Supportive Care Network: Evaluation of Its Impact on the Performance of a Urology Department.

INTRODUCTION: Hospitals are dealing with patients who may have clinical discharge but cannot return to their home due to non-medical issues. MATERIAL AND METHODS: Cross-sectional analysis of all the cases referred to the Integrated Care Network during the year 2016. Evaluation of waiting times, typology, reason for referral and clinical parameters. IBM SPSS 24.0 software was used for all statisticalanalyses. RESULTS: In the evaluated period, 2294 patients were discharged from our department. Of these, 55 were referred to Integrated Care Network. The mean length of hospitalization of the patients referred to the network was 20.6 ± 11.4 days, and the mean overall length of hospital stay in the period analyzed was 4.8 ± 0.9 days. The mean time between hospitalization and referral for continuing care was 10.7 ± 7.2 days. The time between referral and discharge of the hospital was 10.0 ± 8.7 days. Thirty-nine (70.9%) patients were hospitalized for oncological diseases. The most common referral was to Palliative Care units (n = 16; 29.1%). Patients referred to Palliative Care units showed the largest waiting times between the referral for the network and the hospital discharge, 12.2 ± 10.51 days. We observed 289 hospitalization days with patients who had no need of specialized urological care. DISCUSSION: In order to reduce time between referral to the network and hospital discharge, there is a need for enhanced cooperation and coordination among doctors, nurses and social workers. CONCLUSION: Early identification by physicians and nurses of patients who will require care after discharge will provide a better response from social workers and increased hospital performance.

Introdução: Os hospitais deparam-se cada vez mais com doentes que, tendo alta clínica, não têm condições de ordem não clínica para regressar imediatamente ao domicílio. Material e Métodos: Estudo transversal dos casos referenciados para a Rede Nacional de Cuidados Continuados Integrados durante o ano de 2016 no nosso Serviço de Urologia. Foram avaliados os tempos de espera, tipologia, motivo de referenciação e os parâmetros clínicos. Análise estatística realizada com recurso ao software IBM SPSS 24.0. Resultados: No período analisado, 2294 pacientes tiveram alta hospitalar no nosso serviço. Destes, 55 foram referenciados para a Rede Nacional de Cuidados Continuados Integrados. O tempo médio de internamento dos pacientes referenciados foi de 20,6 ± 11,4 dias enquanto o tempo médio global de internamento foi de 4,8 ± 0,9 dias. O tempo médio entre o internamento e a referenciação para a Rede Nacional de Cuidados Continuados Integrados foi de 10,7 ± 7,2 dias. O tempo entre a referenciação e a alta hospitalar foi de 10,0 ± 8,7 dias. Trinta e nove (70,9%) pacientes foram internados por patologias oncológicas. A referenciação mais frequente foi para unidades de cuidados paliativos (n = 16; 29,1%). Os pacientes referenciados para cuidados paliativos foram os que apresentaram os maiores tempos de espera entre a referenciação e a alta hospitalar efetiva, 12,2 ± 10,51 dias. Foram despendidos 289 dias de hospitalização com pacientes que não precisavam de cuidados urológicos especializados. Discussão: Para que o tempo entre a referenciação para a Rede Nacional de Cuidados Continuados Integrados e a alta hospitalar sejam diminuídos, é necessário que haja uma otimização da cooperação e coordenação entre médicos, enfermeiros e assistentes sociais. Conclusão: A identificação precoce dos doentes que necessitarão de apoio após a alta clínica permitirá uma resposta mais atempada por parte dos assistentes sociais e uma consequente melhoria do desempenho dos serviços hospitalares e satisfação dos doentes.

Building the Infrastructure for Value at UCLA: Engaging Clinicians and Developing Patient-Centric Measurement.

