Robert J. Greenstein

Critical care medicine in the United States 1985-2000: An analysis of bed numbers, use, and costs

Objective:To establish a database that permits description and analysis of the evolving role, patterns of use, and costs of critical care medicine (CCM) in the United States from 1985 to 2000. Design:Retrospective study combining data from federal (Hospital Cost Report Information System, Center for Medicare and Medicaid Services, Baltimore, MD) and private (Hospital Statistics, American Hospital Association, Chicago, IL) databases to analyze U.S. hospitals, hospital and CCM beds, and occupancy. CCM costs were calculated by the Russell equation and compared with national health care and financial indexes. Setting:Nonfederal, acute care hospitals with CCM units in the United States. Subjects:None. Interventions:None. Measurements and Main Results:We analyzed hospitals with CCM units and focused on hospital and CCM beds, CCM occupancy, and CCM costs. CCM costs were compared with national cost indexes. Between 1985 and 2000, the total number of U.S. hospitals decreased by 8.9% (6,032 to 5,494) and acute care hospitals offering CCM decreased by 13.7% (4,150 to 3,581). The total number of beds in hospitals with CCM units decreased by 26.4% (889,600 to 654,400). In contrast, CCM beds increased by 26.2% (69,300 to 87,400). CCM occupancy was constant at 65%. CCM bed costs per day increased by 126% (

Postoperative hypertension : a multicenter, prospective, randomized comparison between intravenous nicardipine and sodium nitroprusside

1,185 to

Changes in critical care beds and occupancy in the United States 1985–2000: Differences attributable to hospital size

2,674). Although CCM costs increased by 190.4% (

Esophageal Anatomy and Function in Laparoscopic Gastric Restrictive Bariatric Surgery: Implications for Patient Selection

19.1 billion to

Colonic vascular ectasias and aortic stenosis: Coincidence or causal relationship?

55.5 billion), the proportion of national health expenditures allocated to CCM decreased by 5.4%. In 2000, CCM costs represented 13.3% of hospital costs, 4.2% of national health expenditures, and 0.56% of the gross domestic product. Conclusions:CCM is increasingly used and prominent in a shrinking U.S. hospital system. CCM occupancy is lower than expected. Despite its increasing use and cost, CCM is using proportionally less of national health expenses and the gross domestic product than previously estimated.

Is Adolescent Gastric-Restrictive Antiobesity Surgery Warranted?

ObjectiveTo compare the efficacy and safety of iv nicardipine with sodium nitroprusside in the treatment of postoperative hypertension after both cardiac and noncardiac surgery. DesignMulticenter, prospective, randomized, open-label study. SettingSix tertiary referral medical centers (recovery rooms and surgical ICUs). PatientsA total of 139 patients with postoperative hypertension: iv nicardipine (n = 71), sodium nitroprusside (n = 68). InterventionAdministration of iv nicardipine or sodium nitroprusside. MeasurementsVital signs (BP, heart rate), hemodynamic variables, medication dosage, total number of dose changes, and time to achieve BP control were recorded. Main ResultsBoth medications were equally effective in reducing BP in both the cardiac and noncardiac surgical groups. Under the conditions of the study, iv nicardipine controlled hypertension more rapidly than sodium nitroprusside (iv nicardipine 14.0 ± 1.0 mins and sodium nitroprusside 30.4 ± 3.5 mins, p = .0029). The total number of dose changes required to achieve therapeutic BP response was significantly less in the iv nicardipine-treated patients (iv nicardipine 1.5 ± 0.2 vs. sodium nitroprusside 5.1 ± 1.4, p < .05). Adverse effects were observed with both drugs (iv nicardipine 7% [5/71] and sodium nitroprusside 18% [12/68] [NS]). ConclusionsIntravenous nicardipine is as effective as sodium nitroprusside in the therapy of postoperative hypertension. Specific advantages have been identified. The use of iv nicardipine should be considered in the therapy of postoperative hypertension. (Crit Care Med 1992; 20:1637–1643)

Cell saver autologous transfusion: metabolic consequences of washing blood with normal saline.

