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Objective: Technology-based programs can be cost-effective in the management of chronic obstructive pulmonary disease (COPD). However, cost-effectiveness estimates always contain some uncertainty, and decisions based upon them carry some risk. We conducted a value of information (VOI) analysis to estimate the value of additional research of a web-based self-management intervention for COPD to reduce the costs associated with uncertainty. Methods: We used a 10,000-iteration cost-effectiveness model from the health care payer perspective to calculate the expected value of perfect information (EVPI) at the patient- and population-level. An opportunity loss was incurred when the web-based intervention did not produce a greater net monetary benefit than usual care in an iteration. We calculated the probability of opportunity loss and magnitude of opportunity costs as a function of baseline health utility. We aggregated opportunity costs over the projected incident population of inpatient COPD patients over 10 years and estimated it as a function of the willingness-to-pay (WTP) threshold. Costs are in 2022 U.S. Dollars. Results: Opportunity losses were found in 22.7% of the iterations. The EVPIpatient was $78 per patient (95% confidence interval: $75-$82). The probability that the intervention was the optimal strategy varied across baseline health utilities. The EVPIpopulation was $506,666,882 over 10 years for a WTP of $50,000. Conclusions: Research estimated to cost up to $500 million would be warranted to reduce uncertainty. Future research could focus on identifying the impact of baseline health utilities to maximize the cost savings of the intervention. Other considerations for future research priorities include implementation efforts for technology-based interventions.
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Intervención basada en la Internet , Enfermedad Pulmonar Obstructiva Crónica , Automanejo , Humanos , Enfermedad Pulmonar Obstructiva Crónica/terapia , Probabilidad , Análisis Costo-BeneficioRESUMEN
BACKGROUND: Stroke prevalence varies by race/ethnicity, as do the risk factors that elevate the risk of stroke. Prior analyses have suggested that American Indian/Alaskan Natives (AI/AN) have higher rates of stroke and vascular risk factors. METHODS: We included biyearly data from the 2011-2021 Behavioral Risk Factor Surveillance System (BRFSS) surveys of adults (age ≥18) in the United States. We describe survey-weighted prevalence of stroke per self-report by race and ethnicity. In patients with self-reported stroke (SRS), we also describe the prevalence of modifiable vascular risk factors. RESULTS: The weighted number of U.S. participants represented in BRFSS surveys increased from 237,486,646 in 2011 to 245,350,089 in 2021. SRS prevalence increased from 2.9% in 2011 to 3.3% in 2021 (p<0.001). Amongst all race/ethnicity groups, the prevalence of stroke was highest in AI/AN at 5.4% and 5.6% in 2011 and 2021, compared to 3.0% and 3.4% for White adults (p<0.001). AI/AN with SRS were also the most likely to have four or more vascular risk factors in both 2011 and 2021 at 23.9% and 26.4% compared to 18.2% and 19.6% in White adults (p<0.001). CONCLUSION: From 2011-2021 in the United States, AI/AN consistently had the highest prevalence of self-reported stroke and highest overall burden of modifiable vascular risk factors. This persistent health disparity leaves AI/AN more susceptible to both incident and recurrent stroke.
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Nativos Alasqueños , Sistema de Vigilancia de Factor de Riesgo Conductual , Autoinforme , Accidente Cerebrovascular , Humanos , Prevalencia , Masculino , Femenino , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/etnología , Accidente Cerebrovascular/diagnóstico , Estados Unidos/epidemiología , Persona de Mediana Edad , Factores de Riesgo , Adulto , Anciano , Factores de Tiempo , Medición de Riesgo , Adulto Joven , Adolescente , Indio Americano o Nativo de Alaska , Indígenas Norteamericanos , Disparidades en el Estado de Salud , Factores RacialesRESUMEN
Objective: To evaluate the cost-effectiveness of a technology-based physical activity (PA) intervention for chronic obstructive pulmonary disease (COPD). Design: A secondary data analysis was performed from a randomized controlled trial in COPD of an activity monitor alone or an activity monitor plus a web-based PA intervention. Models estimated cost per quality-adjusted life year (QALY) and incremental cost-effectiveness ratios (ICERs) compared with usual care. Results: The estimated ICER for both groups was below the willingness-to-pay threshold of $50,000/QALY (activity monitor alone = $10,437/QALY; website plus activity monitor intervention = $13,065/QALY). A probabilistic simulation estimated 76% of the activity monitor-alone group and 78% of the intervention group simulations to be cost-effective. Conclusion(s): Both the activity monitor-alone group and the activity monitor plus website group were cost-effective at the base case by using conventional willingness-to-pay thresholds. Further research would benefit from a more direct estimate of health utilities and downstream health care costs. Clinical Trials.gov NCT01102777.