PROBLEM: Evolving payer and patient expectations have challenged academic health centers (AHCs) to improve the value of clinical care. Traditional quality approaches may be unable to meet this challenge. APPROACH: One AHC, UCLA Health, has implemented a systematic approach to delivery system redesign that emphasizes clinician engagement, a patient-centric scope, and condition-specific, clinician-guided measurement. A physician champion serves as quality officer (QO) for each clinical department/division. Each QO, with support from a central measurement team, has developed customized analytics that use clinical data to define targeted populations and measure care across the full treatment episode. OUTCOMES: From October 2012 through June 2015, the approach developed rapidly. Forty-three QOs are actively redesigning care delivery protocols within their specialties, and 95% of the departments/divisions have received a customized measure report for at least one patient population. As an example of how these analytics promote systematic redesign, the authors discuss how Department of Urology physicians have used these new measures, first, to better understand the relationship between clinical practice and outcomes for patients with benign prostatic hyperplasia and, then, to work toward reducing unwarranted variation. Physicians have received these efforts positively. Early outcome data are encouraging. NEXT STEPS: This infrastructure of engaged physicians and targeted measurement is being used to implement systematic care redesign that reliably achieves outcomes that are meaningful to patients and clinicians-incorporating both clinical and cost considerations. QOs are using an approach, for multiple newly launched projects, to identify, test, and implement value-oriented interventions tailored to specific patient populations.

Cost-minimization model of a multidisciplinary antibiotic stewardship team based on a successful implementation on a urology ward of an academic hospital.

BACKGROUND: In order to stimulate appropriate antimicrobial use and thereby lower the chances of resistance development, an Antibiotic Stewardship Team (A-Team) has been implemented at the University Medical Center Groningen, the Netherlands. Focus of the A-Team was a pro-active day 2 case-audit, which was financially evaluated here to calculate the return on investment from a hospital perspective. METHODS: Effects were evaluated by comparing audited patients with a historic cohort with the same diagnosis-related groups. Based upon this evaluation a cost-minimization model was created that can be used to predict the financial effects of a day 2 case-audit. Sensitivity analyses were performed to deal with uncertainties. Finally, the model was used to financially evaluate the A-Team. RESULTS: One whole year including 114 patients was evaluated. Implementation costs were calculated to be €17,732, which represent total costs spent to implement this A-Team. For this specific patient group admitted to a urology ward and consulted on day 2 by the A-Team, the model estimated total savings of €60,306 after one year for this single department, leading to a return on investment of 5.9. CONCLUSIONS: The implemented multi-disciplinary A-Team performing a day 2 case-audit in the hospital had a positive return on investment caused by a reduced length of stay due to a more appropriate antibiotic therapy. Based on the extensive data analysis, a model of this intervention could be constructed. This model could be used by other institutions, using their own data to estimate the effects of a day 2 case-audit in their hospital.

¿Qué aporta la gestión por procesos en un servicio de urología? / No disponible

La búsqueda de la calidad comienza con la identificación de las necesidades y expectativas de los clientes, como pilar fundamental de cualquier organización. En este proceso de búsqueda se identifican áreas de mejora que permitan actuaciones concretas que culminen lo más cerca posible de la satisfacción total de los clientes y otros agentes interesados (trabajadores, accionistas, proveedores, etc.). Este planteamiento es igualmente válido en el ámbito sanitario. El desarrollo de un plan de mejora de la calidad basado en la gestión por procesos es un medio de importante valor para la búsqueda de la excelencia en una unidad clínica. Buena parte de este número monográfico se ha dedicado a exponer la experiencia recopilada en este sentido en una unidad de Urología

The search for quality starts with the identification of client's needs and expectations, as the essential foundation of any organization. In this search process, we identify improvement areas that enable specific actions that finish the closest to total client`s and other interested agents` satisfaction (Workers, shareholders, suppliers, etc). This approach is equally valid in the health care environment. Development of a quality improvement plan based on process management is a resource of important value for the search of excellence in a clinical unit. Great part of this monographic issue is dedicated to show the experience recorded in a Urological unit

Gestión clínica: Bases fundamentales y organización / Clinical Management: Basics and organization

