Biomedical subjects

Melissa Saul

Publications and source records attributed to Melissa Saul.

10 recordsLinked to original sources

PubMed2007

Operating room versus office-based injection laryngoplasty: a comparative analysis of reimbursement.

BACKGROUND: Injection laryngoplasty (IL) continues to evolve as new indications, techniques, approaches, and injection materials are developed. Although historically performed under local or general anesthesia in the operating room suite, IL is now increasingly being performed in an office-based setting. This report presents the results of a reimbursement analysis comparing office-based versus operative IL. OBJECTIVE: The objective of this study was to compare the reimbursement of office-based injection laryngoplasty with the reimbursement of performing the same procedure in the operating room. DESIGN: The authors conducted reimbursement and outcome analysis through retrospective office chart and hospital record review. METHODS: A retrospective review was performed of the hospital records of patients having undergone injection laryngoplasty at the University of Pittsburgh Voice Center from July 1998 through March 2005. Group I included patients who underwent IL in the operating room, whereas group II included those who had office-based IL. A reimbursement analysis for both groups was then performed comparing surgeon fees, anesthesia, and hospital charges and reimbursement. The clinical efficacy of IL performed in either office versus operating room settings was measured by comparing the pre- and postintervention Voice Handicap Index-10 scores for all patients. A predictive model of potential cost savings is developed based on the results of the analysis. RESULTS: Average reimbursement was 2,505 dollars for group I (n = 108) and 496 dollars for group II (n = 50). This reimbursement differential was preserved across the various insurance types examined. There was no significant difference in Voice Handicap Index-10 change after surgery between group I and II. CONCLUSIONS: Office-based IL is both clinically and financially effective, providing patients with a convenient and flexible alternative to operating room-based intervention for glottal insufficiency.

Adolescent↗

PubMed2006

Developing and validating a diabetes database in a large health system.

BACKGROUND: One component of clinical information systems is a registry of patients. Registries allow providers to identify gaps in care at the population level. Registries also allow for rapid cycle continuous quality improvement, targeted practice change and improved outcomes. Most registries are built based on membership with an insurer or other selection criteria. Little, if any data exist on registries representing demographically heterogeneous populations. METHODS: Administrative and clinical data for the period 1/1/2000-12/30/03 were examined. In total, 46,082,941 lab reports, 233,292,544 medical records, and 9,351,415 medical record abstracts, representing approximately 2 million unique patients were searched. The diabetes source population was identified by presence of any one of the following criteria: ICD-9 code 250 (diabetes) for inpatient, emergency room or outpatient visits; any hemoglobin A1c result; blood glucose >200mg/dl; or diabetes medication. A diagnosis of diabetes was verified by trained chart reviewers on a sample of patients. Single indicators and combinations were examined to determine optimal identification of these cases. RESULTS: In two separate validation studies, using two or more indicators or outpatient diagnosis maximized positive predictive value (PPV) (96 and 97%) and sensitivity (99 and 100%) and identified 55,807 individuals. When all patients with a single indicator of outpatient diagnosis (which had the highest single PPV of 94 and 95%) were included together with those having >or=2 indicators, the final sample size was 65,725. CONCLUSION: Two or more indicators or an out-patient-diagnosis identifies a sizeable and unselective diabetes database which can be used to track processes and outcomes.

Databases, Factual↗

PubMed2006

Lactate versus non-lactate metabolic acidosis: a retrospective outcome evaluation of critically ill patients.

