Remote patient monitoring to facilitate same-day discharge after laparoscopic sleeve gastrectomy: a pilot evaluation.

BACKGROUND: Limited hospital inpatient capacity, exacerbated by SARS-CoV-2 (COVID-19) and associated staffing shortages, has driven interest in converting surgeries historically done as inpatient procedures to same-day surgeries (SDS). Remote patient monitoring (RPM) has the potential to increase safety and confidence in SDS but has had mixed success in a bariatric population. OBJECTIVES: Assess the feasibility of and adherence to a protocol offering patients same-day laparoscopic sleeve gastrectomy (SG) supported by RPM with an updated wearable device. Secondary outcomes were readmissions, costs, adherence, and clinical alarm rates. SETTING: Academic, military tertiary referral center (United States). METHODS: A single-center, retrospective case control study of patients undergoing SG, comparing SDS with RPM to patients admitted to the hospital for SG during this time. Patients for SDS were selected by set inclusion/exclusion criteria and patient/surgeon preference, and perioperative management was standardized. RESULTS: Twenty patients were enrolled in the SDS group, then compared with 53 inpatients. Inpatients were older (46 versus 39, P = .006), but with no significant differences in sex, preoperative body mass index, or co-morbidities. RPM wearable and blood pressure adherence was found to be 97% and 80%, respectively. Readmission rates were similar (10% versus 7.5%, P > .05). RPM alarm rates were .5 (0-1.3) per patient for each 24-hour home monitoring period. SDS patients also demonstrated the potential for cost savings over inpatient SG, depending on the number of patients monitored per day as well as the healthcare setting. CONCLUSIONS: SG as SDS with RPM was a feasible approach. It should be evaluated in other surgical procedures and higher-risk patient populations.

Community diagnostic centres: what, where and why?

The British Journal of Healthcare Management's editor discusses the potential benefits of community diagnostic centres for patients and the wider NHS, along with key considerations to drive this model forward.

Venous Sinus Stenting: Safety and Health Care Resource Evaluation for Optimal Recovery in an Evolving Health Care Environment.

BACKGROUND: Increasing evidence supports the effectiveness of venous sinus stenting (VSS) with favorable outcomes, safety, and expenses compared with shunting for idiopathic intracranial hypertension. Yet, no evidence is available regarding optimal postoperative recovery, which has increasing importance with the burdens on health care imposed by the coronavirus disease 2019 pandemic. We examined adverse events and costs after VSS and propose an optimal recovery pathway to maximize patient safety and reduce stress on health care resources. METHODS: A retrospective review was undertaken of elective VSS operations performed from May 2008 to August 2021 at a single institution. Primary data included hospital length of stay, intensive care unit (ICU) length of stay, adverse events, need for ICU interventions, and hospital costs. RESULTS: Fifty-three patients (98.1% female) met the inclusion criteria. Of these patients, 51 (96.2%) were discharged on postoperative day (POD) 1 and 2 patients were discharged on POD 2. Both patients discharged on POD 2 remained because of groin hematomas from femoral artery access. There were no major complications or care that required an ICU. Eight patients (15.1%) were lateralized to other ICUs or remained in a postanesthesia care unit because the neurosciences ICU was above capacity. Total estimated cost for initial recovery day in a neurosciences ICU room was $2361 versus $882 for a neurosurgery/neurology ward room. In our cohort, ward convalescence would save an estimated $79,866 for bed placement alone and increase ICU bed availability. CONCLUSIONS: Our findings reaffirm the safety of VSS. These patients should recover on a neurosurgery/neurology ward, which would save health care costs and increase ICU bed availability.

Contribution of Continuous Virtual Monitoring to Hospital Safety, Quality, and Value of Care for COVID-19 Patients.

