Process Mapping and Activity-Based Costing of the Intravitreal Injection Procedure.

PURPOSE/AIM OF THE STUDY: To quantify the cost of performing an intravitreal injection (IVI) utilizing activity-based costing (ABC), which allocates a cost to each resource involved in a manufacturing process. MATERIALS AND METHODS: A prospective, observational cohort study was performed at an urban, multi-specialty ophthalmology practice affiliated with an academic institution. Fourteen patients scheduled for an IVI-only visit with a retina ophthalmologist were observed from clinic entry to exit to create a process map of time and resource utilization. Indirect costs were allocated with ABC and direct costs were estimated based on process map observations, internal accounting records, employee interviews, and nationally-reported metrics. The primary outcome measure was the cost of an IVI procedure in United States dollars. Secondary outcomes included operating income (cost subtracted from revenue) of an IVI and patient-centric time utilization for an IVI. RESULTS: The total cost of performing an IVI was $128.28; average direct material, direct labor, and overhead costs were $2.14, $97.88, and $28.26, respectively. Compared to the $104.40 reimbursement set by the Centers for Medicare and Medicaid Services for Current Procedural Terminology code 67028, this results in a negative operating income of -$23.88 (-22.87%). The median clinic resource-utilizing time to complete an IVI was 32:58 minutes (range [19:24-1:28:37]); the greatest bottleneck was physician-driven electronic health record documentation. CONCLUSIONS: Our study provides an objective and accurate cost estimate of the IVI procedure and illustrates how ABC may be applied in a clinical context. Our findings suggest that IVIs may currently be undervalued by payors.

Three Pathways of Seclusion Reduction Programs to Sustainability: Ten Years Follow Up in Psychiatry.

From 2004 onwards, above 50 seclusion reduction programs (SRP) were developed, implemented and evaluated in the Netherlands. However, little is known about their sustainability, as to which extent obtained reduction could be maintained. This study monitored three programs over ten years seeking to identify important factors contributing to this. We reviewed documents of three SRPs that received governmental funding to reduce seclusion. Next, we interviewed key figures from each institute, to investigate the SRP documents and their implementation in practice. We monitored the number of seclusion events and the number of seclusion days with the Argus rating scale over ten years in three separate phases: 2008-2010, 2011-2014 and 2015-2017. As we were interested in sustainability after the governmental funding ended in 2012, our focus was on the last phase. Although in different rate, all mental health institutes showed some decline in seclusion events during and immediately after the SRP. After end of funding one institute showed numbers going up and down. The second showed an increase in number of seclusion days. The third institute displayed a sustained and continuous reduction in use of seclusion, even several years after the received funding. This institute was the only one with an ongoing institutional SRP after the governmental funding. To sustain accomplished seclusion reduction, a continuous effort is needed for institutional awareness of the use of seclusion, even after successful implementation of SRPs. If not, successful SRPs implemented in psychiatry will easily relapse in traditional use of seclusion.

Time-Driven Activity-Based Costing in Radiology: An Overview.

Time-driven activity-based costing (TDABC) is a cost-accounting method to assess operational costs at a process-specific level. The purpose of this review is to provide a foundational methodologic overview of TDABC and offer insights from lessons we have learned by applying TDABC in radiology. Understanding these principles can help radiology practice leaders maintain local cost-stewardship while delivering the highest quality of clinical care.

Utilizing Time-Driven Activity-Based Costing to Increase Efficiency in Ultrasound-Guided Breast Biopsy Practice.

