides, assaults, work-related injuries, poisonings and risk factors have been included. Selected epidemiological estimates have been generated and the WHO motorization index has been used to assess road-side accident risk. The lack of reliable data and under-reporting of work-related injuries is revealing. The rising time trend in all injuries, the significant loss of life from injuries and the age of those injured have a critical impact on the national economy and health system. Data on injuries in Pakistan are primarily recorded by police authorities and used for legal purposes. Pakistan must institute an information system to evaluate the true impact of injuries and develop national safety standards. Implementation of such standards is especially important for road traffic safety and occupational health in industrial units within the country.

关键词：事故交通数据收集发展中国家卫生政策杀人职业病/流行病学巴基斯坦/流行病学危险因素暴力创伤和损伤/经济学创伤和损伤/流行病学创伤和损伤/死亡率人类

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Development and implementation of clinical pathways for the management of four trauma diagnoses.

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Journal for healthcare quality : official publication of the National Association for Healthcare Quality 1999年第3期21.0卷 4-11;quiz11页

作者： Waters, J.B. Wolff, R.S. Blansfield, J. LaMorte, W.W. Millham, F.H. Hirsch, E.F. Carolinas Medical Center Charlotte NC United States

Clinical pathways are similar to the production algorithms developed by industry. They are being adapted for use in healthcare to reduce resource utilization, decrease variability, and control expenditures. At Boston Medical Center we identified four trauma diagnoses that we believed to be amenable to the design and implementation of clinical pathways: closed head injury, penetrating wound to the abdomen, penetrating wound to the chest, and penetrating wound to an extremity. Upon implementation of these pathways, appropriate nonoperative, single-system, short-stay trauma patients were enrolled in them. This article details the process by which the four diagnoses were identified and the pathways designed, implemented, and evaluated. Preliminary data demonstrate a significant decrease in resource utilization following implementation of the pathways, without an adverse impact on readmission rates, length of stay, or mortality.

关键词：算法波士顿颅脑损伤/治疗临床路径教育继续表格和记录管理医院收费住院时间试点项目过程评价(卫生保健) 创伤诊治中心/经济学创伤诊治中心/标准创伤和损伤/经济学创伤和损伤/病理生理学创伤和损伤/治疗创伤贯通性/治疗人类

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What's half a lung worth? Civil jurors' accounts of their award decision making

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LAW AND HUMAN BEHAVIOR 2000年第4期24卷 401-419页

作者： Mott, NL Hans, VP Simpson, L Univ Delaware Dept Sociol & Criminal Justice Newark DE 19716 USA

Jury awards are often criticized as being arbitrary and excessive. This paper speaks to that controversy reporting data from interviews with civil jurors' accounts of the strategies that juries use anti the factors that they consider in arriving at a collective award. Jurors reported difficulty in deciding on awards, describing it as "the hardest part" of jury service and were surprised the court did not provide more guidance to them. Relatively few jurors entered the jury deliberation room with a specific award figure in mind. Once in the deliberation room, however they reported discussing a variety of relevant factors such as the seriousness of the injury, the plaintiff's age, and occasionally even more esoteric items such as the impact of inflation. Two frequent topics of discussion, attorneys' fees and insurance, suggest that jurors attempt to estimate the actual impact of an award on both defendant and plaintiff This descriptive account may help to inform the debate about whether jurors require additional guidance or information in the award process.

关键词：加利福尼亚判断责任法律/经济学医疗事故/经济学社会正义美国创伤和损伤/经济学女(雌)性人类男(雄)性

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Expenditures for Unintentional Injuries among the Elderly

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Journal of Aging and Health 1990年第2期2卷 157-178页

作者： Bernstein, Amy B. Schur, Claudia L. National Cancer Institute United States National Center for Health Services Research United States

This article presents national estimates of the probability of having an unintentional injury, the types of medical care associated with unintentional injuries, and the costs of unintentional injuries that occurred in calender year 1977 for persons aged 65 and older. Data come from the 1977 National Medical Care Expenditure Survey (NMCES) and the 1977 National Nursing Home Survey (NNHS). Among persons aged 65 and older, we found differences in the probability of having an unintentional injury by age, sex, and living arrangement, which suggests that unintentional injuries are not “accidental,” or random, events. Our estimates indicate that total medical care expenditures for unintentional injuries for the elderly population in 1977 may have been over $2 billion. Using simple adjustments, we also estimated that the amount expended on injury-related medical care in 1984 might have been as high as $5 billion. Given the large amount of monetary, and presumably nonmonetary, costs associated with unintentional injuries, programs designed to reduce such injuries may well pay off in a cost-benefit or cost-effectiveness framework. © 1990, Sage Publications. All rights reserved.

关键词：事故/经济学成本及成本分析/统计学和数值数据卫生经费支出/统计学和数值数据老年人保健服务/经济学多元分析概率回归分析美国/流行病学创伤和损伤/经济学创伤和损伤/流行病学老年人女(雌)性人类男(雄)性

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Length of stay has minimal impact on the cost of hospital admission

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JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS 2000年第2期191卷 123-130页

作者： Taheri, PA Butz, DA Greenfield, LJ Univ Michigan Med Hlth Syst Dept Surg Div Trauma Burn & Emergency Surg Ann Arbor MI 48109 USA Univ Michigan Sch Business Sect Business Econ Ann Arbor MI 48109 USA

Background: Hospital cost containment, cost reduction, and alternative care delivery systems continue to preoccupy health care providers, payers, employers, and policy makers throughout the United States. The universal metric for gauging the success of these efforts is hospital length of stay (LOS). Reducing the LOS purportedly yields large cost savings. The purpose of this study is to assess precisely how much hospitals save by shortening LOS. Study Design: We reviewed the cost-accounting records of all surviving patients (n = 12,365) discharged from our academic medical center during fiscal year 1998 with LOS of 4 days or more. Actual costs were identified through the University of Michigan cost-accounting system. Individual patient costs were broken out on a daily basis and then decomposed further into variable direct, fixed direct, and indirect categories. The population was analyzed by determining the incremental resource cost of the last full day of stay versus the total cost for the entire stay The data were also stratified by LOS and by surgical costs. An analysis of all trauma patients was then performed on all patients discharged from the hospital's adult level I trauma center (n = 665). Costs were determined on specific days, including admission day, each ICU day, day of discharge from the ICU, and each of the last 2 days before the discharge day. Results: The incremental costs incurred by patients on their last full day of hospital stay were $420 per day on average, or just 2.4% of the $17,734 mean total cost of stay for all 12,365 patients. Mean end-of-stay costs represented only a slightly higher percentage of total costs when LOS was short (eg, 6.8% for patients with LOS of 4 days). Even when the data were stratified to focus on patients without major operations, the $432 average last-day variable direct cost was only 3.4% of the $12,631 average total cost of care. A focus on the trauma center helps to explain this phenomenon. For our trauma center, v

关键词：费用控制费用节省危重病人医疗/经济学直接服务费用急诊室医院/经济学设备和供应医院/经济学卫生资源/经济学医院费用/分类实验室医院/经济学住院时间/经济学密执安护理部医院/经济学病人入院/经济学病人出院药剂科医院/经济学放射科医院/经济学康复/经济学呼吸监护病房/经济学回顾性研究外科手术/经济学创伤诊治中心/经济学创伤和损伤/经济学成年人人类

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