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Ejercicio Físico , Enfermedad Pulmonar Obstructiva Crónica , Análisis Costo-Beneficio , Humanos , Enfermedad Pulmonar Obstructiva Crónica/terapia , TecnologíaRESUMEN
OBJECTIVES: With growing evidence of its efficacy for patients with large-vessel occlusion (LVO) ischemic stroke, the use of endovascular thrombectomy (EVT) has increased. The "weekend effect," whereby patients presenting during weekends/off hours have worse clinical outcomes than those presenting during normal working hours, is a critical area of study in acute ischemic stroke (AIS). Our objective was to evaluate whether a "weekend effect" exists in patients undergoing EVT. METHODS: This retrospective, cross-sectional analysis of the 2016-2018 Nationwide Inpatient Sample data included patients ≥18 years with documented diagnosis of ischemic stroke (ICD-10 codes I63, I64, and H34.1), procedural code for EVT, and National Institutes of Health Stroke Scale (NIHSS) score; the exposure variable was weekend vs. weekday treatment. The primary outcome was in-hospital death; secondary outcomes were favorable discharge, extended hospital stay (LOS), and cost. Logistic regression models were constructed to determine predictors for outcomes. RESULTS: We identified 6052 AIS patients who received EVT (mean age 68.7±14.8 years; 50.8% female; 70.8% White; median (IQR) admission NIHSS 16 (10-21). The primary outcome of in-hospital death occurred in 560 (11.1%); the secondary outcome of favorable discharge occurred in 1039 (20.6%). The mean LOS was 7.8±8.6 days. There were no significant differences in the outcomes or cost based on admission timing. In the mixed-effects models, we found no effect of weekend vs. weekday admission on in-hospital death, favorable discharge, or extended LOS. CONCLUSION: These results demonstrate that the "weekend effect" does not impact outcomes or cost for patients who undergo EVT for LVO.
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Atención Posterior , Procedimientos Endovasculares , Accidente Cerebrovascular Isquémico/terapia , Trombectomía , Anciano , Anciano de 80 o más Años , Estudios Transversales , Bases de Datos Factuales , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/economía , Procedimientos Endovasculares/mortalidad , Femenino , Costos de Hospital , Mortalidad Hospitalaria , Humanos , Pacientes Internos , Accidente Cerebrovascular Isquémico/diagnóstico , Accidente Cerebrovascular Isquémico/economía , Accidente Cerebrovascular Isquémico/mortalidad , Tiempo de Internación , Masculino , Persona de Mediana Edad , Alta del Paciente , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Trombectomía/efectos adversos , Trombectomía/economía , Trombectomía/mortalidad , Factores de Tiempo , Resultado del Tratamiento , Estados UnidosRESUMEN
BACKGROUND: Studies have shown worse outcomes in patients with comorbid ischemic stroke (IS) and coronavirus disease 2019 (COVID-19), but have had small sample sizes. METHODS: We retrospectively identified patients in the Vizient Clinical Data Base® with IS as a discharge diagnosis. The study outcomes were in-hospital death and favorable discharge (home or acute rehabilitation). In the primary analysis, we compared IS patients with laboratory-confirmed COVID-19 (IS-COVID) discharged April 1-July 31, 2020 to pre-COVID IS patients discharged in 2019 (IS controls). In a secondary analysis, we compared a