PURPOSE: In this study, we used time-driven activity-based costing to increase efficiency in our ultrasound-guided breast biopsy practice by understanding costs associated with this procedure. METHODS: We assembled a multidisciplinary team of all relevant stakeholders involved in ultrasound-guided breast biopsies, including a radiologist, a lead technologist, a clinical assistant, a licensed practical nurse, and a procedural support assistant. The team mapped each step in an ultrasound-guided breast biopsy from the time of scheduling a biopsy to patient checkout. We completed on average 20 time observations of each step involved in these biopsies from a provider's perspective. Using capacity cost rate, we calculated the cost of all resources including personnel, supply, room, and equipment costs. Several costly steps were identified in the process, which led to the intervention of changing our overlapping biopsy times to staggered biopsy times. Time observations for each step and cost calculations were repeated postintervention. RESULTS: Our postintervention data showed that the total time spent by the radiologist in an ultrasound breast biopsy decreased by 28%, accounting for 56% of the total cost in comparison with 63% pre-intervention. The radiologist's wait time decreased by 38%, accounting for 28% of the total cost in comparison with 35% pre-intervention. Our total cost of the procedure decreased by 20%, and the personnel cost decreased by 25%. CONCLUSIONS: Time-driven activity-based costing is a practical way to calculate costs and identify non-value-added steps, which can foster strategies to improve efficiency and minimize waste.

The productivity development of total hip arthroplasty in Sweden: a multiple registry-based longitudinal study using the Malmquist Productivity Index.

OBJECTIVE: The increasing demand for total hip arthroplasty (THA) combined with limited resources in healthcare puts pressure on decision-makers in orthopaedics to provide the procedure at minimum costs and with good outcomes while maintaining or increasing access. The objective of this study was to analyse the development in productivity between 2005 and 2012 in the provision of THA. DESIGN: The study was a multiple registry-based longitudinal study. SETTING AND PARTICIPANTS: The study was conducted among 65 orthopaedic departments providing THA in Sweden from 2005 to 2012. OUTCOME MEASURES: The development in productivity was measured by Malmquist Productivity Index by relating department level total costs of THA to the number of non-cemented, hybrid and cemented THAs. We also break down the productivity change into changes in efficiency and technology. RESULTS: Productivity increased significantly in three periods (between 1.6% and 27.0%) and declined significantly in four periods (between 0.8% and 12.1%). Technology improved significantly in three periods (between 3.2% and 16.9%) and deteriorated significantly in two periods (between 10.2% and 12.6%). Significant progress in efficiency was achieved in two periods (ranging from 2.6% to 8.7%), whereas a significant regress was attained in one period (3.9%). For the time span as a whole, an average increase in productivity of 1.4% per year was found, where changes in efficiency contributed more to the improvement (1.1%) than did technical change (0.2%). CONCLUSIONS: We found a slight improvement of productivity over time in the provision of THA, which was mainly driven by changes in efficiency. Further research is, however, needed where differences in quality of care and patient case mix between departments are taken into account.

Recommended quality measures for health-system pharmacy: 2019 update from the Pharmacy Accountability Measures Work Group.

PURPOSE: Pharmacists are accountable for medication-related services provided to patients. As payment models transition from reimbursement for volume to reimbursement for value, pharmacy departments must demonstrate improvements in patient care outcomes and quality measure performance. The transition begins with an awareness of quality measures for which pharmacists and pharmacy personnel can demonstrate accountability across the continuum of care. The objective of the Pharmacy Accountability Measures (PAM) Work Group is to identify measures for which pharmacy departments can and should assume accountability. SUMMARY: The National Quality Forum (NQF) Quality Positioning System (QPS) was queried for NQF-endorsed medication-related measures. Included measures were curated into a data set of 6 therapeutic categories: antithrombotic safety, cardiovascular control, glucose control, pain management, behavioral health, and antimicrobial stewardship. Subject matter expert (SME) panels assigned to each area analyzed each measure according to a predetermined ranking system developed by the PAM Work Group. Measures remaining after SME review were disseminated during a public comment period for review and ballot. Over 1,000 measures are captured in the NQF QPS; 656 of the measures were found to be endorsed and medication use related or impacted by medication management services. A single reviewer categorized 140 measures into therapeutic categories for SME review; the remaining measures were unrelated to those clinical domains. The SME groups identified 28 measures for inclusion. CONCLUSION: An understanding of the endorsed quality measures available for public reporting programs provides an opportunity for pharmacists to demonstrate accountability for performance, thus improving quality and safety and demonstrating value of care provided.

Factors associated with adverse outcomes from cardiovascular events in the kidney transplant population: an analysis of national discharge data, hospital characteristics, and process measures.

