Meta-analysis of Outcomes With Costs

Letters
Maintaining intraoperative normothermia:
Meta-analysis of outcomes with costs
To the Editor:
iioi'iiothlt''iiitgrotl)s...hadtl
1999.
I readl with intterest the April
AANA Journal article titletd
"Maintaining intra(Iperativt' nolrmtothernlia: Meta-analvsis (If
otcttomest'with
cotst,"lby Christiine
'Ilitwilahonev, RN,
andt
MS, anti Jan Odom, RN, MS, (;PAN, FAAN. I have i'ecenitiy
bee'n iecturing (on iptri(Ift'iativet'temperature
anti I too believe that maintaining lpt'iitletl'tivt' nol'i(Itht'l'-
(yinig.
Pi),
maintenant't,
mliad
are
ly,
1Last
imany of t he Ibii
1ility anditi 1)4)itali i f igti's
1
also striking. WAhe'n we reat1 that ". ..2i % of the pat ienIts xvh
eseixes
moure t'ffort anti attentiton.
I compliment the authorls on what is, tlverafl, at fine joll.
This nmeta-analysis was vt'ry mltt(h needed and tlarifit's
(our
uinderstanding of' the clin ical impact Of hvpot herm ia.
Nevertheless, sevteral aspects (If the articit' deserve f'urtht'r tlis-
lpdt ients
550 X
loxvei'-
iortality.."'oWe
and
)i fproc'telures of-iihighi acu1ity
t hat lit)ctalts(
pat
1(11 Is
werte more likely to (lie bl aet' tvIhex'were hl'f)( )t litii (Oiwerie
he xere moie likely 1o stay livl)( t lei'tii(
cuse1they
atl(l/(
(effet'tw
ads
estalfishe('(.
W(e(10c)
wliethitr
notknow
ia
Again,(ldespite
fexw quetst ions1 this is a f ine aititcle that
(leseixes to 1bet'ai'eftilix' i'ad byIWanitstheit sI, 4)atidtg
')(f)iti
'ti'enuses alike.
we arie morle slt'per soiiiel, aniti ie1iolpei'tta
cessf iii at pre'servinig ii()rIili()thelit'iiit ii( )otgholilt I lie (Ifl('i't iV(
As
c't'i510i.
The introduction states that ".it [ hyp(tllierniid I tan be
prietvenIted teasiiy," buit this runs ctont rary t)otciinitcaltexpterit'nct'
and teven the resuits (If' the author's' analysis. 'flblt'
shows
that even with what the autholrs ctorr'ectiy idtentify as the lmost
e fh'ct ive pretventativet' fedstll't, force d air warinilg, liii ht
MTIAf
f
4
Preventative mteasuires should be more witlyvtid,
knowitedgte is ntetied b)efore wte cani tliminate
hypolthermlia.
hilt miort
evtein ihti
A.
R, (:RNA, MS
\.1111)1
'1 ,%o( i(IIV I'lu'rlius~
I/eit'
04?
Vu' :v' ,1Puil'S!u'%iaInrguim~
0e~sly/ 4fI(db(11fl(1 (11tfliit-ilg'he'inir
Response:
'T'he lettecr frionNIMicliael lhiedlei', (:RNA, NMS, (4)1 t'et 'iif otltctOlilts xitf cots,"aitiol'ctc'(h
(
f)x Jan
MS, (:PAN, hAAN, aind me ( 'lAVA /0111
MVeta-aiialxsis
RN,
mio(derate antistever'elhyptlthermia
has
Iteste tflt'tts,
()(ho,
1999;6)17:1I55-
I ami
eff'ct~s of Muld hypothermia, andt the artitcIt'nteitht'r elalborat's
A maljolr focls
t(1
(If
it
tht' artitct' is thiitnlcreased dollar tcost
(If cutre for even mildly hyfpotierit paltents,
tet'mthiat is
easy
acct'pt. This is ctatinily dln important c(Itisitlel'tlitii
anud
makt's ii coiniicinlg arguimeint foi' warmuing
to admfiiistratorIis
not involved in p)atiet'Ic
art'.
illiei'vt'it ionis
Near
thit't'id
If" the initroducittioln the article statt's that costs "...wert'theiti
talculated using avt'ragt' c'ost dtatc'lltc'tt'dlf'r'tm inistitiutionsb
Or
acrtoss tlit'United Stat's."
If'ia sitnglt'avt'ragte ('(151F
eactl
catt'gorly was established1, htow is it that both "high tntctI
assu~mptitons"anti "low end
assimpt ions' uai'eI'tfpretset'letd
ill Ilbles
atndi6?
