Medicare expenditures on unsuccessful out-of-hospital resuscitations.

Numerous studies have shown the futility of continued emergency department (ED) resuscitative efforts for victims of out-of hospital cardiac arrest when prehospital resuscitation has failed. Nevertheless, these patients continue to arrive in the ED, where they create a strain on resources. To assess the economic cost of this, Medicare expenditures were determined for resuscitative efforts on victims of atraumatic, out-of-hospital cardiac arrest subsequently pronounced dead in the ED. Charts of patients pronounced dead in the ED of a 65,000-visit urban teaching hospital during 1995 were reviewed. Selected patients met the following criteria: 1) Medicare recipient age 65 or over; 2) atraumatic, out-of-hospital arrest; 3) transported to the ED by an EMS crew authorized to perform advanced cardiac life support interventions. A total of 105 cases were identified that met inclusion criteria and for which Medicare had claims on file corresponding to the date of death. Ambulance service payments ranged from $105-$391; mean = $263. Physician service payments ranged from $8-$106; mean = $65. Payments for Medicare Part A (hospital facility) ranged from $59-$1,025; mean = $436. The total Medicare reimbursement was $80,197, mean = $764. This annualizes to a national expenditure projection of $58 million. Failed out-of-hospital resuscitation for Medicare patients is associated with poor outcome and high cost. Termination of these efforts in the prehospital arena is unlikely to affect outcome, and would result in considerable cost savings on physician and hospital facility charges. Compassionate protocols that recognize these principles should be developed and implemented.

Depression in older medical inpatients: one-year course and outcome.

OBJECTIVE: This 1-year follow-up survey of 214 medical inpatients aged 65 and older describes the outcome of major depressive episode (MDE), determines the incidence of new episodes and identifies factors associated with outcome and with new episodes of MDE. METHOD: Follow-up information was obtained from 160 patients, 69 men and 91 women. RESULTS: Of the 48 cases of MDE who were interviewed, 44% improved. Underlying dysthymic disorder strongly influenced outcome: of 21 cases of MDE alone, 62% were improved at follow-up; of the 27 cases in which MDE was superimposed on dysthymic disorder initially, only 30% were improved. New episodes of MDE occurred in 21% of patients, and were associated with dysthymic disorder initially and with change of meaning of life. CONCLUSIONS: Among older medical inpatients, MDE, particularly when superimposed upon dysthymic disorder, is a persistent condition. Randomized trials are necessary to identify efficacious treatments.

Effectiveness of geriatric psychiatry consultation in an acute care hospital: a randomized clinical trial.

OBJECTIVE: To evaluate the effectiveness of geriatric psychiatry consultation in reducing the severity of confusion, anxiety, depression, abnormal behavior, and functional disability among a selected group of aged medical and surgical inpatients. DESIGN: Randomized clinical trial. Cases assessed on enrollment at 2, 4, and 8 weeks later. SETTING: Primary acute care hospital. PATIENTS: Eighty hospitalized patients aged 65 or older who were referred to a multi-disciplinary team and had not received a psychiatric consultation in the month prior to referral. Sixty-three patients completed the trial. INTERVENTIONS: Patients in the treatment group received a geriatric psychiatry consultation and, when appropriate, follow-up at least once per week for 8 weeks. Control patients received usual medical care. MAIN OUTCOME MEASURES: Short Portable Mental Status Questionnaire, Anxiety Status Inventory, Geriatric Depression Rating Scale, and Crichton Geriatric Behavioral Rating Scale. RESULTS: The effect of the consultation on psychiatric symptoms and functional status was positive but small. The differences in scores of all measures between treatment and control groups were not statistically significant, but there were consistent trends for more treatment than control cases to have improved on all measures, significantly so on the Anxiety Status Inventory (P less than 0.05). Cases with delirium or depression improved most often. More control than treatment cases were discharged after 4 and 8 weeks, but twice as many treatment cases were discharged home. CONCLUSIONS: Geriatric psychiatry consultation, while not highly effective overall, may be beneficial if targeted to those most likely to benefit and compliance by referring physicians can be improved.

An 11-year follow-up study of 110 depressed patients.