Introduction: The rapid onset of the COVID-19 pandemic increased hospital admissions and shortages for personal protective equipment (PPE) used to slow the spread of infections. In addition, nurses treating COVID-19 patients have time-consuming guidelines to properly don and doff PPE to prevent the spread. Methods: To address these issues, the Medical University of South Carolina repurposed continuous virtual monitoring (CVM) systems to reduce the need for staff to enter patient rooms. The objective of this study was to identify the economic implications associated with using the CVM program for COVID-19 patients. We employed a time-driven activity-based costing approach to determine time and costs saved by implementing CVM. Results: Over the first 52 days of the pandemic, the use of the CVM system helped providers attend to patients needs virtually while averting 19,086 unnecessary in-person interactions. The estimated cost savings for the CVM program for COVID-19 patients in 2020 were $419,319, not including potential savings from avoided COVID-19 transmissions to health care workers. A total of 19,086 PPE changes were avoided, with savings of $186,661. After accounting for cost of the CVM system, the net savings provided an outstanding return on investment of 20.6 for the CVM program for COVID-19 patient care. Conclusion: The successful and cost saving repurposing of CVM systems could be expanded to other infectious disease applications, and be applied to high-risk groups, such as bone marrow and organ transplant patients.

Financial and Clinical Impact of Virtual Care During the COVID-19 Pandemic: Difference-in-Differences Analysis.

BACKGROUND: Virtual care (VC) and remote patient monitoring programs were deployed widely during the COVID-19 pandemic. Deployments were heterogeneous and evolved as the pandemic progressed, complicating subsequent attempts to quantify their impact. The unique arrangement of the US Military Health System (MHS) enabled direct comparison between facilities that did and did not implement a standardized VC program. The VC program enrolled patients symptomatic for COVID-19 or at risk for severe disease. Patients' vital signs were continuously monitored at home with a wearable device (Current Health). A central team monitored vital signs and conducted daily or twice-daily reviews (the nurse-to-patient ratio was 1:30). OBJECTIVE: Our goal was to describe the operational model of a VC program for COVID-19, evaluate its financial impact, and detail its clinical outcomes. METHODS: This was a retrospective difference-in-differences (DiD) evaluation that compared 8 military treatment facilities (MTFs) with and 39 MTFs without a VC program. Tricare Prime beneficiaries diagnosed with COVID-19 (Medicare Severity Diagnosis Related Group 177 or International Classification of Diseases-10 codes U07.1/07.2) who were eligible for care within the MHS and aged 21 years and or older between December 2020 and December 2021 were included. Primary outcomes were length of stay and associated cost savings; secondary outcomes were escalation to physical care from home, 30-day readmissions after VC discharge, adherence to the wearable, and alarms per patient-day. RESULTS: A total of 1838 patients with COVID-19 were admitted to an MTF with a VC program of 3988 admitted to the MHS. Of these patients, 237 (13%) were enrolled in the VC program. The DiD analysis indicated that centers with the program had a 12% lower length of stay averaged across all COVID-19 patients, saving US $2047 per patient. The total cost of equipping, establishing, and staffing the VC program was estimated at US $3816 per day. Total net savings were estimated at US $2.3 million in the first year of the program across the MHS. The wearables were activated by 231 patients (97.5%) and were monitored through the Current Health platform for a total of 3474 (median 7.9, range 3.2-16.5) days. Wearable adherence was 85% (IQR 63%-94%). Patients triggered a median of 1.6 (IQR 0.7-5.2) vital sign alarms per patient per day; 203 (85.7%) were monitored at home and then directly discharged from VC; 27 (11.4%) were escalated to a physical hospital bed as part of their initial admission. There were no increases in 30-day readmissions or emergency department visits. CONCLUSIONS: Monitored patients were adherent to the wearable device and triggered a manageable number of alarms/day for the monitoring-team-to-patient ratio. Despite only enrolling 13% of COVID-19 patients at centers where it was available, the program offered substantial savings averaged across all patients in those centers without adversely affecting clinical outcomes.

Medicare Telehealth Pre and Post-COVID-19 Interstate Framework, Regulations, Licensure, and HIPAA

The COVID-19 pandemic led to temporary relaxations for telehealth with respect to physician licensure, geographic location, and eligible sites for reimbursement. Earlier policies had impacted the rate of adoption of telehealth and retarded the ability to derive full benefits related to cost, access to care, and quality of care. This aspect is analyzed using 2018 Medicare fee-for-service codes and rates for 10 telemedicine services. Based on the analysis of these data, additional research, and literature review, this report describes how interstate practices can be better leveraged to achieve maximum potential for direct and indirect savings that can accrue through such pragmatic approaches for certain services. The interstate collaborations proposed in this report provide examples of broader telehealth policies that could foster increasing access to quality health care for Medicare beneficiaries and can potentially be used as insight to assist federal and state agencies as they review the continuation, cessation, or modifications of relaxations granted due to the COVID-19 pandemic.