BACKGROUND: Kidney transplant (KT) patients presenting with cardiovascular (CVD) events are being managed increasingly in non-transplant facilities. We aimed to identify drivers of mortality and costs, including transplant hospital status. METHODS: Data from the 2009-2011 Nationwide Inpatient Sample, the American Hospital Association, and Hospital Compare were used to evaluate post-KT patients hospitalized for MI, CHF, stroke, cardiac arrest, dysrhythmia, and malignant hypertension. We used generalized estimating equations to identify clinical, structural, and process factors associated with risk-adjusted mortality and high cost hospitalization (HCH). RESULTS: Data on 7803 admissions were abstracted from 275 hospitals. Transplant hospitals had lower crude mortality (3.0% vs. 3.8%, p = 0.06), and higher un-adjusted total episodic costs (Median $33,271 vs. $28,022, p < 0.0001). After risk-adjusting for clinical, structural, and process factors, mortality predictors included: age, CVD burden, CV destination hospital, diagnostic cardiac catheterization without intervention (all, p < 0.001). Female sex, race, documented co-morbidities, and hospital teaching status were protective (all, p < 0.05). Transplant and non-transplant hospitals had similar risk-adjusted mortality. HCH was associated with: age, CVD burden, CV procedures, and staffing patterns. Hospitalizations at transplant facilities had 37% lower risk-adjusted odds of HCH. Cardiovascular process measures were not associated with adverse outcomes. CONCLUSION: KT patients presenting with CVD events had similar risk-adjusted mortality at transplant and non-transplant hospitals, but high cost care was less likely in transplant hospitals. Transplant hospitals may provide better value in cardiovascular care for transplant patients. These data have significant implications for patients, transplant and non-transplant providers, and payers.

Prevalence, treatment patterns, and stay characteristics associated with hospitalizations for major depressive disorder.

BACKGROUND: Hospitalizations for major depressive disorder (MDD) are a significant burden on patients, their families, and to healthcare systems. This study characterized the prevalence of MDD hospitalizations in the US and described clinical characteristics, treatment patterns, length of stay, costs, and MDD-related hospitalization readmissions. METHODS: A retrospective analysis of the Premier Perspective® Hospital Database was conducted using records of hospital admissions for MDD from January 1, 2014 to December 31, 2015. To supplement this analysis, healthcare claims data from Truven MarketScan® Research Database were also evaluated between January 1, 2013 and December 31, 2014. RESULTS: Among adult hospital stays in the Premier network, 1.3% included a primary diagnosis of MDD. The mean length of MDD-related stays was 6 days, with a mean total hospital charge per stay of $6713. Of those with hospital stays, 5.2% of patients had at least 1 readmission for MDD within 30 days of discharge. In the MarketScan database, 4% of adults with MDD had a MDD-related hospital stay, with a mean length of stay of 6 days and total reimbursed amount per stay of $8441. Of those with hospital stays, 5.4% had at least 1 readmission for MDD within 30 days. LIMITATIONS: Results may not be generalizable to hospitals outside of those represented by these databases. CONCLUSIONS: Adult MDD hospitalizations are costly and associated with high rates of readmission. There is a need for new treatments that may help reduce hospitalizations and costs related to hospitalizations in patients with MDD.

Evaluation of the Statewide Variability in the Current Role of Different Specialties in Lower Extremity Endovascular Revascularization for Medicare Beneficiaries.