INTRODUCTION: Acid-base abnormalities are common in the intensive care unit (ICU). Differences in outcome exist between respiratory and metabolic acidosis in similar pH ranges. Some forms of metabolic acidosis (for example, lactate) seem to have worse outcomes than others (for example, chloride). The relative incidence of each type of disorder is unknown. We therefore designed this study to determine the nature and clinical significance of metabolic acidosis in critically ill patients. METHODS: An observational, cohort study of critically ill patients was performed in a tertiary care hospital. Critically ill patients were selected on the clinical suspicion of the presence of lactic acidosis. The inpatient mortality of the entire group was 14%, with a length of stay in hospital of 12 days and a length of stay in the ICU of 5.8 days. RESULTS: We reviewed records of 9,799 patients admitted to the ICUs at our institution between 1 January 2001 and 30 June 2002. We selected a cohort in which clinicians caring for patients ordered a measurement of arterial lactate level. We excluded patients in which any necessary variable required to characterize an acid-base disorder was absent. A total of 851 patients (9% of ICU admissions) met our criteria. Of these, 548 patients (64%) had a metabolic acidosis (standard base excess < -2 mEq/l) and these patients had a 45% mortality, compared with 25% for those with no metabolic acidosis (p < 0.001). We then subclassified metabolic acidosis cases on the basis of the predominant anion present (lactate, chloride, or all other anions). The mortality rate was highest for lactic acidosis (56%); for strong ion gap (SIG) acidosis it was 39% and for hyperchloremic acidosis 29% (p < 0.001). A stepwise logistic regression model identified serum lactate, SIG, phosphate, and age as independent predictors of mortality. CONCLUSION: In critically ill patients in which a measurement of lactate level was ordered, lactate and SIG were strong independent predictors of mortality when they were the major source of metabolic acidosis. Overall, patients with metabolic acidosis were nearly twice as likely to die as patients without metabolic acidosis.

Acidosis↗

PubMed2005

A large outbreak of Clostridium difficile-associated disease with an unexpected proportion of deaths and colectomies at a teaching hospital following increased fluoroquinolone use.

BACKGROUND AND OBJECTIVE: Fluoroquinolones have not been frequently implicated as a cause of Clostridium difficile outbreaks. Nosocomial C. difficile infections increased from 2.7 to 6.8 cases per 1000 discharges (P < .001). During the first 2 years of the outbreak, there were 253 nosocomial C. difficile infections; of these, 26 resulted in colectomy and 18 resulted in death. We conducted an investigation of a large C. difficile outbreak in our hospital to identify risk factors and characterize the outbreak. METHODS: A retrospective case-control study of case-patients with C. difficile infection from January 2000 through April 2001 and control-patients matched by date of hospital admission, type of medical service, and length of stay; an analysis of inpatient antibiotic use; and antibiotic susceptibility testing and molecular subtyping of isolates were performed. RESULTS: On logistic regression analysis, clindamycin (odds ratio [OR], 4.8; 95% confidence interval [CI95], 1.9-12.0), ceftriaxone (OR, 5.4; CI95, 1.8-15.8), and levofloxacin (OR, 2.0; CI95, 1.2-3.3) were independently associated with infection. The etiologic fractions for these three agents were 10.0%, 6.7%, and 30.8%, respectively. Fluoroquinolone use increased before the onset of the outbreak (P < .001); 59% of case-patients and 41% of control-patients had received this antibiotic class. The outbreak was polyclonal, although 52% of isolates belonged to two highly related molecular subtypes. CONCLUSIONS: Exposure to levofloxacin was an independent risk factor for C. difficile-associated diarrhea and appeared to contribute substantially to the outbreak. Restricted use of levofloxacin and the other implicated antibiotics may be required to control the outbreak

Anti-Bacterial Agents↗

PubMed2004

Evaluation of a deidentification (De-Id) software engine to share pathology reports and clinical documents for research.