Unlocking the potential of solar PV electric cooking in households in sub-Saharan Africa – the case of pressurized solar electric cooker (PSEC)

Many households in sub-Saharan Africa (SSA) depend on wood-fuel and biomass for cooking, with associated health and negative environmental impacts. Indoor air pollution from these traditional cooking technologies and practices lead to a number of deaths each year. Clean and smokeless cooking technologies are necessary to minimize respiratory related infections associated with traditional cooking technologies. In addition, modern energy cooking services (MECS), which have lower levelized lifecycle cost have a part to play for post COVID recovery and growth in the sub-region. In this study, a novel pressurized solar electric cooker (PSEC) using diodes as the heating element has been constructed and tested in Kumasi city, Ghana. The PSEC comprises 150 Wp solar panel, 3.3 litre cooking volume, and with the system integrated with PCM for thermal energy storage. From the experiments conducted in this study, the diode-heating element was able to charge the PCM (erythritol) and maintain it at an average temperature of 118 °C to cook rice, which is a common staple food enjoyed in many households in SSA. The result revealed that when the PCM integrated as energy storage medium was fully charged, the PSEC had fast cooking time of 50 minutes. Financial analysis also revealed that the PSEC has potential cost savings of US$ 575 and US$ 365, compared to cooking with charcoal and grid electricity, respectively, over a 10-year period.

Evaluation of Telemedicine Use for Anesthesiology Pain Division: Retrospective, Observational Case Series Study.

BACKGROUND: An increasing number of patients require outpatient and interventional pain management. To help meet the rising demand for anesthesia pain subspecialty care in rural and metropolitan areas, health care providers have used telemedicine for pain management of both interventional patients and those with chronic pain. OBJECTIVE: In this study, we aimed to describe the implementation of a telemedicine program for pain management in an academic pain division in a large metropolitan area. We also aimed to estimate patient cost savings from telemedicine, before and after the California COVID-19 "Safer at Home" directive, and to estimate patient satisfaction with telemedicine for pain management care. METHODS: This was a retrospective, observational case series study of telemedicine use in a pain division at an urban academic medical center. From August 2019 to June 2020, we evaluated 1398 patients and conducted 2948 video visits for remote pain management care. We used the publicly available Internal Revenue Service's Statistics of Income data to estimate hourly earnings by zip code in order to estimate patient cost savings. We estimated median travel time and travel distance with Google Maps' Distance Matrix application programming interface, direct cost of travel with median value for regular fuel cost in California, and time-based opportunity savings from estimated hourly earnings and round-trip time. We reported patient satisfaction scores derived from a postvisit satisfaction survey containing questions with responses on a 5-point Likert scale. RESULTS: Patients who attended telemedicine visits avoided an estimated median round-trip driving distance of 26 miles and a median travel time of 69 minutes during afternoon traffic conditions. Within the sample, their median hourly earnings were US $28 (IQR US $21-$39) per hour. Patients saved a median of US $22 on gas and parking and a median total of US $52 (IQR US $36-$75) per telemedicine visit based on estimated hourly earnings and travel time. Patients who were evaluated serially with telemedicine for medication management saved a median of US $156 over a median of 3 visits. A total of 91.4% (286/313) of patients surveyed were satisfied with their telemedicine experience. CONCLUSIONS: Telemedicine use for pain management reduced travel distance, travel time, and travel and time-based opportunity costs for patients with pain. We achieved the successful implementation of telemedicine across a pain division in an urban academic medical center with high patient satisfaction and patient cost savings.

Cost Implications from an Employer Perspective of a Workplace Intervention for Carer-Employees during the COVID-19 Pandemic.