PURPOSE: To evaluate the statewide variability in the role of different specialties in lower extremity endovascular revascularization (LEER) and associated submitted charges of care and actual reimbursement for Medicare beneficiaries. METHODS: The 2015 "Medicare Provider Utilization and Payment Data: Physician and Other Supplier" data includes provider-specific information regarding the type of service, submitted average charges of care, and actual average Medicare reimbursements per Healthcare Common Procedure Coding System (HCPCS) code per provider. All HCPCS codes related to LEER were identified. The role of vascular surgery (VS), interventional cardiology (IC), and interventional radiology (IR) in each HCPCS-specific intervention was investigated. RESULTS: In 2015, 4113 providers submitted claims for iliac (n = 13,659), femoropopliteal (n = 52,344), and tibioperoneal (n = 32,688) endovascular revascularizations. In the facility setting, VS performed most of these procedures (52%), followed by IC (32%) and IR (8%). In the outpatient-based lab setting, the proportions were 46%, 36%, and 13%, respectively. Substantial statewide variability in the role of different specialties in LEER was noted. In Maine, Vermont, and Hawaii, all facility claims were submitted by VS, while more than 70% of the claims in Arizona and Utah were submitted by IC. The highest share of LEER for IR was observed in Montana and North Dakota (50%). There was substantial statewide variability in the submitted charges. CONCLUSION: Currently, less than 10% of LEER procedures are being performed by IR. The statewide variability in the submitted charges of care by providers and actual reimbursement for Medicare beneficiaries were investigated in this study.

A dual-perspective analysis of the hospital and payer-borne burdens of selected in-hospital surgical complications in low anterior resection for colorectal cancer.

OBJECTIVES: The economic burden of surgical complications is borne in distinctly different ways by hospitals and payers. This study quantified the incidence and economic burden - from both the hospital and payer perspective - of selected major colorectal surgery complications in patients undergoing low anterior resection (LAR) for colorectal cancer. METHODS: Retrospective, observational study of patient undergoing LAR for colorectal cancer between 1/1/2010 and 7/1/2015. Analyses were replicated in two large healthcare administrative databases: Premier (hospital discharge and billing data; hospital perspective) and Optum (insurance claims data; payer perspective). Multivariable analyses evaluated the association between infection (surgical site or bloodstream), anastomotic leak, and bleeding complications and the following outcomes: hospital length of stay (LOS), non-home discharge, 90-day all-cause readmission, index admission costs to the hospital, index admission payer expenditures, and index admission +90-day post-discharge payer expenditures. RESULTS: 9,738 eligible LAR patients were included (7,479 in Premier; 2,259 in Optum). Overall, the incidences of infection, anastomotic leak, and bleeding complications were 6.4%, 10.6%, and 10.9%, respectively, during the index hospitalization. Each complication was associated with statistically significant longer LOS, higher risk of non-home discharge, higher risk of 90-day readmission, greater costs to the hospital, and higher payer expenditures. CONCLUSIONS: In-hospital infection, anastomotic leak, and bleeding were associated with a substantial economic burden, for both hospitals and payers, in patients undergoing LAR for colorectal cancer. This study provides information which may be used to quantify the potential economic value and impact of innovations in surgical care and delivery that reduce the incidence and burden of these complications.

A Decade of Thoracic Endovascular Aortic Aneurysm Repair in New York State: Volumes, Outcomes, and Implications for the Dissemination of Endovascular Technology.

BACKGROUND: The purpose of this study was to characterize utilization and outcomes of thoracic endovascular aortic aneurysm repair (TEVAR) in New York State during the first decade of commercial availability, with respect to evolving indications, results, and costs. Of specific interest was evaluation of the volume-outcome relationship for this relatively uncommon procedure. METHODS: The New York Statewide Planning and Research Cooperative System database was queried to identify patients undergoing TEVAR from 2005 to 2014 for aortic dissection (AD), non-ruptured aneurysm (NRA), and ruptured aneurysm (RA). Outcomes assessed included in-hospital mortality, complications, and costs. Linkage to the National Provider Identifier and New York Office of Professions databases facilitated comparisons by surgeon and facility volume. RESULTS: One thousand eight hundred thirty-eight patients were identified: 334 AD, 226 RA, and 1,278 NRA. Since introduction, TEVAR implantation increased significantly over the 10-year period in all groups (P < 0.01), with recent increase in utilization for AD. Increased in-hospital mortality correlated with RA (OR 5.52 [3.02-10.08], P < 0.01), coagulopathy (3.38 [2.02-5.66], P < 0.01), cerebrovascular disease (2.47 [1.17-5.22], P = 0.02), and nonwhite/nonblack race (1.74 [1.08-2.82], P = 0.02). Early in the experience (2005-2007), patients were more likely to be treated at high-volume facilities (>17 per year) and by high-volume surgeons (>5 per year), (P < 0.01). Since 2011, however, most patients (53%) have undergone TEVAR by low-volume surgeons (<3 per year). Neither surgeon nor hospital volume was associated with clinical outcomes. CONCLUSIONS: Since the introduction of TEVAR, comparable results have been obtained across hospital and surgeon volume strata. Favorable outcomes, even in low-volume settings, underscore the complexity of volume-outcome relationships in high-acuity procedures. These findings have implications for credentialing, regionalization, and future dissemination of advanced endovascular technology.