En los últimos años se han planteado numerosas estrategias de gestión para asegurar la sostenibilidad del sistema sanitario, especialmente tras la reciente crisis económica global. Una de los planteamientos más atractivos es la gestión clínica, que es una forma de organizar las unidades asistenciales, basada en la participación activa de los profesionales y en la transferencia de responsabilidades, para la consecución de objetivos con la misión de asegurar una correcta atención centrada en los pacientes, teniendo en cuenta el uso racional de los recursos (eficiencia). Para la puesta en marcha de estructuras asistenciales basadas en la gestión clínica es necesaria una cultura de gestión previa en los servicios implicados y en el equipo directivo del centro. Además, para lograr los objetivos planteados se deben de utilizar diferentes herramientas como la medicina basada en la evidencia, el análisis de la variabilidad en la práctica clínica, la gestión por procesos, además de estrategias de calidad y seguridad. Las unidades implicadas deben de plantear un plan de gestión que se plasmará en un contrato de gestión con la dirección del centro. En este acuerdo se establecerán unos objetivos de actividad, gasto y calidad que serán cuantificables mediante diversos indicadores. La transferencia de riesgos hacia la unidad debe de incluir cierta capacidad de decisión presupuestaria y de incentivación. La gestión clínica no debe de ser empleada como una herramienta de ahorro por parte de los macro y mesogestores. No existe una estructura asistencial basada en la gestión clínica que tenga un carácter general para todas las organizaciones sanitarias, existiendo una gran variabilidad en la adopción de diferentes fórmulas organizativas y por tanto cada centro debe realizar su propio análisis y decidir el modelo más adecuado. En nuestro país existen numerosas experiencias en gestión clínica, aunque todavía queda mucho camino por recorrer

OBJECTIVES: Many strategies have been proposed over the last years to ensure the Health Care System sustainability, mainly after the recent global economic crisis. One of the most attractive approaches is clinical management, which is a way of organizing health care units based on active participation of professionals who receive the transference of responsibilities to achieve the objectives with the mission of ensuring a proper patient centered care, taking into consideration the rational use of resources (Efficiency) For the start up of Health Care structures based on clinical management, it is necessary a previous management culture within the departments involved and the center`s executive board. Furthermore, to achieve the objectivesproposed various tools must be used, such as evidence based medicine, clinical practice variability analysis, process management, in addition of quality and safety strategies. The units involved have to propose a management plan that will result in a management contract with the center`s executive board. This agreement will establish some activity, expense and quality objectives that will be quantifiable through various indicators. Risk transference to the unit must include certain budget allocation and incentive decision capacity. Clinical management must not be employed as a savings tool from the part of macro and meso management. There is not a health care structure based on clinical management that have a general character for all health care organizations, existing a great variability in the adoption of various organizational formulas, so that every center must perform its own analysis and decide the most adequate model. In our country there are many clinical management experiences, although there is a long way to go

Health care service utilization among patients with bladder pain syndrome/interstitial cystitis in a single payer healthcare system.

BACKGROUND: This study aims to investigate the differences in the utilization of healthcare services between patients with bladder pain syndrome/interstitial cystitis (BPS/IC) and patients without using a population-based database in Taiwan. METHODS: This study comprised of 350 patients with BPS/IC and 1,750 age-matched controls. Healthcare resource utilization was evaluated in the one-year follow-up period as follows: number of outpatient visits and inpatient days, and the mean costs of outpatient and inpatient treatment. A multivariate regression analysis was used to evaluate the relationship between BPS/IC and total costs of health care services. RESULTS: For urological services, patients with BPS/IC had a significantly higher number of outpatient visits (2.5 vs. 0.2, p<0.001) as well as significantly higher outpatient costs ($US166 vs. $US6.8, p<0.001) than the controls. For non-urologic services, patients with BPS/IC had a significantly high number of outpatient visits (35.0 vs. 21.3, p<0.001) as well as significantly higher outpatient cots ($US912 vs. $US675, p<0.001) as compared to the controls. Overall, patients with BPS/IC had 174% more outpatient visits and 150% higher total costs than the controls. Multiple-regression-analyses also showed that the patients with BPS/IC had significantly higher total costs for all healthcare services than the controls. CONCLUSIONS: This study found that patients with BPS/IC have a significantly higher number of healthcare related visits, and have significantly higher healthcare related costs than age-matched controls. The high level of healthcare services utilization accrued with BPS/IC was not necessarily exclusive for BPS/IC, but may have also been associated with medical co-morbidities.