In developed countries, population aging due to advances in living standards and healthcare infrastructure means that the care associated with chronic and degenerative diseases is becoming more prevalent across all facets of society-including the labour market. Informal caregiving, that is, care provision performed by friends and family, is expected to increase in the near future in Canada, with implications for workplaces. Absenteeism, presenteeism, work satisfaction and retention are known to be worse in employees who juggle the dual role of caregiving and paid employment, representing losses to workplaces' bottom line. Recent discourse on addressing the needs of carer-employees (CEs) in the workplace have been centred around carer-friendly workplace policies. This paper aims to assess the potential cost implication of a carer-friendly workplace intervention implemented within a large-sized Canadian workplace. The goal of the intervention was to induce carer-friendly workplace culture change. A workplace-wide survey was circulated twice, prior to and after the intervention, capturing demographic variables, as well as absenteeism, presenteeism, turnover and impact on coworkers. Utilizing the pre-intervention timepoint as a baseline, we employed a cost implication analysis to quantify the immediate impact of the intervention from the employer's perspective. We found that the intervention overall was not cost-saving, although there were some mixed effects regarding some costs, such as absenteeism. Non-tangible benefits, such as changes to employee morale, satisfaction with supervisor, job satisfaction and work culture, were not monetarily quantified within this analysis; hence, we consider it to be a conservative analysis.

Safety and economics of an enhanced recovery after surgery protocol in pelvic reconstructive surgery.

INTRODUCTION AND HYPOTHESIS: We hypothesized that an enhanced recovery after surgery (ERAS) protocol for patients undergoing female pelvic reconstructive surgery would conserve hospital resources without compromising patient safety. METHODS: In June 2020, an ERAS protocol designed to promote same-day discharge was initiated that included pre-operative hydration, a urinary anesthetic, non-narcotic analgesia, perineal ice, a bowel regimen, enrollment of the family to assist with care, and communication regarding planned same-day discharge. We compared demographic, operative, hospital stay, complications, and cost data in patients undergoing pelvic organ prolapse or incontinence surgery over 4 sequential months pre (PRE; N = 82) and post (POST; N = 91) ERAS implementation using univariate statistics. RESULTS: There were no differences in demographics, operative details, or complications (p > 0.05). There were no significant differences in overall revenues or expenses (p > 0.05), but bed unit cost was significantly lower in the POST group ($210 vs $533, p < 0.0001). There was a trend toward an increased operating margin in POST patients ($4,554 vs $2,151, p = 0.1163). Significantly more POST surgeries were performed in an ambulatory setting (73.6% vs 48.8%, p = 0.0008) and resulted in same-day discharge (80.2% vs 50.0%, p = 0.0003). There were no differences in the rates of emergency room or unexpected clinic visits (p > 0.05). Prescribed post-operative opiate dose was significantly reduced in POST patients (p < 0.0001). CONCLUSIONS: In patients undergoing female pelvic reconstructive surgery, an ERAS protocol facilitated transfer of procedures to an ambulatory surgical site and permitted same-day discharge without increasing complications, clinic visits, or emergency room visits. It also reduced bed unit cost and may improve operating margins.

Decreasing drug waste, reducing drug costs, and improving workflow efficiency through the implementation of automated chemotherapy dose rounding rules in the electronic health record system.

PURPOSE: To decrease drug waste and cost by implementing automated chemotherapy dose rounding rules in the electronic health record (EHR). Dose rounding of chemotherapy is a recognized method for reducing drug waste, and professional organizations have published guidelines recommending dose rounding when possible. SUMMARY: On the basis of current literature and guideline recommendations, Mayo Clinic developed system-wide consensus to allow dose rounding for biologic and chemotherapy agents to the nearest vial size if rounding resulted in the dose being within 10% of the originally calculated dose or to a convenient measurable volume, based on concentration of the drug, if rounding to the nearest vial size resulted in the dose being outside the 10% range. Oncology pharmacists reviewed and analyzed all drugs listed in the EHR used in injectable form for the treatment of cancer and developed dose rounding rules. The rules were implemented and applied at the dose calculation stage before provider signature. From January to June 2019, approximately 40,000 cancer treatment doses were administered. The rounding rules saved a total of 9,814 vials of drug, of which 5,329 were for biologic agents and 4,485 were for oncolytic drugs. This resulted in a total 6-month cost savings of $7,284,796 (in 2019 dollars; biologics, $5,727,402; oncolytics, $1,557,394). CONCLUSION: Systematic implementation of dose rounding rules utilizing the EHR can result in significant reduction of drug waste and realization of savings.

Improving Hospital Length of Stay: Results of a Retrospective Cohort Study.