Claims Variability in Charges and Payments for Common Open and Endovascular Procedures.

BACKGROUND: Cost-effectiveness in healthcare is being increasingly scrutinized. Data regarding claims variability for vascular operations are lacking. Herein, we aim to describe variability in charges and payments for aortoiliac (AI) and infrainguinal (II) revascularizations. METHODS: We analyzed 2012-2014 claims data from a statewide claims database for procedures grouped by Current Procedural Terminology codes into II-open (II-O), II-endovascular (II-E), AI-open (AI-O), and AI-endovascular interventions (AI-E). We compared charges and payments in urban (≥50,000 people, UAs) versus rural areas (<50,000 people, RAs). Amounts are reported in $US as median with interquartile range. Cost-to-charge ratios (CCRs) as a measure of reimbursement were calculated as the percentage of the charges covered by the payments. Wilcoxon rank-sum tests were performed to determine significant differences. RESULTS: A total of 5,239 persons had complete claims data. There were 7,239 UA and 6,891 RA claims, and 1,057 AI claims (AI-E = 879, AI-O = 178) and 4,182 II claims (II-E = 3,012, II-0 = 1,170). Median charges were $5,357 for AI [$1,846-$27,107] and $2,955 for II [$1,484-$9,338.5] (P < 0.0001). Median plan payment was $454 for AI [$0-$1,380] and $454 for II [$54-$1,060] (P = 0.67). For AI and II, charges were significantly higher for UA than RA (AI: UA $9,875 [$2,489-$34,427], RA $3,732 [$1,450-$20,595], P < 0.0001; II: UA $3,596 [$1,700-$21,664], RA $2,534 [$1,298-$6,169], P < 0.0001). AI-E charges were higher than AI-O (AI-E $7,960 [$1,699-$32,507], AI-O $4,774 [$2,636-$7,147], P < 0.0001), but AI-O payments were higher (AI-E $424 [$0-$1,270], AI-O $869 [$164-$1,435], P = 0.0067). II-E charges were higher (II-E $2,994 [$1,552-$22,164], II-O $2,873 [$1,108-$5,345], P < 0.0001), but II-O payments were higher (II-E $427 [$50-$907], II-O $596 [$73-$1,299], P < 0.0001). CCRs were highest for II operations and UAs. CONCLUSIONS: Wide variability in claim charges and payments exists for vascular operations. AI procedures had higher charges than II, without any difference in payments. UA charged more than RA for both AI and II operations, but RA had higher payments and CCRs. Endovascular procedures had higher charges, while open procedures had higher payments. Charge differences may be related to endovascular device costs, and further research is necessary to determine the reasons behind consistent claims variability between UA and RA.

Managing the Economic Challenges in the Treatment of Heart Failure.

The economics of heart failure (HF) touches all patients with HF, their families, and the physicians and health systems that care for them. HF is specifically targeted by cost-reduction and care quality initiatives from the Centers for Medicare and Medicaid Services (CMS). The changing quality assessment and payment landscape is, and will continue to be, challenging for hospitals and HF specialists as they provide care for patients with this debilitating disease. Quality-based payment systems with evolving performance metrics are replacing traditional volume-based fee-for-service models. A critical objective of quality-based models is to improve care and reduce cost, but there are few data to support decision-making on how to improve. CMS payment programs and their implications for health systems treating HF were reviewed at a symposium at the Heart Failure Society of America conference in Nashville, Tennessee on September 15, 2018. This article constitutes the proceedings from that symposium.

Effect of hospital volume on outcomes of percutaneous peripheral atherectomy - An observational analysis from National Inpatient Sample.