Objective:To determine the relationship between hospital size and changes in the number of critical care medicine (CCM) beds, proportion of hospital beds allocated to CCM, and CCM occupancy in acute care hospitals in the United States from 1985 to 2000. Design:A 16-yr (1985 to 2000) retrospective analysis was performed using the Hospital Cost Report Information System (Centers for Medicare and Medicaid Services, Baltimore, MD) on U.S. acute care hospitals that provided CCM. Hospitals were stratified into four groups (small, 1–100 beds; medium, 101–300 beds; large 301–500 beds; and extra large, >500 beds). Setting:Nonfederal, acute care hospitals with CCM units in the United States. Subjects:None. Interventions:None. Measurements:Changes in the number of hospitals, non-CCM and CCM beds, the proportion of CCM to hospital beds, and their occupancy rates. Main Results:Between 1985 and 2000, the number of hospitals providing CCM decreased overall (4,150 to 3,581, −13.7%). The greatest decreases were seen in large (−39%) and extra-large (−40%) hospitals. Small hospitals increased minimally (3.3%). The number of non-CCM beds decreased (820,300 to 566,900, −30.9%), most prominently in large (−44.2%) and extra-large (−46.1%) hospitals. In contrast, CCM beds increased overall (69,300 to 87,400, 26.1%), especially in small (27%) and medium (44.2%) hospitals. The proportion of total hospital beds assigned to CCM increased (71.8%), most markedly in large (93.5%) and extra-large (85.7%) hospitals. Non-CCM occupancy decreased (−6.4%), particularly in small (−7.5%) and extra-large (−5.8%) hospitals. However, regardless of hospital size, CCM occupancy changed negligibly (0.4%). At every time point studied, CCM occupancy was greater than non-CCM occupancy within each size group. As hospital size increased, occupancy rates increased. Conclusions:Across hospitals of all sizes, CCM bed numbers are increasing, whereas non-CCM bed numbers are decreasing. Although the CCM bed capacity is increasing at a greater percentage rate in smaller hospitals, the assignment of hospital beds to CCM remains higher in the larger hospitals. In addition, CCM bed occupancy is greater in larger institutions. These findings may help guide the future development of hospital size–based CCM benchmarking standards and guidelines.

Nicardipine infusion for postoperative hypertension after surgery of the head and neck

Background: The purpose of this study was to assess factors of clinical importance in morbidly obese patients having a laparoscopically adjustable gastric band (LAP-BAND®) implanted in order to achieve weight loss. Methods: Preoperative evaluation of hiatus hernia and esophageal (dys)motility were compared with the need for reoperation. Results are presented for the first 50 consecutive patients entered. Results: Nine of the first 50 patients required reoperation (18%). Five (10%) were for LAP-BAND slippage on the stomach. Of these five, reoperation was required in four of 12 (33%) with hiatus hernia (P = 0.0093); three of nine (33%) with a motility disorder (P = 0.025); and three of six (50%) with both hiatus hernia and a motility disorder (P = 0.0076). Conclusions: We identify two factors, hiatus hernia and esophageal dysmotility, which are associated, both independently as well as in combination, with reoperation for LAP-BAND® slippage. Both patients and their physicians should consider these data when considering the LAP-BAND® as possible therapy for morbid obesity.

Critical care medicine use and cost among Medicare beneficiaries 1995-2000: major discrepancies between two United States federal Medicare databases.

Eleven patients with vascular ectasias of the colon and associated gastrointestinal hemorrhage were evaluated. All had the clinical features associated with aortic stenosis. In two patients, the configuration of the pulse wave in the mesenteric vessel was studied. In both, the abnormal peripheral pulse wave pattern associated with aortic stenosis was also transmitted to the ileocolic artery, where it differed quite clearly from the pattern in control patients. In a parallel study, the computer records of 3,623 patients with aortic or mitral stenosis admitted to the Mount Sinai Hospital over a 10 year period were reviewed for the presence of cryptogenic gastrointestinal hemorrhage. Twenty-one of 1,811 patients with aortic stenosis but only 1 of 1,812 patients with mitral stenosis had concomitant gastrointestinal hemorrhage (chi-square = 18, p less than 0.001). These data suggest that the cause of colonic vascular ectasias should be attributed to pathologic abnormalities of the arterial inflow pulse wave, rather than to chronic intermittent submucosal venous outflow obstruction.

Weight Loss Reporting

Background: There is a paucity of information about adolescent morbid obesity and bariatric surgery. Methods: We interviewed 78% of an adolescent (≤21 years) bariatric surgical population who had a vertical banded gastroplasty between 3 and 120 months previously. There were three males (M) and 11 females (F). History of obesity, post-operative change in diet, time spent exercising, weight change and subjective impressions were addressed. Results: Males weighed more pre-operatively, lost more weight post-operatively and took longer to lose it than females. (Pre-op BMI: M = 59 ± 2 vs F = 45 ± 1; p ≤ 0.001. Months to lowest weight post-surgery: M = 37 ± 17 vs F = 13 ± 4; p ≤ 0.05. Post-operative BMI: M = 35 ± 5 vs F = 33 ± 3 NS). Length of follow up (years) was similar (M = 7 ± 0.5 vs F = 4.1 ± 1 NS). Both groups Increased the amount of exercise following surgery. (Exercise minutes per week: M = Pre-op 13 ± 13 vs Post-op 245 ± 126 NS; F = Pre-op 18 ± 16 vs Post-op 147 ± 48; p ≤ 0.05). Males eat more than females (total K calorie per day: M = 4309 ± 1677 vs F - 2324 ± 417 NS). However, both groups have a high-fat diet (fat as per cent of total diet: M = 45 ± 2 vs F = 42 ± 3). The 13/14 patients who lost weight support the concept of bariatric surgery being offered to an adolescent population. We ascribe the acceptable weight loss to the decrease in food intake, coupled with a major increase in physical activity. Conclusion: These data indicate that the adolescent morbidly obese population may be offered the same gastric-restrictive antiobesity therapy as adults, albeit with intensive dietary counselling.