We evaluated a comprehensive deidentification engine at the University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, that uses a complex set of rules, dictionaries, pattern-matching algorithms, and the Unified Medical Language System to identify and replace identifying text in clinical reports while preserving medical information for sharing in research. In our initial data set of 967 surgical pathology reports, the software did not suppress outside (103), UPMC (47), and non-UPMC (56) accession numbers; dates (7); names (9) or initials (25) of case pathologists; or hospital or laboratory names (46). In 150 reports, some clinical information was suppressed inadvertently (overmarking). The engine retained eponymic patient names, eg, Barrett and Gleason. In the second evaluation (1,000 reports), the software did not suppress outside (90) or UPMC (6) accession numbers or names (4) or initials (2) of case pathologists. In the third evaluation, the software removed names of patients, hospitals (297/300), pathologists (297/300), transcriptionists, residents and physicians, dates of procedures, and accession numbers (298/300). By the end of the evaluation, the system was reliably and specifically removing safe-harbor identifiers and producing highly readable deidentified text without removing important clinical information. Collaboration between pathology domain experts and system developers and continuous quality assurance are needed to optimize ongoing deidentification processes.

Confidentiality↗

PubMed2003

Impact of intensive care unit (ICU) drug use on hospital costs: a descriptive analysis, with recommendations for optimizing ICU pharmacotherapy.

OBJECTIVE: To determine the cost impact of intensive care unit (ICU) drug use on a hospital's total drug expense and to compare ICU pharmacy resource utilization with resource utilization of other hospital departments that provided services to the ICU. Additionally, to suggest strategies, based on these methods and results, to optimize ICU drug use. METHODS: Financial transactions for all ICU patients (n = 23,107) treated during fiscal years 1999-2002 were retrieved from the hospital's data repository. ICU drug costs were calculated both as the percentage of total drug costs for each fiscal year and adjusted for hospital volume (ICU patient days). ICU department charges were calculated as a percentage of total ICU charges and analyzed by simple descriptive statistics (mean +/- sd). Drug utilization was retrieved for those patients accounting for the highest percentage of ICU pharmacy charges. MAIN RESULTS: ICU drug costs accounted for 38.4% (+/-4.1% sd) of the total drug costs and have increased at a rate greater than non-ICU drug costs (12% vs. 6%). ICU pharmacy charges accounted for an average of 11.1% (+/-9.2% sd) of the total ICU charges, ranking as the fourth most costly of ICU charges. Both costly and highly used ICU therapies were identified for focus on cost-effectiveness analyses or application of an evidence-based drug use and disease state management program model to ICU pharmacotherapy. CONCLUSIONS: ICU drug therapies have a significant impact on hospital costs, and effective clinical informatics services and multidisciplinary collaboration programs are necessary to optimize ICU pharmacotherapy.

Academic Medical Centers↗

PubMed2003

Detecting adverse drug events in discharge summaries using variations on the simple Bayes model.

Detection and prevention of adverse events and, in particular, adverse drug events (ADEs), is an important problem in health care today. We describe the implementation and evaluation of four variations on the simple Bayes model for identifying ADE-related discharge summaries. Our results show that these probabilistic techniques achieve an ROC curve area of up to 0.77 in correctly determining which patient cases should be assigned an ADE-related ICD-9-CM code. These results suggest a potential for these techniques to contribute to the development of an automated system that helps identify ADEs, as a step toward further understanding and preventing them.

Abstracting and Indexing↗

PubMed2002

The effects of comorbid conditions on the outcomes of patients undergoing peritoneal dialysis.

PURPOSE: Dialysis patients frequently have comorbid conditions. We examined the effects of age and comorbid conditions on technique failure (i.e., transfer to hemodialysis), death, hospital costs, and kidney transplantation in patients treated with peritoneal dialysis. METHODS: We studied 97 patients who began peritoneal dialysis from January 1, 1993, to December 31, 1998, at the University of Pittsburgh outpatient dialysis unit. Demographic characteristics, comorbid conditions, and outcomes were determined by reviewing the Medical Archival Retrieval System database and outpatient records. Because the comorbidity (Charlson) score was colinear with age, we used a modified version of the score without an age component. Low, moderate, and high comorbidity groups were defined based on the 33rd and 66th percentiles of the comorbidity score. RESULTS: In multivariate-adjusted models, each decade increase in age was associated with an increased risk of death (hazard ratio [HR] = 1.7; 95% confidence interval [CI]: 1.1 to 2.5) and technique failure (HR = 1.5; 95% CI: 1.0 to 2.3). High (versus low) comorbidity was associated with an increased risk of death or technique failure (HR = 3.5; 95% CI: 1.0 to 12) and significantly higher average inpatient costs. There were no differences in age or comorbidity score between patients who transferred to hemodialysis and those who died. CONCLUSION: Patients who are older and more ill have a greater risk of death and of transfer to hemodialysis from peritoneal dialysis.

