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Biomedical subjects

J A Zupancic

Publications and source records attributed to J A Zupancic.

10 recordsLinked to original sources
PubMed2001

A critical review of cost reduction in neonatal intensive care. II. Strategies for reduction.

Neonatal intensive care is extremely expensive; there is both a financial and an ethical obligation to practice efficiently. In the current era of intense cost containment in hospital care, neonatologists and hospital administrators are under pressure to find strategies for cost reduction for neonatal services. In this review, we address reducing discretionary admissions, the high costs of low-cost testing, minimizing use of selected high-cost technologies (ventilators and parenteral nutrition), shortening length of stay, and optimizing nursing allocation.

Cost Control↗
PubMed2001

A critical review of cost reduction in neonatal intensive care. I. The structure of costs.

Neonatal intensive care is expensive. In the current era of intense cost containment in hospital care, neonatologists and hospital administrators are under intense pressure to find strategies for cost reduction for neonatal services. Few neonatal clinicians are trained in economics, management, or accounting, and few hospital administrators are familiar with neonatal intensive care. In this review, we describe the structure and sources of hospital costs and the accounting systems needed to isolate and measure such costs. We discuss where efficiencies might be found and consider specific issues in capitated settings such as health maintenance organizations in the United States, the Canadian health care system and the National Health System in the United Kingdom.

Accounting↗
PubMed2001

Transport risk index of physiologic stability: a practical system for assessing infant transport care.

OBJECTIVES: To develop and validate a practical, physiology-based system for assessment of infant transport care. STUDY DESIGN: Transport teams prospectively collected data, before and after transport, from 1723 infants at 8 neonatal intensive care units (NICUs) from 1996 to 1997. We used logistic regression to derive a prediction model for mortality within 7 days of NICU admission and develop the Transport Risk Index of Physiologic Stability (TRIPS). We validated TRIPS for prediction of 7-day mortality, total NICU mortality (until discharge), and severe (> or =grade 3) intraventricular hemorrhage. RESULTS: TRIPS comprises 4 empirically weighted items (temperature, blood pressure, respiratory status, and response to noxious stimuli). TRIPS discriminated 7-day NICU mortality and total NICU mortality from survival with receiver operating characteristic areas of 0.83 and 0.76, respectively. There was good calibration across the full range of TRIPS scores and gestational age groups. Increase and decrease in TRIPS scores after transport were associated with increased and decreased mortality, respectively. The receiver operating characteristic area for TRIPS prediction of severe intraventricular hemorrhage was 0.74. Addition of TRIPS improved performance of prediction models in which gestational age and baseline population risk variables were used. CONCLUSIONS: TRIPS is validated for infant transport assessment.

APACHE↗
PubMed2000

Cost-effectiveness and implications of newborn screening for prolongation of QT interval for the prevention of sudden infant death syndrome.

OBJECTIVE: To determine the cost-effectiveness of universal and high-risk neonatal electrocardiographic (ECG) screening for QT prolongation as a predictor of sudden infant death syndrome (SIDS) risk in a theoretical group of neonates. STUDY DESIGN: Incremental cost-effectiveness analysis with decision analytic modeling. A hypothetical cohort of healthy, term infants was modeled, comparing options of no screening, high-risk neonate screening, and universal screening. The high-risk strategy is speculative, because no currently accepted methodology is known for identifying infants at high risk for SIDS. Given the uncertain mechanisms of association between prolonged corrected QT interval (QTc) and SIDS, analyses were repeated under different assumptions. Sensitivity analyses were also performed on all input variables for both costs and effectiveness. RESULTS: Under the assumption that neonatal electrocardiographic screening detects long QT syndrome responsive to conventional therapy, the cost-effectiveness of high-risk screening was $3403 per life year gained, whereas universal screening cost $18,465 per additional life year gained. However, if the effectiveness of SIDS therapy falls below 10%, the cost-effectiveness deteriorates to $28,376 per life year saved for the high-risk strategy and $118,900 for universal screening. The analyses were robust to a broad array of sensitivity analyses. CONCLUSIONS: The acceptability of the cost-effectiveness of neonatal electrocardiographic screening is heavily dependent on the pathophysiologic mechanism of SIDS and on the efficacy of monitoring and antiarrhythmic treatment. The nature of this association must be elucidated before routine neonatal electrocardiographic screening is warranted.

Cost-Benefit Analysis↗
PubMed2000

Economics of prematurity in the era of managed care.

Both the acute intensive care of premature infants and the management of their long-term medical and educational sequelae are costly. Because neonatal intensive care is very effective in reducing mortality, however, its cost effectiveness as described previously is actually quite favorable when compared with other well-accepted medical interventions, such as coronary artery bypass grafting and renal dialysis. This article has highlighted the relatively scant literature on which those estimates of costs and cost effectiveness of both neonatal intensive care and its component interventions rest. This is particularly true with respect to long-term resource use by graduates of NICUs. Without such information, we cannot hope to allocate resources in a way that ensures optimal care of this vulnerable population.

