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Biomedical subjects

D B Chalfin

Publications and source records attributed to D B Chalfin.

At least 19 recordsLinked to original sources
PubMed2002

Definitions and methods of cost assessment: an intensivist's guide. ESICM section on health research and outcome working group on cost effectiveness.

OBJECTIVE: To define the different types of costs incurred in the care of critically ill patients and to describe some of the most commonly used methods for measuring and allocating these costs. DESIGN: Literature review. Definitions for opportunity, direct and indirect, fixed, variable, marginal, and total costs are described and interpreted in the context of the critical care setting. Two main methods of costing are described: the 'top-down' and 'bottom-up' methods together with a number of cost proxies, such as the use of weighted hospital days, diagnosis-related groups, severity and activity scores, and effective costs per survivor. CONCLUSIONS: The assessment and allocation of costs to critically ill patients is complex and as a result of the different definitions and methods used, meaningful comparisons between studies are plagued with difficulty. When undertaking a study looking to measure costs, it is important to state: (a) the aim of the cost assessment study; (b) the perspective (point of view); (c) the type of costs that need to be measured; and (d) the time span of assessment. By being explicit about the rationale of the study and the methods used, it is hoped that the results of economic evaluations will be better understood, and hence implemented within the critical care setting.

Cost Allocation↗
PubMed2001

The World Trade Center attack. Eye witness: observations of a physician on the outside looking in.

Having personally witnessed the destruction at the World Trade Center on 11 September 2001, this paper presents my personal feelings and observations as an observer of both disaster and terror. Aside from the unimaginable horror as a result of the carnage, a feeling of helplessness was particularly prominent due to the inability to be able to care for casualties since most victims were fatalities. The passage of time has enabled a return to normalcy, however 'normalcy' carries a new definition due to the vastness of the tragedy and the sudden threat of bioterrorism and other weapons of mass destruction.

Anecdotes as Topic↗
PubMed2001

'Round-table' ethical debate: is a suicide note an authoritative 'living will'?

Living wills are often considered by physicians who are faced with a dying patient. Although popular with the general public, they remain problems of authenticity and authority. It is difficult for the examining physician to know whether the patient understood the terms of the advance directive when they signed it, and whether they still consider it authoritative at the time that it is produced. Also, there is little consensus on what spectrum of instruments constitutes a binding advance directive in real life. Does a 'suicide note' constitute an authentic and authoritative 'living will'? Our panel of authorities considers this problem in a round-table discussion.

Critical Care↗
PubMed2001

Pharmacoeconomic investigations in intensive care.

Financial constraints in health care in general and critical care services in particular have placed increasing demands upon health care professionals and decision-makers to ensure the highest quality of care with the best possible outcomes are attained for the least possible expenditure of resources. As such, pharmacoeconomic methods have become increasingly applied to pressing clinical problems to facilitate cost-effective delivery of health care services to the critically ill. This manuscript briefly details the basic tenets of pharmaco-economic analysis and provides an overview of recent applications to critical care issues.

Delivery of Health Care↗
PubMed1999

Decision analysis in critical care medicine.

Decision analysis, a quantitative approach to problem solving, has been applied to many clinical scenarios and has applications for the intensivist and for problems in the critically ill. This article provides a brief overview of the fundamental features of decision analysis along with an overview of its application to problems in critical care medicine and related fields.

Analysis of Variance↗
PubMed1998

Evidence-based medicine and cost-effectiveness analysis.

Health care has become increasingly expensive and clinicians have come under increased scrutiny to critically appraise the economic impact of medical programs and interventions. To ensure an equitable allocation of scarce resources and the attainment of maximal clinical benefit, it is vital to adhere to certain basic tenets of economic analysis and to understand the basic approach to cost-effectiveness analysis. These principles are applied to critical care medicine and analogies are made to the methodological rigor of evidence-based medicine.

Cost-Benefit Analysis↗
PubMed1998

A "closed" medical intensive care unit (MICU) improves resource utilization when compared with an "open" MICU.

