Balthasar L. Hug

The Costs of Adverse Drug Events in Community Hospitals

BACKGROUND Adverse drug events (ADEs) occur often in hospitals, causing high morbidity and a longer length of stay (LOS), and are costly. However, most studies on the impact of ADEs have been conducted in tertiary referral centers, which are systematically different than community hospitals, where the bulk of care is delivered, and most available data about ADE costs in any setting are dated. Costs in community settings are generally lower than in academic hospitals, and the costs of ADEs might be as well. To assess the additional costs and LOS associated with patients with ADEs, a multicenter retrospective cohort study was conducted in six community hospitals with 100 to 300 beds in Massachusetts during a 20-month observation period (January 2005-August 2006). METHODS A random sample of 2,100 patients (350 patients per study site) was drawn from a pool of 109,641 patients treated within the 20-month observation period. Unadjusted and adjusted cost of ADEs as well as LOS were calculated. RESULTS ADEs were associated with an increased adjusted cost of

Occurrence of adverse, often preventable, events in community hospitals involving nephrotoxic drugs or those excreted by the kidney

3,420 and an adjusted increase in length of stay (LOS) of 3.15 days. For preventable ADEs, the respective figures were +

Quality of care delivered by fee-for-service and DRG hospitals in Switzerland in patients with community-acquired pneumonia

3,511 and +3.37 days. The severity of the ADE was also associated with higher costs--the costs were +

Head-to-head comparison of fee-for-service and diagnosis related groups in two tertiary referral hospitals in Switzerland: an observational study.

2,852 for significant ADEs (LOS +2.77 days), +

Diagnosis and treatment of iron deficiency in medical inpatients at a Swiss tertiary university referral hospital : a retrospective observational cohort study of clinical practice

3,650 for serious ADEs (LOS +3.47 days), and +

Use of hepatotoxic drugs in chronic liver disease.

8,116 for life-threatening ADEs (LOS +5.54 days, all p < .001). CONCLUSIONS ADEs in community hospitals cost more than

Iron supplementation in Switzerland - A bi-national, descriptive and observational study

3,000 dollars on average and an average increase of LOS of 3.1 days--increments that were similar to previous estimates from academic institutions. The LOS increase was actually greater. A number of approaches, including computerized provider order entry and bar coding, have the potential to improve medication safety.

Iron homeostasis in inflammation: a single centre prospective observational study in medical inpatients

Medication errors in patients with reduced creatinine clearance are harmful and costly; however, most studies have been conducted in large academic hospitals. As there are few studies regarding this issue in smaller community hospitals, we conducted a multicenter, retrospective cohort study in six community hospitals (100 to 300 beds) to assess the incidence and severity of adverse drug events (ADEs) in patients with reduced creatinine clearance. A chart review was performed on adult patients hospitalized during a 20-month study period with serum creatinine over 1.5 mg/dl who were exposed to drugs that are nephrotoxic or cleared by the kidney. Among 109,641 patients, 17,614 had reduced creatinine clearance, and in a random sample of 900 of these patients, there were 498 potential ADEs and 90 ADEs. Among these ADEs, 91% were preventable, 51% were serious, 44% were significant, and 4.5% were life threatening. Of the potential ADEs, 54% were serious, 44% were significant, 1.6% were life threatening, and 96.6% were not intercepted. All 82 preventable events could have been intercepted by renal dose checking. Our study shows that ADEs were common in patients with impaired kidney function in community hospitals, and many appear potentially preventable with renal dose checking.

Adverse Drug Event Rates in Six Community Hospitals and the Potential Impact of Computerized Physician Order Entry for Prevention

PRINCIPLES Reimbursement for inpatient treatment in Switzerland is in transition. While hospitals in some cantons already use Diagnosis Related Groups (DRG) based systems for hospital financing, others use fee-for-service (FFS) based systems, a situation that provides the opportunity to perform a head-to-head comparison between the two reimbursement systems. The aim of this analysis was to compare reimbursement systems with regard to length of hospital stay (LOS) and patient outcomes in a cohort of community-acquired pneumonia patients from a previous prospective multicentre study in Switzerland. METHODS This is a post-hoc analysis of 925 patients with community-acquired pneumonia from a previous randomised-controlled trial. We calculated multivariate regression models adjusted for age, gender, comorbidities and severity of illness (using the Pneumonia Severity Index) and accounting for clustering within hospitals to compare LOS and outcomes between FFS (n = 4) or DRG hospitals (n = 2). RESULTS LOS in DRG hospitals was significantly shorter compared to FFS hospitals (8.4 vs 10.3 days, absolute difference 1.9 days [95%CI 0.8-3.1]). This was confirmed in multivariate adjusted Cox models (hazard ratio 1.2 [95% 1.1-1.3]). There were no differences in 30-day and 18-month mortality rates (adjusted odds ratio 1.7 [95% 0.9-3.2] and 1.3 [95% 0.9-1.9]) or recurrence rates within 30 days (adjusted odds ratio 0.8 [95% 0.4-1.7]). Also, no differences were found in the rate of still ongoing clinical symptoms at 30 days, satisfaction with the discharge process and quality of life measures at 30 days of follow-up. CONCLUSIONS This study focusing on community-acquired pneumonia patients with different severities found a 20% shorter LOS in hospitals with DRG financing compared to FFS hospitals without apparent harmful effects on patient outcomes, satisfaction with care and different quality of life measures. Further studies are required to validate these findings for other medical and surgical patient populations.

Mortality and drug exposure in a 5-year cohort of patients with chronic liver disease.

BACKGROUND Reimbursement for inpatients in Switzerland differed among states until 2012. Some hospitals used diagnosis related groups (DRG) and others used fee-for-service (FFS). We compared length of hospital stay (LOS), patient satisfaction and quality of life between the two systems before a nation-wide implementation of DRG. METHODS In a prospective, two-centre observational cohort study, we identified all patients with a main diagnosis of either community-acquired pneumonia, exacerbation of chronic pulmonary obstructive disease, acute heart failure or hip fracture from January to June 2011 and performed a systematic questionnaire survey 2-4 months after hospital discharge. RESULTS Of 1,093 inpatients, 450 were included. Mean age was 71.1 (±SD 19.5) years (48% male). Patients in the FFS hospital were older (mean age 74.8 vs. 65.2 years; p <0.001) and suffered from more co-morbidities. Mean LOS was 9 days and shorter in the all-patient DRG (AP-DRG) hospital (unadjusted mean 8.2 vs. 9.5 days, p = 0.04). After multivariate adjustment, no significant difference in LOS was found (p = 0.24). More patients from the FFS hospital were re-hospitalised for any reason (35% vs. 17.5%; p = 0.01), re-admitted to acute-care institutions (11.7% vs. 5.2%; p = 0.014), not satisfied with the discharge process (15.3% vs. 9.7%; p = 0.02), showed problems with self-care (93.8% vs. 88%; p = 0.03) and usual activities (79.3% vs. 76%; p = 0.02). DISCUSSION This study suggested that the AP-DRG hospital showed higher patient satisfaction regarding discharge, lower re-hospitalisation rates and shorter LOS partly explained by a lower burden of co-morbidities and disease severity. This study needs validation in a larger cohort of patients and at multiple time points.