Skin signs in the diagnosis of thallium poisoning

OBJECTIVES: We sought to determine the cost advantage of a strategy of same-sitting diagnostic catheterization and percutaneous transluminal coronary angioplasty (PTCA) (ad hoc) in comparison with staged PTCA. BACKGROUND: It is widely assumed that an ad hoc strategy lowers costs by reducing the length of hospital stay (LOS). However, this assumption has not been examined in a contemporary data set. METHODS: We studied 395 patients undergoing PTCA during 6 consecutive months. Cost analysis was performed using standard cost-accounting methods and a mature cost-accounting system. Costs were examined within three clinical strata based on the indication for PTCA (stable angina, unstable angina and after myocardial infarction [MI]). RESULTS: For the entire patient cohort, there was no significant cost advantage of an ad hoc approach within any of the strata, although there was a nonsignificant trend toward an ad hoc approach in patients with stable angina. For patients treated with conventional balloon PTCA alone, the lack of a significant difference between ad hoc and staged strategies persisted. For patients who received stents, there was a significant cost advantage of an ad hoc approach in all three clinical strata. An important cost driver was the occurrence of complications. Differences in the rates of complications did not reach statistical significance between ad hoc and staged strategies, but even a small trend toward greater complications in patients who had the ad hoc strategy negated cost and LOS advantages. Our study had the power to detect significant cost differences of $1,300 for patients with stable angina, $2,100 for patients with unstable angina and $2,500 for post-MI patients. It is possible that we failed to detect smaller cost advantages as significant. CONCLUSIONS: A cost savings with an ad hoc strategy of PTCA could not be consistently demonstrated. The cost advantage of an ad hoc approach may be most readily realized in clinical settings where the intrinsic risks are low (e.g., stable angina) or in which the device used carries a reduced risk of complications (e.g., stenting), because even a small increase in the complication rate will negate any financial advantage of an ad hoc approach.