matched cohort of IS-COVID patients to patients within the IS controls who had pneumonia (IS-PNA), created with inverse-probability-weighting (IPW). RESULTS: In the primary analysis, we included 166,586 IS controls and 2086 IS-COVID from 312 hospitals in 46 states. Compared to IS controls, IS-COVID were less likely to have hypertension, dyslipidemia, or be smokers, but more likely to be male, younger, have diabetes, obesity, acute renal failure, acute coronary syndrome, venous thromboembolism, intubation, and comorbid intracerebral or subarachnoid hemorrhage (all p<0.05). Black and Hispanic patients accounted for 21.7% and 7.4% of IS controls, respectively, but 33.7% and 18.5% of IS-COVID (p<0.001). IS-COVID, versus IS controls, were less likely to receive alteplase (1.8% vs 5.6%, p<0.001), mechanical thrombectomy (4.4% vs. 6.7%, p<0.001), to have favorable discharge (33.9% vs. 66.4%, p<0.001), but more likely to die (30.4% vs. 6.5%, p<0.001). In the matched cohort of patients with IS-COVID and IS-PNA, IS-COVID had a higher risk of death (IPW-weighted OR 1.56, 95% CI 1.33-1.82) and lower odds of favorable discharge (IPW-weighted OR 0.63, 95% CI 0.54-0.73). CONCLUSIONS: Ischemic stroke patients with COVID-19 are more likely to be male, younger, and Black or Hispanic, with significant increases in morbidity and mortality compared to both ischemic stroke controls from 2019 and to patients with ischemic stroke and pneumonia.
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COVID-19/epidemiología , Accidente Cerebrovascular Isquémico/epidemiología , Adolescente , Adulto , Factores de Edad , Anciano , COVID-19/diagnóstico , COVID-19/mortalidad , COVID-19/terapia , Comorbilidad , Bases de Datos Factuales , Femenino , Mortalidad Hospitalaria , Humanos , Accidente Cerebrovascular Isquémico/diagnóstico , Accidente Cerebrovascular Isquémico/mortalidad , Accidente Cerebrovascular Isquémico/terapia , Masculino , Persona de Mediana Edad , Alta del Paciente , Factores Raciales , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores Sexuales , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos , Adulto JovenRESUMEN
OBJECTIVES: To assess the impact of computerized prescriber order entry (CPOE) on opioid-prescribing practices. METHODS: This study analyzed 233,390 office-based medical visits in the 2011-2015 National Ambulatory Medical Care Survey. We used survey-adjusted logistic regression analysis comparing prescription of opiate medications by physicians with and without CPOE. Results were adjusted by covariates describing patient demographics, insurance status, and geography; clinical factors including noncancer pain, cancer, and other chronic medical problems; and physician specialty category and solo practitioner status. RESULTS: Opiates were prescribed in 10.4% of patient visits to physicians with access to CPOE in the sample, compared with 7.5% of visits to physicians without access to CPOE. The adjusted odds of opiate prescription were 1.35 times greater in visits to physicians who had access to CPOE (P = 0.001; 95% CI 1.14-1.58). Among patients visits citing pain (n = 52,978), the adjusted odds of opioid prescription were significantly greater when physicians had access to CPOE (odds ratio 1.28, 95% CI 1.02-1.61; P = 0.035). CONCLUSION: These findings support efforts to review and redesign embedded CPOE tools to improve guideline adherence and reduce problematic opiate prescription.