In 1972 the World Health Organization organized a cross-cultural five-centre study of depressive disorders. This report is concerned with data collected, after an 11-year follow-up period, in the sample of 110 depressed patients in Montreal, Canada. Eighty-five percent were traced and 59% were interviewed. Of 93 patients, 20 were dead at the follow-up date, 11 by suicide. Fifty-two percent of patients were receiving psychiatric treatment at follow-up, but there was no relation between psychiatric morbidity and treatment-seeking. Moderate or severe impairment of social functioning was present in 32%; in women, a trend linking the presence of social impairment and the time spent in episodes was observed. Of the episodes of psychiatric illness recorded after the index episode, 86% were diagnosed as depressive, 14% as unspecified affective disorder. The mean durations of the index and four subsequent episodes were 10, 11, 7, 11, and 2 months respectively. At least one recurrence after the index episode was reported by 78%, at least four recurrences by 19%. Episodes lasted at least one year in 5%, 4%, 6%, and 6% in the first, second, third and fourth episodes respectively. Sixteen percent were depressed for at least one year and 31% for at least 2 years. There was a marked trend from inpatient to outpatient treatment and from ECT to drug therapy over time. Twenty-two percent reported either moderate or severe problems with alcohol or substance abuse. There was a statistically significant association between the amount of time patients spent in depressive episodes and the number of life events they reported.(ABSTRACT TRUNCATED AT 250 WORDS)

A two-year follow-up of a comparative trial of the cost-effectiveness of home and hospital psychiatric treatment.

The manpower and operating cost of home-based treatment was compared with the manpower and operating cost of hospital-based treatment during the second year and at the end of two years of treatment. Of the 155 patients destined to receive inpatient treatment, 76 were randomly assigned to home treatment, 79 to hospital treatment. The two groups were similar as to important social, demographic, and clinical characteristics, including psychiatric diagnosis. The manpower and operating cost of treatment, measured in two ways, was similar in the two groups during the second year. However, over the 2-year period hospital-based treatment of patients in each of the three diagnostic groups was more expensive than home-based treatment. Also, regardless of which treatment was given, the cost of treating schizophrenics was higher than the cost of treating manic-depressives which, in turn, was higher than the cost of treating individuals with depressive neurosis. Treatment failures were discussed. Over the 2-year period, failures in home-based treatment accounted for 39.1% of the total manpower and operating cost of home-based treatment, calculated according to Cost Model 1, and for 67.1% of the cost calculated according to Cost Model 2. The concept of failure in hospital-based treatment is also discussed.

A comparative trial of home and hospital psychiatric treatment: financial costs.

The financial costs of community-based treatment, stressing home treatment, were compared with the cost of hospital-based treatment during one year. Of 155 patients destined to receive inpatient treatment, 76 were randomly assigned to home treatment, 79 to hospital treatment; the two groups were similar as to important social, demographic, and clinical characteristics. The principal differences between the two treatments concerned the focus of treatment, the locale of treatment, the degree to which continuity of treatment was maintained, and the roles of the respective treatment staffs. Manpower and operating costs, measured in dollars, were estimated in two ways. Either way, hospital-based treatment was more expensive during the year: 64.1% more expensive (+3,250 vs. +1,980 per patient) in the first instance, 108.9% more expensive (+6,750 vs. +3,230 per patient) in the second. With two exceptions during the first month of treatment, the proportions of patients and families receiving either treatment who incurred other costs of treatment were low, and the differences between groups were not significantly different. A higher proportion of patients and families receiving home-based treatment defrayed the cost of the patient's psychotropic drugs; second, a higher proportion of families of patients receiving hospital-based treatment defrayed transportation costs. The proportions of patients and families incurring costs of the consequences of illness were low, and the differences between treatment groups were not significant. We compared this study with similar studies, discussed the generalizability of the results of this study and similar studies, and identified issues for future research.

A comparative trial of home and hospital psychiatric care. One-year follow-up.

The effectiveness of community-based treatment stressing home care was compared with hospital-based psychiatric care. One hundred and fifty-five patients destined for inpatient psychiatric care were randomly assigned to Home Care (76 patients) and to Hospital Care (79 patients). Symptoms, role functioning, and psychosocial burden on the family were similar at admission, one month, three months, six months, and one year. The mean in-hospital stay of Hospital Care patients was 41.7 days compared with a mean stay of 14.5 days for Home Care patients. The difference in the amount of ambulatory care received by patients in the two groups was not significant. The evidence is consistent: community-based psychiatric care is an effective alternative to hospital-based care for many but not all severely disabled patients. The active ingredients of successful community treatment are known, yet the lag in implementing these programs persists.