(1) Background: Jersey Shore University Medical Center (JSUMC) is a 646-bed tertiary medical center located in central New Jersey. Over the past several years, development and maturation of tertiary services at JSUMC has resulted in tremendous growth, with the inpatient volume increasing by 17% between 2016 and 2018. As hospital floors functioned at maximum capacity, the medical center was frequently forced into crisis mode with substantial increases in emergency department (ED) waiting times and a paradoxical increase in-hospital length of stay (hLOS). Prolonged hLOS can contribute to worse patient outcomes and satisfaction, as well as increased medical costs. (2) Methods: A root cause analysis was conducted to identify the factors leading to delays in providing in-hospital services. Four main bottlenecks were identified by the in-hospital phase sub-committee: incomplete orders, delays in placement to rehabilitation facilities, delays due to testing (mainly imaging), and delays in entering the discharge order. Similarly, the discharge process itself was analyzed, and obstacles were identified. Specific interventions to address each obstacle were implemented. Mean CMI-adjusted hospital LOS (CMI-hLOS) was the primary outcome measure. (3) Results: After interventions, CMI-hLOS decreased from 2.99 in 2017 to 2.84 and 2.76 days in 2018 and 2019, respectively. To correct for aberrations due to the COVID pandemic, we compared June-August 2019 to June-August 2020 and found a further decrease to 2.42 days after full implementation of all interventions. We estimate that the intervention led to an absolute reduction in costs of USD 3 million in the second half of 2019 and more than USD 7 million in 2020. On the other hand, the total expenses, represented by salaries for additional staffing, were USD 2,103,274, resulting in an estimated net saving for 2020 of USD 5,400,000. (4) Conclusions: At JSUMC, hLOS was found to be a complex and costly issue. A comprehensive approach, starting with the identification of all correctable delays followed by interventions to mitigate delays, led to a significant reduction in hLOS along with significant cost savings.

Analysis of Facility and Home Isolation Strategies in COVID 19 Pandemic: Evidences from Jodhpur, India.

PURPOSE: Jodhpur administration directed its efforts to control and mitigate COVID 19 infection by implementing and monitoring facility isolation (FI) and home isolation (HI) measures. This study is conducted with a hypothesis that there is no difference in the quality of life and cost-effectiveness of mildly symptomatic or asymptomatic patients in HI and FI. PATIENTS AND METHODS: A mixed-method study was conducted in Jodhpur in September 2020. The purposive sampling technique was used and data from 120 individuals admitted in HI and FI were collected. The information about the status and functioning of isolation facilities was collected from various sources. Multi-stakeholder interactions with 15 personnel engaged in managing isolation facilities were done. EQ-5D version (EQ-5D-5L) which consists of the EQ-5D descriptive system and the EQ visual analog scale (EQ-VAS) was used to assess health-related quality of life. RESULTS: The strength of HI strategy is demonstrated by its ability to provide psychological and social support with minimal logistic requirements but the issue of sufficient household infrastructure, adequate family and societal support for implementing this strategy is of concern. The strength of FI strategy includes its ability to provide support to patients who have issues of sufficient household infrastructure, adequate family and societal support, but this strategy poses a threat of increasing human resource constraints and financial load on the health system. The respondents from HI obtained a mean EQ-5D index score of 0.90 and a mean VAS score of 85, whereas it was 0.80 and 78.5, respectively, for FI. The cost estimated for home isolation was Rs 549 (7.43 US $) per person, whereas it was Rs 2440 (33.02 US $) for facility Isolation. CONCLUSION: Though HI seems advantageous in terms of a better quality of life and cost-saving over FI, both the strategies are context-specific having their own trade-offs.

A single-center cost analysis assessing a change in vasopressin formulation.