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Atención Ambulatoria/estadística & datos numéricos , Prescripciones de Medicamentos/estadística & datos numéricos , Sistemas de Entrada de Órdenes Médicas/estadística & datos numéricos , Alcaloides Opiáceos/uso terapéutico , Estudios Transversales , Adhesión a Directriz , Encuestas de Atención de la Salud , Humanos , Sistemas de Entrada de Órdenes Médicas/normas , Errores de Medicación/estadística & datos numéricos , Médicos , Pautas de la Práctica en Medicina/estadística & datos numéricos , PrescripcionesRESUMEN
Objective To assess the association of neurologist ambulatory care with healthcare utilization and expenditure in headache. Methods This was a longitudinal cohort study from two-year duration panel data, pooled from 2002-2013, of adult respondents identified with diagnostic codes for headache in the Medical Expenditure Panel Survey. Those with a neurologist ambulatory care visit in year one of panel participation were compared with those who did not for the change in annual aggregate direct headache-related health care costs from year one to year two of panel participation, inflated to 2015 US dollars. Results were adjusted via multiple linear regression for demographic and clinical variables, utilizing survey variables for accurate estimates and standard errors. Results Eight hundred and eighty-seven respondents were included, with 23.3% (207/887) seeing a neurologist in year one. The neurologist group had higher year-one mean headache-related expenditures ($3032 vs. $1636), but nearly equal mean year-two expenditures compared to controls ($1900 vs. $1929). Adjusted association between neurologist care and difference in mean annual expenditures from year two to year one was -$1579 (95% CI -$2468, -$690, p < 0.001). Conclusion Among headache sufferers, particularly those with higher headache-related healthcare expenditures, neurologist care is associated with a significant reduction in costs over two years.
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Atención Ambulatoria/economía , Cefalea/economía , Gastos en Salud/estadística & datos numéricos , Neurólogos/economía , Adulto , Anciano , Femenino , Humanos , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Estados UnidosAsunto(s)
Síndrome Coronario Agudo/epidemiología , Isquemia Encefálica/epidemiología , COVID-19/epidemiología , Accidente Cerebrovascular Isquémico/epidemiología , Alta del Paciente/tendencias , Síndrome Coronario Agudo/diagnóstico , Anciano , Anciano de 80 o más Años , Isquemia Encefálica/diagnóstico , COVID-19/diagnóstico , Femenino , Humanos , Accidente Cerebrovascular Isquémico/diagnóstico , Masculino , Estudios Retrospectivos , Estados Unidos/epidemiologíaRESUMEN
OBJECTIVES: We compared the incremental cost-effectiveness of 2 primary molar sealant strategies-always seal and never seal-with standard care for Medicaid-enrolled children. METHODS: We used Iowa Medicaid claims data (2008-2011), developed a tooth-level Markov model for 10 000 teeth, and compared costs, treatment avoided, and incremental cost per treatment avoided for the 2 sealant strategies with standard care. RESULTS: In 10 000 simulated teeth, standard care cost $214 510, always seal cost $232 141, and never seal cost $186 010. Relative to standard care, always seal reduced the number of restorations to 340 from 2389, whereas never seal increased restorations to 2853. Compared with standard care, always seal cost $8.12 per restoration avoided (95% confidence interval [CI] = $4.10, $12.26; P ≤ .001). Compared with never seal, standard care cost $65.62 per restoration avoided (95% CI = $52.99, $78.26; P ≤ .001). CONCLUSIONS: Relative to standard care, always sealing primary molars is more costly but reduces subsequent dental treatment. Never sealing costs less but leads to more treatment. State Medicaid programs that do not currently reimburse dentists for primary molar sealants should consider reimbursement for primary molar sealant procedures as a population-based strategy to prevent tooth decay and reduce later treatment needs in vulnerable young children.
