[Activity-based financing: is ambulatory care profitable for the institution]. / T2A et chirurgie orbitopalpébrale : l'ambulatoire est-il vraiment rentable pour l'établissement ?

INTRODUCTION: The aim of this study was to evaluate the impact of the 11th version of the National Health System's Activity-Based Financing on the income of a University Hospital department for palpebral, lacrimal, and orbital surgeries. PATIENTS AND METHODS: The number of such surgeries in 2008 was based on the Medicalization Program of the Information System. Using the 11th version of the Activity-Based Financing for Diagnosis-Related Groups, we compared the income in both inpatient and outpatient settings. RESULTS: Two hundred and forty-eight patients undergoing palpebral, lacrimal, or orbital surgery between January and December 2008 were included, with 87% treated on an outpatient basis. The lower reimbursement for outpatient surgery resulted in a loss of 184,500 euros (79%) for our department compared to the inpatient procedure. DISCUSSION: With rigorous organization, ambulatory surgery is feasible for palpebral, lacrimal, and orbital surgery. Nonetheless, with department incomes related to activity, ambulatory care seems financially disadvantageous. Many departments are trying to develop an ambulatory structure, but the need to balance their budget requires improved coherence.

[Impact of the Activity-Based Financing (11th Version) on glaucoma surgery payment in hospital resources]. / Retentissement de la version 11 de la T2A sur le financement de la chirurgie des glaucomes.

AIM: In this study, the potential impact of 11(th) version of the National Health System's Activity-Based Financing on the income of a University Hospital department was evaluated for glaucoma surgeries. PATIENTS AND METHODS: The number of glaucoma surgeries in 2008 was analyzed based on the Medicalization Program of Information Systems. Using the 11(th) version of the Activity-Based Financing for Diagnosis-Related Groups (DRG), we compared the income of these surgical procedures on both an inpatient and an outpatient setting. RESULTS: One hundred and forty-nine patients undergoing glaucoma surgery between January and December 2008 were included, 94% of whom were treated on an outpatient basis. The lower reimbursement for outpatient surgery resulted in a loss of euro 100,000 or 64% of revenues compared to an inpatient procedure. DISCUSSION: Ambulatory glaucoma surgery is feasible but requires rigorous organization. Nonetheless, while department incomes are related to activity, ambulatory care seems financially disadvantageous. Many departments are trying to develop an ambulatory structure, but the apparent contradiction between the objectives of public health insurance and the hospital's need to balance its budget requires further clarification.

[Vitreoretinal outpatient surgery: clinical and financial considerations]. / Chirurgie rétino-vitréenne en ambulatoire: une expérience enrichissante, mais coûteuse...

INTRODUCTION: Vitreoretinal surgery has benefited from great advances opening the opportunity for outpatient management. METHODS: We report on the 6-month experience of outpatient surgery for vitreoretinal diseases. RESULTS: From November 2007 to April 2008, 270 patients benefited from a vitreoretinal surgery, with 173 retinal detachments, 63 epiretinal membranes, and 34 other procedures. Only 8.5% (n=23) of the patients had to stay at the hospital one or two nights. The main reasons were the distance from the hospital and surgery on a single-eye patient. The questionnaire given after the surgery showed that almost all the patients were satisfied with the outpatient setting. In contrast, the financial results showed a loss of income of around 400,000 euros due to the low level of payment of outpatient surgery in France by the national health insurance system. DISCUSSION: Vitreoretinal surgery can be achieved in outpatient surgery with an improvement in the information given to the patients and the overall organization of the hospitalization. However, the current income provided with vitreoretinal outpatient surgery is highly disadvantageous in France, preventing this method from being generalized.

Spread of extended-spectrum beta-lactamase-producing Klebsiella pneumoniae: are beta-lactamase inhibitors of therapeutic value?