Prospective tracking of pediatric urology consults: knowing is half the battle.

PURPOSE: The planned clinical activity of pediatric urologists has been well described. However, little is known about nonscheduled work (eg consultation requests). We describe the unplanned clinical activity of pediatric urologists at a high volume academic medical center. MATERIALS AND METHODS: Demographic data regarding inpatient, operating room and emergency department pediatric urology consults were prospectively entered into an internal database. Consults from July 2008 through June 2010 underwent retrospective chart abstraction to identify reasons for consultation. Bivariate and multivariate statistics were used to evaluate 1) temporal trends in unplanned clinical activity, and 2) patient and service specific factors associated with whether a consult was billable (ie seen by attending physician within 24 hours). RESULTS: During the study period 665 pediatric consults were obtained. Mean ± SD patient age was 8.4 ± 7.7 years. Nearly all consults were seen at the emergency department (51%) or the inpatient wards (47%). The most common primary diagnoses were infection, obstruction/hydronephrosis and neurogenic bladder. The number of consults per month decreased during the course of the academic year (r(2) = 0.1422). Nearly three fourths of consults were eligible for billing. The factors associated with consult eligibility for billing included specific attending physician (p = 0.03), location (p <0.0001) and house officer experience (p = 0.007). CONCLUSIONS: At our academic pediatric hospital we averaged nearly 1 unplanned pediatric urology consult per day. Several service specific factors (unrelated to patient diagnosis or acuity) were associated with whether the consult had the potential to generate revenue. Unplanned clinical activity is an important factor to consider when planning departmental funding, staffing and training.

Developing a successful robotics program.

PURPOSE OF REVIEW: Advancements in the robotic surgical technology have revolutionized the standard of care for many surgical procedures. The purpose of this review is to evaluate the important considerations in developing a new robotics program at a given healthcare institution. RECENT FINDINGS: Patients' interest in robotic-assisted surgery has and continues to grow because of improved outcomes and decreased periods of hospitalization. Resulting market forces have created a solid foundation for the implementation of robotic surgery into surgical practice. Given proper surgeon experience and an efficient system, robotic-assisted procedures have been cost comparable to open surgical alternatives. Surgeon training and experience is closely linked to the efficiency of a new robotics program. Formally trained robotic surgeons have better patient outcomes and shorter operative times. Training in robotics has shown no negative impact on patient outcomes or mentor learning curves. SUMMARY: Individual economic factors of local healthcare settings must be evaluated when planning for a new robotics program. The high cost of the robotic surgical platform is best offset with a large surgical volume. A mature, experienced surgeon is integral to the success of a new robotics program.

The operational cost of a urology unit.

OBJECTIVES: To assess the operational cost of a urology unit, individual cost for certain index operations in urology, and to develop a framework to audit finances of a unit. DESIGN: A financial audit. SETTING: Urology unit in a teaching hospital. METHODS: Data of cost in providing urology services during one month were collected. It included three main areas: ward, operating theatre and outpatient clinic. Direct costs included staff wages, drugs, consumables, investigations and food. Indirect expenses such as administration, water, electricity and cleaning services were also calculated. For each type of operation a relative value was assigned depending on the nature of the operation. When direct expenses were not available, the hospital was divided into different cost centres and apportioning of the cost was done accordingly. RESULTS: The monthly operational cost of running a 19 bed urology unit with three operating sessions a week was Rs. 1 294 259. Staff wages constituted 61.2% of the cost. The cost of performing a pyelolithotomy was Rs. 18 669. Transurethral resection of the prostate (TURP) was done at a cost of Rs. 21 271. CONCLUSION: When the basic principles and the framework are understood, clinicians can perform financial audit and cost analysis of their units.