PURPOSE: Cost savings achieved at an academic medical center by reformulating the institution's standard vasopressin infusions to reduce waste are described. SUMMARY: After a retrospective review of vasopressin utilization over a 4-month period revealed that only approximately 40% of dispensed vasopressin units were actually administered to patients, pharmacy leaders determined that the institution's standard vasopressin concentration for continuous infusions (100 units in 100 mL of sodium chloride 0.9% injection) was resulting in substantial waste, as many infusion preparations were not needed within the 18- to 24-hour expiration window. A concentration of 20 units/100 mL was adopted as the new standard formulation for vasopressin continuous infusions, with use of alternative concentrations allowed on a restricted basis. A pre-post study to assess the impact of the formulation change indicated a 38.7% decrease in vasopressin utilization (from 21,900 to 8,480 units) relative to utilization in a retrospective sample of patients who received vasopressin infusions prior to the formulation change. This reduced utilization equated to a cost decrease of $55,656.20 (as calculated on the basis of 2017 cost estimates) or $77,214.23 (as calculated on the basis of 2019 cost estimates) for the time period collected. It was estimated that the new formulations could yield annual cost savings ranging from $222,625 to $308,857. CONCLUSION: To our knowledge, this is the first description of cost savings following a change in formulation of vasopressin for continuous infusions. Other institutions could consider employing a similar approach in addition to the previously reported cost-saving interventions, such as lower vasopressin starting doses and vasopressin restriction policies.

The Financial Impact of an Inpatient Diabetes Management Service.

CONTEXT: Diabetes is a leading metabolic disorder with a substantial cost burden, especially in inpatient settings. The complexity of inpatient glycemic management has led to the emergence of inpatient diabetes management service (IDMS), a multidisciplinary team approach to glycemic management. OBJECTIVE: To review recent literature on the financial and clinical impact of IDMS in hospital settings. METHODS: We searched PubMed using a combination of controlled vocabulary and keyword terms to describe the concept of IDMS and combined the search terms with a comparative effectiveness filter for costs and cost analysis developed by the National Library of Medicine. FINDINGS: In addition to several improved clinical endpoints such as glycemic management outcomes, IDMS implementation is associated with hospital cost savings through decreased length of stay, preventing hospital readmissions, hypoglycemia reduction, and optimizing resource allocation. There are other downstream potential cost savings in long-term patient health outcomes and avoidance of litigation related to suboptimal glycemic management. CONCLUSION: IDMS may play an important role in helping both academic and community hospitals to improve the quality of diabetes care and reduce costs. Clinicians and policymakers can utilize existing literature to build a compelling business case for IDMS to hospital administrations and state legislatures in the era of value-based healthcare.

Open educational resources: undertheorized research and untapped potential.

This paper is in response to the manuscript entitled "Open educational resources and college textbook choices: a review of research on efficacy and perceptions" (Hilton in Educ Technol Res Dev 64(4): 573-590, 2016) from a theoretical perspective. The response describes the way many of the papers reviewed by Hilton were undertheorized, limiting their potential for impact. A brief summary of more recent research shows one current direction toward stronger theorization of OER research. Over the short-term, including during the rapid shift to digital learning catalyzed by the COVID-19 pandemic, OER adoption can be expected to save college students money and close the achievement gap between Pell-eligible students and their wealthier peers. Over the longer term, this benefit will likely disappear, and faculty will need to more fully explore the affordances of the 5Rs in order to create dramatic improvements in success for all students.

Off the Shelf: Rapid Deployment of an Emergency Department Telemedicine Platform Using Readily Available Consumer Products.

BACKGROUND: For 20 years, telemedicine has been waiting in the wings for its time in the spotlight. The Coronavirus Disease 2019 (COVID-19) pandemic, with its emphasis on personal protective equipment (PPE) and reducing high-risk contacts, was the catalyst needed to bring telemedicine into mainstream consciousness and acceptance. OBJECTIVES: We first review some of the key factors that precipitated this abrupt alteration of the perception of telemedicine. We then detail the creation of a department-wide telemedicine network using off-the-shelf consumer products. Our goal was to very rapidly install a system that was familiar to end-users for the purpose of reducing high-risk contacts and conserving PPE. Sourcing from the consumer realm proved to be advantageous over enterprise-level equipment when these goals were desired. DISCUSSION: After a rollout of 1.5 weeks from zero to fully operational, we showed an immediate decrease in high-risk contacts and PPE use. All 80 rooms plus all triage areas in our department were outfitted with Apple iPads running Zoom. User adoption was high and telemedicine use increased from ∼17 to ∼90 instances a day, a 429% increase. We saw a decrease in high-risk contacts of about 75%, with a concomitant cost savings in PPE. CONCLUSIONS: We propose that the use of consumer products sourced from local vendors is a viable solution for telemedicine systems focusing on speed, reducing costs, and ease of deployment. Future work will focus on studying its performance characteristics vs. other systems in an evolving landscape.