Complications and hospital costs during hematopoietic stem cell transplantation for non-Hodgkin lymphoma in the United States.

While the initial hospitalization accounts for 75% of total healthcare costs during the first 100 days following hematopoietic stem cell transplantation (HSCT), there is a lack of studies evaluating the considerable variation in cost estimates. Using the National Inpatient Sample (NIS) database from 2012-2014, we identified 1832 adult non-Hodgkin lymphoma (NHL) patients who received autologous or allogeneic HSCT and examined complications as predictors of hospital cost. Complications occurred in >70% of patients, and the presence of one or more complications was associated with an increase in mean hospital costs of 46% in autologous HSCT and 81% in allogeneic HSCT. The most common complications (∼40%) were mucositis, febrile neutropenia, and infection. Acute organ failure, acute graft-versus-host disease, and death were less frequent (∼10%) but had a greater impact on increasing hospital costs and length of stays. Despite recent advances in supportive care and pre-conditioning regimens, complications are common and costly during HSCT.

Unrelated HLA mismatched microtransplantation in a patient with refractory secondary acute myeloid leukemia.

Microtransplantation (MST), a type of HLA-mismatched allogeneic cellular therapy, is a promising, cellular therapy for acute myeloid leukemia (AML). MST transfuses granulocyte colony-stimulating factor (G-CSF)-mobilized, HLA-mismatched donor peripheral blood stem cells into patients undergoing conventional chemotherapy. MST, using haploidentical donors, has been shown to yield clinical benefit without any permanent marrow engraftment in AML. Consequently, graft-versus-host disease concerns are rendered irrelevant with no need for immunosuppression. We describe the first reported patient with refractory AML who underwent salvage MST from an unrelated, complete HLA-mismatched donor. The patient achieved remission without complication, warranting further study of unrelated HLA-mismatched donor MST in AML.

Office-based anesthesia: safety and outcomes.

The increasing volume of office-based medical and surgical procedures has fostered the emergence of office-based anesthesia (OBA), a subspecialty within ambulatory anesthesia. The growth of OBA has been facilitated by numerous trends, including innovations in medical and surgical procedures and anesthetic drugs, as well as improved provider reimbursement and greater convenience for patients. There is a lack of randomized controlled trials to determine how office-based procedures and anesthesia affect patient morbidity and mortality. As a result, studies on this topic are retrospective in nature. Some of the early literature broaches concerns about the safety of office-based procedures and anesthesia. However, more recent data have shown that care in ambulatory settings is comparable to hospitals and ambulatory surgery centers, especially when offices are accredited and their proceduralists are board-certified. Office-based suites can continue to enhance the quality of care that they deliver to patients by engaging in proper procedure and patient selection, provider credentialing, facility accreditation, and incorporating patient safety checklists and professional society guidelines into practice. These strategies aiming at patient morbidity and mortality in the office setting will be increasingly important as more states, and possibly the federal government, exercise regulatory authority over the ambulatory setting. We explore these trends, their implications for patient safety, strategies for minimizing patient complications and mortality in OBA, and future developments that could impact the field.

Office-based surgery: embracing patient safety strategies.

Office-based surgery continues to grow as more procedures are being performed in the outpatient setting. With this exponential growth, there is an increasing emphasis on safe and effective patient care. Current research shows both gaps in safety and opportunities for improvement. Practice managers, clinicians, and other personnel should be cognizant that office procedures are coming under intense regulatory scrutiny. Effective strategies to maintain quality and patient safety include the use of checklists, obtaining office accreditation, encouraging board-certification and proper credentialing of proceduralists, and appropriate patient and procedure selection. There is increasing regulation of ambulatory surgery on state and national levels that will likely affect the financial and care quality aspects of office-based practice. Socioeconomic and political forces will continue to shape the future of office-based surgery.

Safety considerations for office-based obstetric and gynecologic procedures.

The migration of gynecologic procedures to office-based settings provides numerous advantages for patients and providers alike, including reduced patient expenses, improved scheduling convenience, favorable provider reimbursement, and enhanced continuity of care and patient satisfaction. With rising health care costs-a major concern in health care-procedures will continue to shift to practice environments that optimize care, quality, value, and efficiency. It is imperative that gynecologic offices ensure that performance and quality variations are minimized across different sites of care; physicians should strive to provide care to patients that optimizes safety and is at least equivalent to that delivered at traditional sites. The gynecologic community should nonetheless heed the Institute of Medicine's recommendations and embrace continuous quality improvement. By exercising leadership, office-based gynecologists can forge a culture of competency, teamwork, communication, and performance measurement.

Office-based surgical and medical procedures: educational gaps.

Over the past decade, the number of procedures performed in office-based settings by a variety of practitioners-including surgeons, gastroenterologists, ophthalmologists, radiologists, dermatologists, and others-has grown significantly. At the same time, patient safety concerns have intensified and include issues such as proper patient selection, safe sedation practices, maintenance of facilities and resuscitation equipment, facility accreditation and practitioner licensing, and the office staff's ability to deal with emergencies and complications. An urgent need exists to educate practitioners about safety concerns in the office-based setting and to develop various educational strategies that can meet the continued growth of these procedures. This review outlines educational needs and possible solutions such as simulation exercises and education during residency training.

Patient safety and office-based anesthesia.

PURPOSE OF REVIEW: Office-based anesthesia is a new and growing subspecialty within ambulatory anesthesia. We examine major developments in office-based anesthesia and how patient safety can be maintained. RECENT FINDINGS: The emergence of office-based anesthesia as a subspecialty of ambulatory anesthesia is a result of economic and social factors, and is also due to the development of better surgical techniques and anesthestic drugs. There is still a dearth of primary literature that addresses patient safety in the office-based setting. Some existing literature points to increased risk in the office, although others suggest that proper provider credentialing, qualifications, and appropriate facility accreditation can improve patient outcomes compared to surgicenters and inpatient facilities. There is a lack of state and federal oversight of office-based facilities. Increased regulation and standardization of care, such as the use of check lists and professional society guidelines, can help promote safer practices. SUMMARY: There is no uniform standard of care for performing procedures in the office-based setting. Healthcare providers are facing the challenge of creating a safer, efficient, cost-effective and patient-centered environment. Available data show that the office-based practice can be as safe as any ambulatory surgicenter or hospital, as long as patients, regulators, and physicians become educated advocates of safer practices. In addition, procedures can be performed safely with general anesthesia or conscious sedation, provided that there are properly trained personnel and adequate equipment and facilities. Moreover, physicians should be credentialed to perform the same procedure in a hospital that they perform in an office.