We hypothesized that a "closed" intensive care unit (ICU) was more efficient that an "open" one. ICU admissions were retrospectively analyzed before and after ICU closure at one hospital; prospective analysis in that ICU with an open ICU nearby was done. Illness severity was gauged by the Mortality Prediction Model (MPM0). Outcomes included mortality, ICU length of stay (LOS), hospital LOS, and mechanical ventilation (MV). There were no differences in age, MPM0, and use of MV. ICU and hospital LOS were lower when "closed" (ICU LOS: prospective 6.1 versus 12.6 d, p < 0.0001; retrospective 6.1 versus 9.3 d, p < 0.05; hospital LOS: prospective 19.2 versus 33.2 d, p < 0.008; retrospective 22.2 versus 31.2 d, p < 0.02). Days on MV were lower when "closed" (prospective 2.3 versus 8.5 d, p < 0.0005; retrospective 3.3 versus 6.4 d, p < 0.05). Pooled data revealed the following: MV predicted ICU LOS; ICU organization and MPM0 predicted days on MV; MV and ICU organization predicted hospital LOS; mortality predictors were open ICU (odds ratio [OR] 1.5, p < 0.04), MPM0 (OR 1.16 for MPM0 increase 0.1, p < 0.002), and MV (OR 2.43, p < 0.0001). We conclude that patient care is more efficient with a closed ICU, and that mortality is not adversely affected.

Adolescent↗
PubMed1997

Clinical and economic outcome of patients undergoing tracheostomy for prolonged mechanical ventilation in New York state during 1993: analysis of 6,353 cases under diagnosis-related group 483.

OBJECTIVE: To examine and describe the relation between age and disposition in patients undergoing tracheostomy. DESIGN: Retrospective analysis of a statewide database. SETTING: All acute care hospitals in New York state. PATIENTS: All patients (n = 6,353) > or = 18 yrs of age who were discharged from the hospital during 1993 with a final diagnosis-related groups code of 483. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The final disposition, according to six disposition codes (other acute care facility, residential healthcare facility, other healthcare facility, home, home healthcare services, and death) was examined for the entire population. Cost per case was assumed to equal the average statewide Medicaid rate. An inverse relation between survival rate and age was observed, which resulted in an age-related increased cost per survivor. Also, survivors in older age groups had an increased rate of discharge to residential healthcare facilities. There was a negative, albeit less marked, effect of older age on the rates of survivors discharged to home and to other healthcare facilities. CONCLUSIONS: Care of patients who undergo tracheostomy for prolonged mechanical ventilation is expensive. The older the patient, the less satisfactory the outcome from an economic, clinical, and possibly social perspective.

Adolescent↗
PubMed1997

The pulmonary artery catheter: economic aspects.

OBJECTIVE: To review the literature addressing economic issues related to use of the pulmonary artery catheter (PAC). DATA SOURCE: All pertinent English language articles related to economic analysis of the use of pulmonary artery catheterization were retrieved from 1977 through 1996. STUDY SELECTION: Articles were chosen for review if an economic analysis related to use of the PAC was studied or reviewed. DATA EXTRACTION: From the articles selected, information was obtained about economic aspects related to pulmonary artery catheterization. DATA SYNTHESIS: Inadequate evidence exists to accurately determine if PAC use is truly cost-effective. CONCLUSION: Widespread use of the PAC has significant economic ramifications. Data regarding cost-effectiveness of the PAC is extremely limited in terms of methodology and scope. Economic impact and cost-effectiveness are moot prior to establishing clinical efficacy.

Catheterization, Swan-Ganz↗
PubMed1994

Critical care medicine in managed competition and a managed care environment.

The high cost of medical care in the United States and diminishing access to health care for many Americans has spurred healthcare reform efforts in this country. Several bills have been introduced into Congress. Many of these healthcare bills and other proposals embrace the concept of managed care and managed competition as their central feature. The steady growth of managed care organizations and the possible adoption of managed competition stands to significantly alter the way critical care medicine is practiced and delivered in the United States. The number of ICUs and ICU beds may be reduced, affecting both patient case mix and the overall mission of the ICU and critical care practice. Furthermore, fewer critical care practitioners may be available as a result of diminished educational funding and reduced training programs. In view of these and other impending changes in the American healthcare system, it is vital to investigate the impact of managed care on ICU practice and patient outcome and to study the incremental and value-added contributions of critical care medicine.