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Medicaid , Diente Molar , Selladores de Fosas y Fisuras/economía , Adolescente , Niño , Preescolar , Intervalos de Confianza , Análisis Costo-Beneficio , Bases de Datos Factuales , Atención Dental para Niños/economía , Humanos , Reembolso de Seguro de Salud , Iowa , Cadenas de Markov , Medicaid/economía , Selladores de Fosas y Fisuras/uso terapéutico , Diente Primario , Estados UnidosRESUMEN
Aims: Point-of-care electroencephalogram (POC-EEG) is an acute care bedside screening tool for the identification of nonconvulsive seizures (NCS) and nonconvulsive status epilepticus (NCSE). The objective of this narrative review is to describe the economic themes related to POC-EEG in the United States (US).Materials and methods: We examined peer-reviewed, published manuscripts on the economic findings of POC-EEG for bedside use in US hospitals, which included those found through targeted searches on PubMed and Google Scholar. Conference abstracts, gray literature offerings, frank advertisements, white papers, and studies conducted outside the US were excluded.Results: Twelve manuscripts were identified and reviewed; results were then grouped into four categories of economic evidence. First, POC-EEG usage was associated with clinical management amendments and antiseizure medication reductions. Second, POC-EEG was correlated with fewer unnecessary transfers to other facilities for monitoring and reduced hospital length of stay (LOS). Third, when identifying NCS or NCSE onsite, POC-EEG was associated with greater reimbursement in Medical Severity-Diagnosis Related Group coding. Fourth, POC-EEG may lower labor costs via decreasing after-hours requests to EEG technologists for conventional EEG (convEEG).Limitations: We conducted a narrative review, not a systematic review. The studies were observational and utilized one rapid circumferential headband system, which limited generalizability of the findings and indicated publication bias. Some sample sizes were small and hospital characteristics may not represent all US hospitals. POC-EEG studies in pediatric populations were also lacking. Ultimately, further research is justified.Conclusions: POC-EEG is a rapid screening tool for NCS and NCSE in critical care and emergency medicine with potential financial benefits through refining clinical management, reducing unnecessary patient transfers and hospital LOS, improving reimbursement, and mitigating burdens on healthcare staff and hospitals. Since POC-EEG has limitations (i.e. no video component and reduced montage), the studies asserted that it did not replace convEEG.
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Sistemas de Atención de Punto , Estado Epiléptico , Niño , Humanos , Convulsiones , Estado Epiléptico/diagnóstico , Estado Epiléptico/tratamiento farmacológico , Electroencefalografía/métodos , Cuidados Críticos/métodosRESUMEN
Background and Objectives: High costs associated with after-hour electroencephalography (EEG) constitute a barrier for financially constrained hospitals to provide this neurodiagnostic procedure outside regular working hours. Our study aims to deepen our understanding of the cost elements involved in delivering EEG services during after-hours. Methods: We accessed publicly available data sets and created a cost model depending on 3 most commonly seen staffing scenarios: (1) technologist on-site, (2) technologist on-call from home, and (3) a hybrid of the two. Results: Cost of EEG depends on the volume of testing and the staffing plan. Within the various cost elements, labor cost of EEG technologists is the predominant expenditure, which varies across geographic regions and urban areas. Discussion: We provide a model to explain why access to EEGs during after-hours has a substantial expense. This model provides a cost calculator tool (made available as part of this publication in eAppendix 1, links.lww.com/CPJ/A513) to estimate the cost of EEG platform based on site-specific staffing scenarios and annual volume.
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BACKGROUND: The relationship between multiple medication consumption and medication adherence is not well understood. OBJECTIVE: To determine the association between the number of active medications on the patient medication profile at baseline and adherence in new users of statins. METHODS: This was a retrospective cohort study of new users of statin medications from the Veterans Health Administration. We explored the correlation between the number of baseline medications and adherence, grouping patients by number of active medications on the study index date via Cochran-Armitage trend test and multiple linear regression. The adherence metric calculated for each patient was the medication possession ratio (MPR). Adherence was defined as achieving a 0.8 MPR or greater in primary analysis and a 0.9 MPR or greater in the secondary analysis. RESULTS: There was a statistically significant trend of increasing proportion of adherent participants as baseline medication count grew (P value < .001). The regression further demonstrated that statin MPR was increased by 0.04, 0.07, 0.10, and 0.14 for the 6 to 10 medication count, 11 to 15 medication count, 16 to 20 medication count, and >20 medication count groups, respectively, in comparison with the reference 1 to 5 medication count group (P < .001 for all comparisons). An MPR threshold of 0.9 provided consistent evidence of improved adherence as number of medications increased (P < .001). CONCLUSIONS: Increased medication count at baseline was associated with improved adherence for new users of statins.
