Financial impact of coronary stenting in emergency for acute coronary syndromes.

BACKGROUND: Since the prospective payment system, health institutions have only specific payments for the emergency care in the emergency room. The direct urgent admissions in coronary care units for acute coronary syndrome (ACS) do not collect this complementary refund. For the patient's stay, hospital is remunerated with fixed national prices which are similar even in case of emergent or planed coronary revascularization when realized. AIMS: To analyze and compare the financial impact between emergent and planed coronary stenting in the setting of ACS. PATIENTS AND METHODS: This retrospective study was based on patients suffering from ACS who experienced emergent coronary stenting during the year 2005. On 154 patients, 127 were age-, sex- and diagnosis-related group (called "groupe homogène de malades" in the French Health Care system)-matched with 127 suffering from same ACS but with planed "ad hoc" coronary stenting. The overall charges (medical and paramedical team, pharmacy, biology, implantable coronary devices, radiology) were compared between the two groups. RESULTS: Mean stay duration was 6.7 days and did not differ between the two groups. Mean financial retributions were significantly higher in the emergent group (7338 euro [6831-7846] IC95 vs 6509 euro [5994-7023]; p=0,02) but with a much more raised consumption (6810 euro [6283-7336] vs 5223 euro [4632-5814]; p=0,001). This overcost was due especially to drugs and biological expenses. The hospitalization payments did not cover the overall expenses for 25% of the patients' stays (N=64) among whom 39 have had emergent coronary stenting (30.7%, p=0.04). Among the different GHM, the most important difference was observed in non-STEMI without complication with a negative receipts/costs ratio for 37.8% of the stay with coronary stenting in emergency. CONCLUSION: The application of the recent guidelines for coronary revascularization in the management of ACS represents a financial venture for hospital institutions. The engaged charges for emergent coronary stenting are covered with difficulties contrary to planed revascularization.

Effects of prolonged oral nutritional support in malnourished cirrhotic patients: results of a pilot study.

OBJECTIVES: The aim of this prospective study was to evaluate the acceptance and the effects of nutritional supplementation in malnourished ambulatory patients with liver cirrhosis. METHODS: From June 1999 through June 2000, alcoholic cirrhotic patients with moderate to severe malnutrition as assessed with the Detsky index were included in the study. Patients were instructed to consume, in addition to their regular diet, a commercial solution that provided 500 kcal/day. Physical examination, dietary recalls and laboratory tests were performed at 1, 2 and 3 Month. RESULTS: Twenty-nine patients with a mean age of 52 Years were included. The Child-Pugh grade was A in 6 patients, B in 14 and C in 8. Eighteen patients (62%) completed the 3 Month study protocol. Mean non-alcohol calorie intake increased significantly by 31% at 1 Month and by 48% at 3 Months. At the same time alcohol calorie intake decreased significantly by 68% and 77%, respectively. Subjective improvement in nutritional status was associated with significant improvement of mean Child-Pugh score (P=0.0007) and triceps skinfold thickness (P=0.005). The increase of mid-arm circumference was not significant. CONCLUSION: This study showed that oral supplementation in ambulatory patients with liver cirrhosis is feasible and associated with a significant improvement of nutritional status and biological parameters including the Child-Pugh score. This benefit was associated with a concomitant reduction of alcohol intake.

Cirrhosis and bleeding: the need for very early management.

BACKGROUND/AIMS: Retrospective studies suggest that the prognosis of patients with cirrhosis and variceal hemorrhage has improved in more recent decades. In a prospective cohort study in which the choice of prophylactic therapy was left to each practitioner, we followed cirrhotic patients with medium/large varices to determine factors predictive of bleeding and death. METHODS: Three hundred fourteen patients with grades 2 or 3 esophageal varices (Child A and B/C: 218 and 96) were enrolled. One hundred seventy-three patients had no previous history of variceal bleeding. Only 245 patients (100% of patients with prior variceal hemorrhage, 61% of patients without prior hemorrhage) were receiving some form of prophylactic therapy. The median follow-up was 18 months. RESULTS: There were 76 bleeding events and 14 related deaths (18%); nine of these deaths occurred within 24 h of bleeding onset (two at home, two during hospital transfer, and five in hospital, a mean of 2.5 h after onset; six involved Child C patients). Twenty-five deaths were not due to bleeding but were closely related to cirrhosis. In a Cox model, the presence of tense ascites (relative risk 3.4, 95% confidence interval, CI 2.5-5.9) and a prior history of hemorrhage (relative risk 4.4, 95% CI 2.6-7.5) were independent predictors of variceal hemorrhage. In patients without a prior history of bleeding, bleeding risk was higher with more prolonged prothrombin time and lower when patients were receiving propranolol. CONCLUSIONS: Despite the advent of effective drugs and endoscopic therapy for variceal bleeding, about a quarter of deaths occur very early after bleeding onset, confirming the need for rapid specific management.