BACKGROUND: Although the published literature has reported an inverse association between hospital volume and outcomes of coronary interventions, sparse data are available for percutaneous peripheral atherectomy (PPA). The aim of our study was to examine the effect of hospital volume on outcomes of PPA. METHODS: Using the Nationwide Inpatient Sample (NIS) database of the year 2012, PPA with ICD-9 code of 17.56 was identified. The primary outcomes were mortality and amputation rates; secondary outcomes were peri-procedural complications, cost, and length of hospitalization and discharge disposition of the patient. Multivariate models were generated for predictors of the outcomes. RESULTS: We identified a total of 21,015 patients with mean age of 69.53 years, with 56% males. Higher hospital volume centers were associated with a significantly lower mortality (OR 0.42, 95% CI 0.30-0.57, p < 0.0001), amputation rates (5.34% vs. 9.32%, p < 0.0001), combined endpoint of mortality and complications (OR 0.53, 95% CI 0.49-0.58, p < 0.0001), shorter length of hospital stay (LOS) (4.86 vs. 6.79 days, p < 0.0001) and lower hospitalization cost ($23,062 vs. $30,794, p < 0.0001). Subgroup analysis for acute and chronic limb ischemia showed similar results. CONCLUSION: Hospital procedure volume is an independent predictor of mortality, amputation rates, complications, LOS, and costs in patients undergoing PPA with an inverse relationship.

Predictors of high-cost hospitalization in the treatment of acute coronary syndrome in Asia: findings from EPICOR Asia.

BACKGROUND: The EPICOR Asia (long-tErm follow-uP of antithrombotic management patterns In acute CORonary syndrome patients in Asia) study (NCT01361386) was an observational study of patients hospitalized for acute coronary syndromes (ACS) enrolled in 218 hospitals in eight countries/regions in Asia. This study examined costs, length of stay and the predictors of high costs during an ACS hospitalization. METHODS AND RESULTS: Data for patients hospitalized for an ACS (n = 12,922) were collected on demographics, medical history, event characteristics, socioeconomic and insurance status at discharge. Patients were followed up at 6 weeks' post-hospitalization for an ACS event to assess associated treatment costs from a health sector perspective. Primary outcome was the incurring of costs in the highest quintile by country and index event diagnosis, and identification of associated predictors. Cost data were available for 10,819 patients. Mean length of stay was 10.1 days. The highest-cost countries were China, Singapore, and South Korea. Significant predictors of high-cost care were age, male sex, income, country, prior disease history, hospitalization in 3 months before index event, no dependency before index event, having an invasive procedure, hospital type and length of stay. CONCLUSIONS: Substantial variability exists in healthcare costs for hospitalized ACS patients across Asia. Of concern is the observation that the highest costs were reported in China, given the rapidly increasing numbers of procedures in recent years. TRIAL REGISTRATION: NCT01361386 .

Health Care Utilization and Expenditures Following Diagnosis of Nontuberculous Mycobacterial Lung Disease in the United States.