T'l-figures iiin alt'
1(1(k x'try high
indee'd'(,
without having more~t details about 1h(w thiest'
t'osts were ar'rivted at ont' Imighit wt'll(fquestiont theii' applicability. Even
the figure's inl Table 6 (low ('e(1dassumtlionits) art'
accepted, we must remember thattihit'c'ost savings fprotjetettt
f'tr eachl patie'nt kept nltmothe'imic atre applicabc' otly to1
the types tof patients/cases recpresented in tlie'tnleta-aalysis
(maijor
vascular stirgery, maxillofacial,
muajolr(Irthopedit',
sfpin'al fuisionl, liver tratnsplantaititon) atnd are
tildouibtedly
5
and
if'
('()St
~
x'eiitetf easily" isit (filet 1 tiott'My
fpitr'flcst' inl making this
statemiitiwxas to ref ert'o(1the fact ihat iiil't
ois itcilix'vasiv't
nit't itis ( t f'
)st tfflet 1ix'e attii
hg to 'searl'tch b einI g
foircttedaiir warminig) air(' aailai)it' that are tffetctix'e inlfpre-
(
illitiaoflelatix('
iivf)otieitliil.
Most of tfit mild
iivl)totlte'l llilt tin's when Ino elilirt is iiai(' ill )i'vt'\tiiIit.
"'fe
st'totlii conlllintn
regard(inlg
ifie stattitietlt
"..iit'i'eeclt(i'otlilfii'tioii d(istti-iaiit'ts
alltgativeot'o ofic tff'et'tcattstd
('(1(1dit'e onllottiindt'dbhvinhalation(ialitstlietics." is atitiress't iniiist'x'tral it ties."
vetiiig
anit
by
5
States."'If a sinlet'ax'eriage' cost f t'atchcattegolix xas ('stahl
11sfhitd, liow is it thiatth t i'high et 'iit (atissumplft
ionhstiind Ilow
t'iiti
tiost
assluilptitions'ar
rt'tctixved.
'Tiiis i'esttti
(If
claimnig
hitspitals
[)R(
as
tt'i'
t'elitagt' (f
lt ti)i't'set'i
iliia binitldial
i
'
aflit's
(list
llrit
signific'anitly iighitr
tossandititli t'
thlit 1)R( as thlirii'
het
it'lasigif
ts.
A11Nil Jourea!/A1
itt
cand
ti?"
i ti--(oItit'gi'iaii)
ctntagt'
(f
thit
lohwv't er i'-
icatl
(Inlst ituions ref used to
,ru.4I
/!)!)!/
,',.
6 7. No. 4
307
of availalbility.) 1)ata providetd showed that hospitals viewedl
very (lifferentI things as par of he "ots" (lephllding
how
numerous overheadl costs were allocated t) costs centers.
The method that was tused follows: f'orait)DR(:,
l
"average city," for example, Minneapolis, and then calctulate
costs as a percentage of what is paid for the D)RG.
This
provided the high end (costs at 80%~ of 1)R(; paymet) and1
the low end (costs at 60% of t)R; Paynletlt) estimates
costs. The exception is
1)100( prodtucts where costs were
received from both hospitals and blood banks. The lower ('0(1
costs for blood prodttcts do not include costs for administrattion
the hlood produtcts, assuming lower cost blood
products (maybe autologouts), no extra typing, crossmatching, or labor for administering the blood prodtict.
The foutrth comment concerning "..24%7 of the
lpatients who t'emainedl hypothermic for 2 hours (liedl
compared with 4% of ptilents who remained normothermic"
and "Patients in the nortmothermic grotips.. had
lower
on
ue
for
for
of'
morttality...", we should
generated with patients
that these nlumb~ers were
and/or procedutres of high acuity
antI
dutres
While it is definitely trtue that these patients had
of high acttity, some woutld atgtt( that since some of
these studies are randomized, controlled clinical trials that
they (10, in fatct, establish cautse and effect. The only differ-
tnce be'tween patient grotsill
i this type of study is the mild
journal
intraoperative hypothmriia. As pointed outt ili a
n/'
Amierican Medical
editorial, if' most an'estliesiologists
of'
informally adopt the practice
maintaining nlormothermlia,
so that it becomes "standard ptract ice," it will become increasingly' diffictilt to do raitdotmized sttidies in the ftutre as
comtlmittees
of'
of'
antI
REFERENCES
N Lgf/Aled. I1997,336i:1I730-1737.