Age Factors↗

PubMedDate not supplied

Deploying the chronic care model to implement and sustain diabetes self-management training programs.

PURPOSE: The purpose of this project was to evaluate the utility of using the 6 elements of the chronic care model (CCM; health system, community, decision support, self-management support, clinical information systems, and delivery system design) to implement and financially sustain an effective diabetes self-management training (DSMT) program. METHODS: The University of Pittsburgh Medical Center (UPMC) uses all elements of the CCM. Partnerships were formed between UPMC and western Pennsylvanian community hospitals and practices; the American Diabetes Association DSMT recognition program provided decision support. A clinical data repository and reorganization of primary care practices aided in supporting DSMT. The following process and patient outcomes were measured: number of recognized programs, reimbursement, patient hemoglobin A1C levels, and the proportion of patients who received DSMT in primary care practices versus hospital-based programs. RESULTS: Using elements of the CCM, the researchers were able to gain administrative support; expand the number of recognized programs from 3 to 21; cover costs through increased reimbursement; reduce hemoglobin A1C levels (P < .0001), and increase the proportion of patients receiving DSMT through delivery in primary care (26.4% suburban; 19.8% urban) versus hospital-based practices (8.3%; P < .0001). CONCLUSIONS: The CCM serves as an effective model for implementing and sustaining DSMT programs.

Chronic Disease↗

PubMedDate not supplied

Prevalence and predictors of corticosteroid-related hyperglycemia in hospitalized patients.

OBJECTIVE: To investigate the prevalence of and risk factors for hyperglycemia in hospitalized patients receiving corticosteroids, which have been identified as an independent predictor of hyperglycemia. METHODS: We conducted a retrospective review of electronic medical records of patients admitted to the general medicine service at a university hospital during a 1-month period. Pharmacy charges were used to identify patients receiving high doses (> or = 40 mg/day of prednisone or the equivalent) of corticosteroids for at least 2 days. Occurrence of hyperglycemia and the presence of risk factors, including history of diabetes, duration of corticosteroid therapy, concurrent parenteral nutrition, antibiotic therapy, use of medications associated with hyperglycemia, severity of illness scores, and hospital length of stay, were determined. Patients experiencing multiple episodes of hyperglycemia (glucose levels > or = 200 mg/dL) were compared with those who had < or = 1 hyperglycemic episode. Patients without a history of diabetes were assessed separately. RESULTS: During the 1-month study period, 66 of 617 patients received high doses of corticosteroids, but only 50 of the 66 had glucose measurements. Hyperglycemia was documented in 32 of these 50 patients (64%), and multiple hyperglycemic episodes occurred in 26 (52%). A history of diabetes was documented in 12 of 26 patients who experienced multiple episodes, in comparison with 4 of 24 patients with < or = 1 episode of hyperglycemia (P = 0.035). Among patients without a history of diabetes, 19 of 34 (56%) had hyperglycemia at least once. Patients with multiple episodes of hyperglycemia had more comorbid diseases, longer duration of corticosteroid therapy, and longer duration of hospital stay. CONCLUSION: Hyperglycemia occurs in a majority of hospitalized patients receiving high doses of corticosteroids. In light of the poor outcomes associated with hyperglycemia, protocols targeting its detection and management should be available for patients who receive corticosteroid therapy.

Adrenal Cortex Hormones↗