Is Resident-Driven Inpatient Care More Expensive? Challenging a Long-Held Assumption.

PURPOSE: The financial impact of graduate medical education (GME) on teaching hospitals remains poorly understood, while calls for increased federal support continue alongside legislative threats to reduce funding. Despite studies suggesting that residents are more "economical" than alternative providers, GME is widely believed to be an expensive investment. Assumptions that residents increase the cost of patient care have persisted in the absence of convincing evidence to the contrary. Thus, the authors sought to examine resident influence on patient care costs by comparing costs between a resident-driven service (RS) and a nonresident-covered service (NRS), with attention to clinical outcomes and how potential cost differences relate to the utilization of resources, length of stay (LOS), and other factors. METHOD: This prospective study compared costs and clinical outcomes of internal medicine patients admitted to an RS versus an NRS at Massachusetts General Hospital (July 1, 2016-June 30, 2017). Total variable direct costs of inpatient admission was the primary outcome measure. LOS; 30-day readmission rate; utilization related to diagnostic radiology, pharmaceuticals, and clinical labs; and other outcome measures were also compared. Linear regression models quantified the relationship between log-transformed variable direct costs and service. RESULTS: Baseline characteristics of 5,448 patients on the 2 services (3,250 on an RS and 2,198 on an NRS) were similar. On an RS, patient care costs were slightly less and LOS was slightly shorter than on an NRS, with no significant differences in hospital mortality or 30-day readmission rate detected. Resource utilization was comparable between the services. CONCLUSIONS: These findings undermine long-held assumptions that residents increase the cost of patient care. Though not generalizable to ambulatory settings or other specialties, this study can help inform hospital decision making around sponsorship of GME programs, especially if federal funding for GME remains capped or is subject to additional reductions.

In-Hospital Complications following Arthrotomy versus Arthroscopy for Septic Knee Arthritis: A Cohort-Matched Comparison.

There is a paucity of literature comparing the relative merits of open arthrotomy versus arthroscopy for the surgical treatment of septic knee arthritis. The primary goal of this study is to compare the risk of perioperative complications between these two surgical techniques. To this end, 560 patients treated for septic arthritis of the native knee with arthroscopy were statistically matched 1:1 with 560 patients treated with open arthrotomy. The outcome measures included major complications, minor complications, mortality, inpatient hospital charges, and length of stay (LOS). Major complications were defined as myocardial infarction, cardiac arrest, stroke, deep vein thrombosis, pulmonary embolism, pneumonia, postoperative shock, unplanned ventilation, deep surgical site infection, wound dehiscence, infected postoperative seroma, hospital acquired urinary tract infection, and retained surgical item. Minor complications included phlebitis and thrombophlebitis, postprocedural emphysema, minor surgical site infection, peripheral nerve complication, and intraoperative hemorrhage. Mortality data were extracted from the database using the Uniform Bill patient disposition. Complications were analyzed using univariate and multivariate logistic regression models, whereas mean costs and LOS were compared using the Kruskal-Wallis H-test. Major complications occurred in 3.8% of the patients in the arthroscopy cohort and 5.4% of the patients in the arthrotomy cohort (p = 0.20). Too few patients in our sample died to report based on National (Nationwide) Impatient Sample (NIS) minimum reporting standards. Rates of minor complications were similar for the arthroscopy and arthrotomy cohorts (12.5 vs. 13.9%; p = 0.48). Multivariate analysis did not reveal any greater risk of minor or major complication between the two procedures. Inpatient hospital cost was similar for arthroscopy ( = $15,917; standard deviation [SD] = 14,424) and arthrotomy ( = $16,020; SD = 18,665; p = 0.42). LOS was also similar for both arthrotomy (6.78 days, SD = 6.75) and arthroscopy (6.24 days, SD = 5.95; p = 0.23). Patients undergoing arthroscopic treatment of septic arthritis of the knee showed no difference in relative risk of perioperative complications, LOS, or hospital cost compared with patients who underwent open arthrotomy.

A Patient-Centered Utility Index for Non-Small Cell Lung Cancer in the United States.

Background. A preference-based quality-of-life index for non-small cell lung cancer was developed with a subset of Functional Assessment of Cancer Therapy (FACT)-General (G) and FACT-Lung (L) items, based on clinician input and the literature. Design. A total of 236 non-small cell lung carcinoma patients contributed their preferences, randomly allocated among three survey groups to decrease burden. The FACT-L Utility Index (FACT-LUI) was constructed with two methods: 1) multiattribute utility theory (MAUT), where a visual analog scale (VAS)-based index was transformed to standard gamble (SG); and 2) an unweighted index, where items were summed, normalized to a 0 to 1.0 scale, and the result transformed to a scale length equivalent to the VAS or SG MAUT-based model on a Dead to Full Health scale. Agreement between patients' direct utility and the indexes for current health was assessed. Results. The agreement of the unweighted index with direct SG was superior to the MAUT-based index (intraclass correlation for absolute agreement: 0.60 v. 0.35; mean difference: 0.03 v. 0.19; and mean absolute difference 0.09 v. 0.21, respectively). Mountain plots showed substantial differences, with the unweighted index demonstrating a median bias of 0.02 versus the MAUT model at 0.2. There was a significant difference (P = 0.0002) between early (I-II) and late stage (III-IV) patients, the mean difference for both indexes being greater than distribution-based estimates of minimal important difference. Limitations. The population was limited to non-small cell lung cancer patients. However, most quality-of-life literature consulted and the FACT instruments do not differentiate between lung cancer cell types. Minorities were also limited in this sample. Conclusions. The FACT-LUI shows early evidence of validity for informing economic analysis of lung cancer treatments.