Because of recurrent colonization by Klebsiella pneumoniae strains producing type SHV-4 extended-spectrum beta-lactamases (ESBLs), a case-control study was conducted in an intensive care unit to investigate the risk of acquisition, with special reference to antibiotic therapy and resuscitation procedures. Fifty-one patients colonized or infected by ESBL-producing K. pneumoniae (cases) were matched with 51 noncolonized patients (controls). Duration of intubation was significantly longer for cases than for controls, while duration of beta-lactamase inhibitor therapy was significantly shorter. By means of multivariate analysis, intubation was the only risk factor identified (odds ratio [OR] = 1.19), while beta-lactamase inhibitor therapy was shown to be a protective factor (OR = 0.849). During outbreaks of SHV-4 type ESBL-producing K. pneumoniae in intensive care units, preferential use of beta-lactamase inhibitors may help control the emergence and spread of these pathogens even if essential hand washing and isolation procedures are adhered to.

Plasma lipid peroxidation in critically ill patients: importance of mechanical ventilation.

Oxygen free radicals may be implicated in the pathogenesis of both ischemia-reperfusion damage and in circulatory shock. The attack on the cell membrane by free radicals leads to lipid peroxidation, which can be assessed by the plasma malondialdehyde (MDA) level. The aim of this study was to determine the importance of lipid peroxidation in critically ill patients. The MDA level was measured by the thiobarbituric acid test. Nineteen patients at an early stage of circulatory shock, 11 patients in the weaning period of ventilation, 9 gastro-enterological patients without cardio-circulatory distress or sepsis, and 9 healthy volunteers were studied. The MDA level was higher in critically ill patients than in control subjects (61% in patients with shock and 40% in patients on mechanical ventilation). No correlation was found between the MDA level and the outcome: multiple organ failure or acute respiratory distress syndrome. This proposal leads to the question of systematic antioxidant therapy in intensive care patients.

Risk factors for septic shock in the early management of bacteremia.

PURPOSE: Aggressive treatment of bacteremia in patients at high risk of septic shock may prove to be beneficial and cost-effective since these patients account for 50% of the mortality. The purpose of this study was to identify risk factors for septic shock in bacteremic patients. PATIENTS AND METHODS: We retrospectively collected clinical, biologic, and radiologic data from medical records of patients who experienced one episode of bacteremia between March 1 and December 31, 1990, at the University Hospital of Dijon, France. Statistical analysis was univariate and multivariate (logistic regression). RESULTS: During the survey, 331 patients experienced one episode of bacteremia. Bacteremia due to gram-negative species was more frequently found in surgical units. Septic shocks were equally attributed to gram-negative and gram-positive bacteria. The do-not-resuscitate order was associated with nearly half of the deaths secondary to underlying diseases or poor general condition. Neither hospital-acquired bacteremia nor underlying diseases were associated with a high risk of septic shock. Multivariate analysis showed the following to be risk factors for septic shock: male gender and age older than 75 years (odds ratio = 2.91), creatinine level greater than 20 mg/L (odds ratio = 4.52), prothrombin time less than 60% (odds ratio = 4.86), and presence of an interstitial pattern on the chest radiograph involving more than half of both lung fields (odds ratio = 4.1). Our logistic model with these selected parameters allowed an overall classification of 77% of the studied patients, with a positive predictive value of 55% and a negative predictive value of 89%. CONCLUSION: Our results provide a positive predictive value that is similar to that of the clinical scores of severity proposed by other authors in selected populations. Our classification, in conjunction with a clinical classification, would allow improvement in the prognosis of patients with bacteremia by early treatment of those at high risk for developing septic shock. Validation of these results with further studies involving a larger population that includes patients with suspected infections, as well as bacteremic patients, is needed.

[Spontaneous intracerebral hemorrhages in young patients. Study of 33 cases]. / Les hémorragies intracérébrales spontanées du sujet jeune. Etude de 33 cas.

We report 33 cases of intracerebral hemorrhage (ICH) in patients aged from to 9/44 years (male: 20, female: 13, mean age: 32.5 years). ICH was due to vascular malformations in 39 p. 100 of cases, to arterial hypertension in 30% and to various causes in 18% no cause could be found in 13% of the cases. ICH was lobar in 64%, deep in 33% and infratentorial in 3% of the cases. The diagnosis was assessed by arteriography in 9 patients. The vascular malformations were arterial angiomas, saccular aneurysms and cavernous angiomas. Death rate was 24%. There was a fast ICH handicap in 40% of cases. Only 36% of the patients were not disabled.