(2) Bunsh I Jr, I Ivdo I;4, FistcIi(r F.(Iet . 1I
I pot herria(duinig eletiv e
abdoinial aort ic' aneiirvsni Irepair: the high 1)1ice of tv( nlat)te iniithidity..1I utSig. 1995;921:392--4O2.
(3) Frank SM, Fleisher
Bresliow MJ, tet al. I iti'ai )Jt'at Vt tiin~ti"lialict'
of ioiniottiei'nia reducILes theiniicidenc e of
cariac'i
IA,
JAM A.199)7;977:
Al i
violoiugs'.
miortitd
1127-113-1.
(4) Fiank SM, IBeattie C, (
hiypothieriita
nIMI), hoiiti os A, Vani Akt'ii11, l fliiii'lig W.
it'5et I Ittit50)11
LthetiVl)( ititi iii it' iv( l lSi 11
Ft tr'r
of
J'Abstrac.
t
1 neol/u'dololgs. I990;73: \ 574.
.
fix poi lti nitlog I:\tr iaCtI . .1
uoeI/ueoo/fgN. I1979;150:291Kin ir A, Se'ssttrI )1, I.enfiid R. I'ei i01)eidiise IlOliiiith"iti iitii
I ect-di
e ilti
the i t' i n t e ut isirgitcat-wi Uintl in firticn
of )i
rn
(L
i5 aiiticni
Situty (itWoiiiid lftiit'tln ad iiitt
it-intit n t (Giip.
.' Ingi
/
I1996;334:1209-2.0)15.
(8)
4-111c1
Mtid.
sin get's?%/AM1A.
1997;277:116(5-t1166.
CHLRISTINE IBROWN MAHIONE-Y, RN, PlhI), MS
I ' 1 ii's n/ A 1lin !1soda
(1,,il~tSo
(I ol'(?/[Aa nagement
Aim Ull'I/)Oli.S,
Alip1i
11(501(1
itV
Voice and touch: Florence Henderson on
the skills of an ether specialist
To the Editor
I noIt it'tl theo talet'hat listedtliitich'cs at lioi'et by
loreiit't I Ititoleisomi, (:RNA, in "Vo)ict anid
l-lort'nt't'
I lt'mutt's( l iltilt'skills
o~f
tiether'specialist ," by ji ani
Itin.ik'r-Ih'an, CRNA, MNA (AA\AJouna. I999(0:2(3-
an
touch:
269), omiiitt'od Ms. I lt'idt'i'so i's finmal art itct. Slit wr lt' ti' last
articlt
af tt'msli t iiovt'd
( alifor-nia. It is thel it
t I citatioin
inl the tablte betlow.
to
may be reltic tanlt to apptove pro-
tocols that allow mild inttaoperativ(' hypothermia)' A randomized, (controlledtrial examining the impact
mild intraoperative hypothermia dutring pro)cedtures
less acutity wotil(l
certainly ptovide (lata and conclusions on patient otutcomes
that would be valuable to praictitioners.
I appreciate Mr. l'ie(ller's positive remarks
corninlendattion on the article generally andI hope that I have
answeredl the questions hie has posed. Further questions 01
('o1mletits concerning Illy article ar(e welcomedl via emiiailI
(cmlalio )Iey
cSon1.til nied tin)
e'veints.
L i
proce'(-
that no cause and effect was estab~lished.
hutmlan StiI)je(ts
M ttLIt'ii
tie" Vi ltit(
55%
remember
A ssociation
(6) Iii
Ciristophfison
oi K,
asiaSILted(twithIipostoil)(rative'
I
:568-476:
is
ttat.
Uinte(ntionlt
iiV()~('ilial is'hienlia.
Table.
Articles authored by Florence Henderson,
CRNA
1. Henderson F. The nurse as an anaesthetist. The
American Journal of Nursing. 1909;9:947-949.
Discussion, 950-953.
2. Henderson F. Ether Anesthesia. The Saint Paul
Medical Journal. 1914;16(2):74-81. Discussion, 8182.
3. Henderson
Ether Anesthesia. In: Collected
Papers by the Staff of St. Mary's Hospital, Mayo
Clinic, Rochester, Minnesota, 1913. Philadelphia, Pa:
WB Saunders Co; 1914:701 -708. [Reprint of previous
article with slight editorial changes and without discussion.]
4. Henderson F.Observations drawn from an experience of twenty-two thousand surgical anaesthesias.
Southern California Practitioner. 191 7;32:1 54-158.
F.
9378
NANCY A. IIARRIS, (CRNA, MNA
/,,
J I(1
A n liie(
308
iAI NA Journal/A dlgit( 1999/ V~ol.67,
No.
4
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