[Further development of urology in the tension field of surgical and molecular medicine]. / Weiterentwicklung der Urologie im Spannungsfeld von operativer und molekularer Medizin.

Methods based on molecular biology and molecular medicine now have important practical applications in many areas of theoretical and clinical medicine, and it is no longer possible to imagine life without them. This means that in a largely surgical discipline, such as urology, completely new challenges are coming to the fore, which urology, as an academic and clinical discipline, now has to face up to, and to a much greater degree than hitherto. However, there is less and less freedom of action in any university department of urology, as a result not only of intensified legal outline conditions in the healthcare sector and tight public budgets, but also of faculty- and hospital-specific blocks to innovation. There is an urgent need for the creation of appropriate outline conditions and innovative structures that will allow efficient surgical care and also an efficient way of working scientifically.

Clinical waste generation from renal units: implications and solutions.

The treatment of end-stage renal disease (ESRD) makes extensive use of presterilized disposable items which, after use, are contaminated by blood. The preferred route of disposal of such items is by incineration. Disposal costs have risen and this increase in costs has not been matched by waste management programs in renal units. Many of the waste items generated also contain polyvinyl chloride (PVC) whose incineration is environmentally sensitive. Furthermore blood tubing sets contain plasticizers such as di(2-ethylhexyl) phthalate (DEHP), which is known to pose health risks to specific groups of patients. The generation of clinical waste in a dialysis unit is analyzed, issues associated with disposal are discussed, and approaches toward a cost-effective, environmentally sustainable clinical waste management program are reviewed.

Effects of a shared protocol between urologists and general practitioners on referral patterns and initial diagnostic management of men with lower urinary tract symptoms in Italy: the Prostate Destination study.

OBJECTIVE: To assess whether adopting a shared protocol between urologists and general practitioners (GPs) might change diagnostic procedures and referral patterns in the management of men with lower urinary tract symptoms (LUTS). SUBJECTS AND METHODS: Forty-five urological centres and 263 GPs in Italy participated in this prospective study. Procedures adopted by GPs for evaluating five consecutive patients (aged > or = 50 years) were compared before (phase 1) and after (phase 2) implementation of the shared protocol. An evidence-based diagnostic algorithm was developed and approved by participating urologists and presented to local GPs at a training session. Protocol modifications were allowed after discussion with GPs. Direct costs of diagnostic procedures carried out before and after implementing the protocol were calculated from the perspective of the national health service. RESULTS: In all, 903 patients were evaluable in phase 1 and 856 in phase 2. Implementation of the protocol did not change referral patterns, with about half the patients being managed entirely by GPs. The use of a digital rectal examination by GPs increased from 32% to 41%, use of transrectal and suprapubic ultrasonography decreased from 33% to 23% and 53% to 44%, respectively, (all P < 0.001) and use of the International Prostate Symptom Score increased from 4.5% to 23.1% (P < 0.001). Overall, protocol-recommended tests were used more frequently, while those not recommended decreased after implementing the protocol. However, overuse of the tests not recommended (i.e. urine culture and free/total prostate specific antigen ratio) remained high. The mean cost per patient of diagnostic procedures ordered by GPs decreased from Euros 71.82 to Euros 61.93, with Euros 9.9 saved for each patient. CONCLUSION: Our intervention failed to decrease the percentage of cases of LUTS being referred to specialists, but was moderately effective in inducing changes in the diagnostic management by GPs that were indicative of increased compliance with best-practice principles, and produced cost savings of 13.8%.