Cost Control↗
PubMed1994

Preoperative evaluation and postoperative care of the elderly patient undergoing major surgery.

As the population ages and as surgical and anesthetic techniques advance, more and more elderly patients are referred for surgery. As a result, the physician must be increasingly aware of the aged response to surgery and the management of the geriatric surgical patient in the perioperative period. Elderly patients are prone to cardiac, respiratory, and infectious complications, and thus, they need to be screened for the presence of pre-existing disease. In addition, the geriatric patient needs to be carefully monitored in the proper postoperative environment to guard against untoward sequelae.

Age Factors↗
PubMed1993

Cost-effectiveness of monoclonal antibodies to gram-negative endotoxin in the treatment of gram-negative sepsis in ICU patients.

OBJECTIVE: To evaluate the fiscal impact and the cost-effectiveness of monoclonal antibodies against gram-negative endotoxin (MAbGNE) in the treatment of presumed gram-negative sepsis. DESIGN: A decision analysis model was developed from (1) data from two phase III trials that studied the E5 or HA-1A MAbGNE, and (2) financial data from 1405 septic patients who required intensive care at a large tertiary hospital. SETTING: Intensive care unit (ICU) patients with presumed gram-negative sepsis. PATIENTS: The E5 trial evaluated 468 patients, and the HA-1A study enrolled 543 patients with presumed gram-negative sepsis. INTERVENTIONS: The addition of MAbGNE to standard regimens or standard regimens alone. MAIN OUTCOME MEASURES: Total expected charges and the expected probability of survival were determined for each option. Cost-effectiveness and marginal cost-effectiveness ratios were also derived. Multiple sensitivity and Monte Carlo analyses were performed to test the underlying assumptions. RESULTS: MAbGNE therapy always resulted in higher expected charges; however, these differences were less than its acquisition cost by $870. The cost-effectiveness ratio for MAbGNE, for $2000 and $4000 acquisition costs, was $71,674 and $74,900 per probability of survival, respectively. Sensitivity analysis showed that cost-effectiveness was most affected by diagnostic accuracy, patient selection, and acquisition cost. Monte Carlo analysis showed that MAbGNE was more costly for 71% of simulations, yet the most efficacious option for 79% of simulations. CONCLUSIONS: From the perspective of acute care institutions, MAbGNE is expensive and cannot be justified on a cost-saving basis. However, it may be cost-effective throughout a reasonable range of assumptions.

Antibodies, Monoclonal↗
PubMed1993

The economic impact and cost-effectiveness of monoclonal antibody therapy for sepsis.

Monoclonal antibodies directed against the endotoxins produced by gram-negative organisms have been developed for the treatment of patients with sepsis. Phase 3 clinical trials in which two of these agents, E5 and HA-1A, have been evaluated have suggested possible benefit in terms of improved survival and reversal of organ dysfunction for certain subgroups. Since monoclonal antibodies are expected to be expensive, cost-effectiveness analysis is necessary to assess the joint clinical and economic impact. Cost-effectiveness studies based on the clinical data from these phase 3 trials have suggested that monoclonal antibodies may represent a cost-effective approach to the treatment of sepsis. However, an increase in the number of questions concerning the clinical efficacy of these agents and their ultimate impact on survival mandates the need for further clinical and economic investigation.

Antibodies, Monoclonal↗
PubMed1993

Outcome assessment in elderly patients with critical illness and respiratory failure.

Although elderly patients tend to have diminished physiologic reserve, the independent impact of age on outcome from critical illness is controversial. Physiologic status is perhaps a more important measure of a patient's underlying health and anticipated response to critical illness. Age, therefore, should not be used as a sole determinant for intensive care department admission.

Aged↗