Child Health Services↗
PubMed1998

Characterization of the triage process in neonatal intensive care.

OBJECTIVE: Despite intense interest in allocation of resources to neonatal intensive care, no description exists of resource use by the large numbers of newborns admitted for triage, the process of short-term evaluation and management of infants after delivery. This study characterized the triage phase of neonatal care with respect to infant demographics, risk factors for illness, and the course of the hospital admission. We hypothesized that triage infants were responsible for a significant fraction of total intensive care resource utilization, and that patterns of use were predictable. DESIGN: Cross-sectional cost analysis of prospectively collected data. PARTICIPANTS: Data were collected prospectively on 2486 inborn infants admitted to two neonatal intensive care units (NICUs) for <24 hours and subsequently discharged to routine care. Over the 11-month study period, these two hospitals delivered 15 097 live births and admitted a further 1837 infants for nontriage NICU care. INTERVENTIONS: On a 50% random subsample, we calculated severity of illness using the Score for Neonatal Acute Physiology (SNAP) and applied a NICU resource checklist. Daily NICU workload was estimated according to the number and labor intensity of NICU admissions using Medicus and SNAP. Charges were obtained from patient-level item charge records and converted to costs using Medicare ratios of costs to charges. Length of stay (LOS) and costs for triage were correlated with diagnoses, perinatal descriptors, severity of illness, and markers of concurrent NICU workload using stepwise regression. RESULTS: Mean birth weight for triage infants was 3367 g (standard deviation, 600 g) and mean gestational age 39.1 weeks (standard deviation, 1.8 weeks). The predominant reasons for evaluation were exclusion of sepsis (34%), birth complications including meconium aspiration, perinatal depression and trauma (24%), and transitional respiratory distress (23%). Severity illness, as measured by SNAP, was minimal, with 70% having scores of 0, indicating no derangement. Only 6% experienced depressed 5-minute Apgar scores (<7), and 80% required no delivery room resuscitation. The most frequent forms of resource use were antibiotic administration (34%), placement of a peripheral intravenous line (40%), cardiac monitoring (53%) and external warming (26%). Median LOS was 102 minutes, corresponding over the study period to 2% of total NICU hours but 7% of NICU days charged. Median cost was $870, with aggregate costs accounting for a total of 9.5% of total NICU costs. In the multivariate model, LOS was increased by respiratory diagnosis or hypoglycemia, severity of illness, lower gestational age, the need for intravenous placement, daytime shift, hospital, and lower acuity of concurrent NICU admissions (R2 = 0.24). CONCLUSIONS: Neonatal triage is a low-acuity but time-intensive process that contributes significantly to total resource use by newborns because of the large numbers of infants involved. Both LOS and costs are affected not only by infant medical characteristics but also by nonmedical markers of unit structure, which may be amenable to change. This source of resource consumption should be recognized in future assessments of costs associated with neonatal intensive care.

Academic Medical Centers↗
PubMed1997

Determinants of parental authorization for involvement of newborn infants in clinical trials.

OBJECTIVE: Parents have the right to decide on behalf of their infants whether to enroll them in controlled clinical trials. We determined the degree to which such parental decisions are influenced by risk and benefit considerations compared with other factors. DESIGN: Cross-sectional survey. PARTICIPANTS: Parents who had recently given or declined consent to one of three controlled trials in the neonatal intensive care unit. INTERVENTION: Parents were asked to complete a questionnaire that consisted of 15 sociodemographic items and 13 scaled responses to statements assessing the probability and magnitude of risk and benefit as well as perceived illness severity, attitudes toward research, and the consent process. ANALYSIS: Responses were subjected to factor analysis to identify underlying constructs. The sample was then randomly split, and multiple regression was performed on each half. RESULTS: The response rate was 83% (103 of 124) for those who had consented and 86% (37 of 43) for those who had declined. Factor analysis yielded three factors: (1) illness severity, (2) perceptions of risk or benefit and attitudes to research, and (3) sociodemographic characteristics. Multiple linear regression showed a significant multiple correlation of consent decision (r = .502), but only the second factor contributed. The analyses on split halves of the sample were comparable. Thirty-two percent of all parents agreed with the statement, "I would prefer to have the doctors advise me whether my baby should be in the study, rather than asking me to decide." CONCLUSIONS: In making consent decisions on behalf of their newborn infants, parents are influenced by risk and benefit assessments, attitudes toward research, and the integrity of the consent process. Illness severity or sociodemographic characteristics do not seem to be of similar importance. Rather than making the decision alone, a significant minority of parents would prefer to have the physicians advise them whether to volunteer their infants for a clinical trial.

Attitude to Health↗