BACKGROUND: Nontuberculous mycobacterial lung disease (NTMLD) is an important public health concern that has been increasing in prevalence. OBJECTIVES: To (a) describe hospitalizations and health care expenditures among patients with newly diagnosed NTMLD and (b) estimate attributable hospitalizations and expenditures to NTMLD in the United States. METHODS: In this matched cohort study, patients and controls were identified from a large U.S. national managed care insurance database containing aggregated health claims of up to 18 million fully covered members annually. NTMLD was defined based on diagnostic claims for NTMLD on ≥ 2 separate occasions ≥ 30 days apart between 2007 and 2016. Thirty-six months of continuous enrollment (12 months before and 24 months after the first diagnostic claim) was required. Health care utilization and standardized health care expenditures were summarized over 12 months before NTMLD diagnosis and for 2 subsequent years. The percentage of patients that were hospitalized in years 1 and 2 was evaluated using a generalized mixed effects model with adjustment for baseline hospitalizations, Charlson Comorbidity Index, and baseline diseases. A general estimating equation model was used to evaluate health care expenditures. RESULTS: There were 1,039 patients in the NTMLD cohort and 2,078 in the control cohort. NTMLD patients had a 55.0% risk of hospitalization in year 1 (95% CI = 45.4-64.3) and a 38.8% risk in year 2 (95% CI = 30.0-48.4). The adjusted risk of hospitalization was significantly higher in the NTMLD group compared with the control group in year 1 (OR = 4.64; 95% CI = 3.74-5.76; P < 0.001) and year 2 (OR = 2.26; 95% CI = 1.78-2.87; P < 0.001). Year 1 adjusted mean health care expenditures for the total NTMLD patient population were $72,475 (95% CI = $58,510-$86,440) and for the matched control population were $28,405 (95% CI = $8,859-$47,950), with a difference of $44,070 (95% CI = $27,132-$61,008; P < 0.001). Year 2 adjusted mean expenditures for the overall NTMLD patient group were $48,114 (95% CI = $31,722-$64,507) and for the matched control group were $28,990 (95% CI = $9,429-$48,552), with a difference of $19,124 (95% CI = $7,865-$30,383; P < 0.001). CONCLUSIONS: Patients with NTMLD have a significantly greater risk of hospitalization and higher total health care expenditures than matched control patients without NTMLD. DISCLOSURES: This study was financially sponsored by Insmed. Marras reports fees from Insmed, Astra Zeneca, RedHill, and Horizon, all outside the current work. Mirsaeidi has nothing to disclose. Eagle, Q. Zhang, Chou, and Leuchars are employees of Insmed. R. Zhang is a contracted consultant at Insmed. The views expressed here are those of the authors and are not to be attributed to their respective affiliations.

Systematic analysis of annual health resource utilization and costs in hospitalized patients with inflammatory bowel disease in Switzerland.

BACKGROUND AND AIMS: Real-life data on health resource utilization and costs of hospitalized patients with inflammatory bowel disease are lacking in Switzerland. We aimed to assess health resource utilization and costs during a 1-year follow-up period starting with an index hospitalization. PATIENTS AND METHODS: On the basis of claims data of the Helsana health insurance group, health resource utilization was assessed and costs reimbursed by mandatory basic health insurance [in Swiss Francs (CHF); 1 CHF=0.991 US$] were calculated during a 1-year follow-up period starting with an index hospitalization in the time period between 1 January 2013 and 31 December 2014. RESULTS: Of 202 002 patients with at least one hospitalization in 2013-2014, a total of 270 (0.13%) patients had inflammatory bowel disease as main diagnosis [112 (41.5%) ulcerative colitis (UC), 158 (58.5%) Crohn's disease (CD), 154/270 (57.0%) females]. In comparison with patients with UC, patients with CD were significantly more frequently treated with biologics (45.6 vs. 20.5%, P<0.001) and more frequently underwent surgery during index hospitalization (27.8 vs. 9.8%, P=0.002). Compared with patients with UC, those with CD had significantly more consultations [odds ratio (OR): 1.06, 95% confidence interval (CI): 1.01-1.12, P=0.016], higher median annual total costs (OR: 1.25, 95% CI: 1.05-1.48, P=0.012), and higher outpatient costs (OR: 1.33, 95% CI: 1.07-1.66, P=0.011). In the bivariate model, median total costs for patients with CD and those with UC were 24 270 and 17 270 CHF, respectively (P=0.032). CONCLUSION: When compared with patients with UC, hospitalized patients with CD have during a 1-year follow-up a higher rate of outpatient consultations and generate higher costs.

A Unique All-Payer Rate-Setting System Controls the Cost but Not the Racial Disparity in Lower Extremity Revascularization Procedures.