Egresos hospitalarios por cáncer urogenital en Chile: segunda parte / Hospital discharges due to urogenital cancer in Chile: second part

El siguiente trabajo comprendió el análisis de los Egresos Hospitalarios por cáncer urogenital (CUG) para los años 1993, 1996 y 2001. Estos antecedentes permitirán establecer una tendencia que refleje más fielmente el verdadero rol del cáncer urogenital dentro de los egresos hospitalarios totales y más específicamente dentro de las patologías que afectan al aparato génitourinario. Se analizó la base de datos correspondiente al Boletín de Egresos Hospitalarios del MINSAL para los años 1993, 1996 y 2001. Se obtuvo para cada año información concerniente a los egresos hospitalarios totales, por patología génitourinaria y específicamente por cáncer de próstata, testículo, vejiga y riñón. Estos fueron caracterizados según sexo, edad y región del país desde donde egresaron. En 1993, 1996 y 2001 hubo respectivamente: 1.870, 2.745 y 3.544 egresos por cáncer prostático, 964, 964 y 1.071 por cáncer testicular, 826, 962 y 1.195 por cáncer vesical y 469, 535 y 905 egresos por cáncer renal. Estas patologías abarcaron, en su conjunto, el 0,29; 0,36 y 0,43 porciento de los Egresos Hospitalarios totales, y el 6,6, 7,5 y 10,4 porciento de los egresos hospitalarios por patología génitourinaria. Casi la mitad de los egresos corresponde a cáncer prostático, el que se ubica, lejos, como la primera causa de egresos hospitalarios por cáncer urogenital en Chile.

Cost comparison of hand assisted laparoscopic nephrectomy and open nephrectomy: analysis of individual parameters.

PURPOSE: Hand assisted laparoscopic nephrectomy (HAL) is an effective approach to nephrectomy that is less morbid than open nephrectomy (ON). In response to budgetary pressure at our large county hospital we reviewed the published experience and identified the cost components of HAL that could be targeted to decrease procedure cost. MATERIALS AND METHODS: A comprehensive literature review of HAL and ON was performed and certain parameters were abstracted, including operative (OR) time, operative equipment and hospital stay (LOS). Using these data the projected overall cost and individual cost centers at our institution for HAL and ON were compared. Decision tree analysis models were devised to estimate the cost of each treatment using computer software. One and 2-way sensitivity analyses were performed to evaluate the effect of individual treatment variables on overall cost. RESULTS: The literature showed 6 and 9 reports on 127 and 419 patients for ON and HAL, respectively. LOS was 5 and 3 days for ON and HAL, respectively. OR time was 169 and 204 minutes for ON and HAL, respectively. Based on a review of the costs at our institution ON was a less costly procedure by $205 ($6,882 vs $7,087 US dollars). The slight cost superiority of the open approach was due to significantly lower costs associated with operating room time and equipment. On the other hand, HAL demonstrated a cost advantage for LOS. One-way sensitivity analyses showed that HAL was less costly if HAL OR time was less than 184 minutes, LOS following HAL was less than 2.5 days or HAL OR supply costs were less than $718 US dollars. Two-way sensitivity analysis demonstrated that HAL was cost advantageous if performed in less than 3 hours and the patient was discharged home within 3 postoperative days. CONCLUSIONS: Primary cost variables for nephrectomy include OR time, LOS stay and equipment cost. Using published data and decision tree analysis ON is slightly less costly by $205 US dollars than HAL at our institution. However, HAL can be more cost-effective than ON when OR time and LOS are low. Our model identifies several measures that can be used at any institution to render HAL economically superior to ON.

The internal market--exposing clinical services to competitive tendering.

BACKGROUND: There exists in the National Health Service a history of compulsory competitive tendering for equipment and services (e.g. medical equipment, building construction). However, introduction of the internal market has galvanized some purchasers and providers to market test clinical services. Perceived shortcomings in the urology service in Walsall led to the Health Authority undertaking such an exercise. METHODS: A formal tendering process was undertaken by the Health Authority in the winter of 1993-1994 for the provision of the urology service. RESULTS: Three provider units tendered for the provision of the urology service, with the contract being awarded to the local provider, who submitted a bid for an enhanced level of service in terms of quantitative and qualitative measures. CONCLUSIONS: Market testing is a complex and lengthy process but can produce improvements in the quality of services. It is unlikely that many Health Authorities are fully aware of the issues involved in undertaking such an exercise. Major consideration needs to be given to the definition of the service required and objective measurements of service quality. Few such measures are as yet routinely available.