BACKGROUND: Patients with peripheral arterial disease often have high comorbidity burden that may complicate post-interventional course and drive increased health-care expenditures. Racial disparity had been observed in lower extremity revascularization (LER) patterns and outcomes. In 2014, Maryland adopted an all-payer rate-setting system to limit the rising hospitalization costs. This resulted in an aggregate payment system in which hospital compensation takes place as an overall per capita expenditure for hospital services. We sought to examine racial differences and other patient-level factors that might lead to discrepancies in LER hospital costs in the State of Maryland. METHODS: We used International Classification of Diseases, Ninth Revision codes to identify patients who underwent infrainguinal open bypass (open) and endovascular repair (endo) in the Maryland Health Services Cost Review Commission database (2009-2015). Multivariable generalized linear model regression analysis was conducted to report cost differences adjusting for patient-specific demographics, comorbidities, and insurance status. Logistic regression analysis was used to assess quality metrics: intensive care unit (ICU) admission, 30-day readmission, protracted length of stay (pLOS) (endo: pLOS >9, open: pLOS > 10 days) and in-hospital mortality. RESULTS: Among patients undergoing open, costs were higher for nonwhite patients (African-American [AA]: $6,092 [4,682-7,501], other: $3,324 [437-6,212]; both P ≤ 0.024), diabetics ($2,058 [837-3,279]; P < 0.001), and patients with Medicaid had an increased cost over Medicare patients by $4,325 (1,441-7,209). Critical limb ischemia (CLI) was associated with $5,254 (4,014-6,495) risk-adjusted cost increment. In addition, AA patients demonstrated higher risk-adjusted odds of ICU admission (adjusted odds ratio [aOR] [95% confidence interval {CI}]:1.65 [1.46-1.86]; P < 0.001) and pLOS (aOR [95% CI]: 1.56 [1.37-1.79]; P < 0.001) than their white counterparts. For patients undergoing endo, costs were higher for nonwhite patients (AA: $2,642 [1,574-3,711], other: $4,124 [2,091-6,157]; both P < 0.001). Patients with CLI and heart failure had increased costs after endo. AA patients were more likely to be readmitted or stayed longer after endo (1.16 [1.03-1.29], 1.34 [1.21-1.49]; both P < 0.010, respectively). The overall cost trend was rapidly increasing before all-payer rate policy implementation but it dramatically plateaued after 2014. CONCLUSIONS: This study showed that the all-payer rate-setting system has curbed the LER rising costs, but these costs remained disproportionally higher for disadvantaged populations such as AA and Medicaid communities. This underpins the existing racial disparity in LER. AA patients had higher LER costs, most likely driven by extended hospitalization and ICU admission. Efforts could be directed to evaluate the contributing socioeconomic factors, invest in primary prevention of comorbid conditions that had shown to be associated with prohibitive costs, and identify mechanisms to overcome the existing racial disparity in LER within the promising cost-saving payment system at the State of Maryland.

Biting the Hands that Feed "the Alligators": A Case Study in Morbid Obesity Extremes, End-of-Life Care, and Prohibitions on Harming and Accelerating the End of Life.

Obesity, recognized as a disease in the U.S. and at times as a terminal illness due to associated medical complications, is an American epidemic according to the Centers for Disease Control and Prevention ("CDC"), American Heart Association ("AHA"), and other authorities. More than one third of Americans (39.8% of adults and 18.5% of children) are medically obese. This article focuses on cases of "extreme morbid obesity" ("EMO")-situations in which death is imminent without aggressive medical interventions, and bariatric surgery is the only treatment option with a realistic possibility of success. Bariatric surgeries themselves are very high risk for EMO patients. Individuals in this state have impeded mobility and are partially, if not entirely, bedridden, highly vulnerable, and dependent upon caregivers who often are enablers feeding their food addictions. The article draws from existing Centers for Medicare and Medicaid Services ("CMS") and Social Security Administration ("SSA") policies and procedures for severe obesity treatment and disability benefits. The discussion also encompasses myriad areas in which the law imposes a duty to report on professionals to protect vulnerable individuals from harm from others, and constraints and prohibitions on accelerating the end of life. The article proposes, among other law and policy measures, to introduce an obligation on medical professionals to investigate and report instances of enablement when food addiction has put the lives of individuals at risk of imminent death. The objectives of the proposals are to give providers more leverage to prevent food addiction enablers from impeding treatment and to enable EMO patients to comply with treatment protocols, to save lives and, ironically, to empower enablers to stand firm against the demands of individuals whose lives have been consumed by their food addictions.