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Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Cumplimiento de la Medicación/estadística & datos numéricos , Polifarmacia , United States Department of Veterans Affairs/estadística & datos numéricos , Veteranos/estadística & datos numéricos , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Estados UnidosRESUMEN
Intraoperative neurophysiological monitoring (IONM) is used as an adjunct for surgeries that pose risk to nervous system structures. IONM is performed by a technologist in the operating room and is overseen by a highly trained fellowship-trained physician clinical neurophysiologist. Telemedicine has allowed the professional oversight component to be done remotely, with reimbursement for multiple simultaneous cases. Recent changes to Current Procedure Terminology coding and Medicare reimbursement policies provide options only for exclusive 1:1 technologist:oversight physician billing. This policy change may create profound repercussions in the practice of telemedicine by actively discouraging the leveraging of highly specialized and scarce expertise through on-site physician extenders.
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Centers for Medicare and Medicaid Services, U.S. , Monitorización Neurofisiológica Intraoperatoria/economía , Política Organizacional , Mecanismo de Reembolso/organización & administración , Telemedicina , Humanos , Estados UnidosRESUMEN
BACKGROUND AND OBJECTIVES: The objective of this study was to determine the external validity of the Axon Registry by comparing the 2019 calendar year data with 2 nationally representative, publicly available data sources, specifically the National Ambulatory Medical Care Survey (NAMCS) and the Medical Expenditure Panel Survey (MEPS). The Axon Registry is the American Academy of Neurology's neurology-focused qualified clinical data registry that reports and analyzes electronic health record data from participating US neurology providers. Its key function is to support quality improvement within ambulatory neurology practices while also promoting high-quality evidence-based care in clinical neurology. We compared demographics of patients who had an outpatient or office visit with a neurologist along with prevalence of selected neurologic conditions and neurologic procedures across the 3 data sets. METHODS: We performed a cross-sectional, retrospective comparison of 3 data sets: NAMCS (2012-2016), MEPS (2013-2017, 2019), and Axon Registry (2019). We obtained patient demographics (age, birth sex, race, ethnicity), patient neurologic conditions (headache, epilepsy, cerebrovascular disease, multiple sclerosis, parkinsonism, dementia, spinal pain, and polyneuropathy), provider location, and neurologic procedures (neurology visits, MR/CT neuroimaging studies and EEG/EMG neurophysiologic studies). Parameter estimates from the pooled 5-year samples of the 2 public data sets, calculated at the visit level, were compared descriptively with those of the Axon Registry. We calculated Cohen h and performed Wald tests (α = 0.05) to conduct person-level statistical comparisons between MEPS 2019 and Axon Registry 2019 data. RESULTS: The Axon Registry recorded 1.3 M annual neurology visits (NAMCS, 11 M; MEPS, 22 M) and 645 K people with neurologic conditions (MEPS, 10 M). Compared with the pooled national surveys, the Axon Registry has similar patient demographics, neurologic condition prevalence, neuroimaging and neurophysiologic utilization, and provider location. In direct comparison with MEPS 2019, the Axon Registry 2019 had fewer children (2% vs 7%), more elderly persons (21% vs 16%), fewer non-Black and non-White race persons (5% vs 8%), less number of patients with epilepsy (10% vs 13%), more patients with dementia (8% vs 6%), more patients with cerebrovascular disease (11% vs 8%), and a greater predominance of neurology providers in the Midwest (25% vs 20%). The only difference with a non-negligible effect size was the proportion of people younger than 15 years (Cohen h = 0.25). DISCUSSION: The Axon Registry demonstrates high concordance with 2 nationally representative surveys. Recruiting more and diverse neurology providers will further improve the volume, representativeness, and value of the Axon Registry.
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Demencia , Enfermedades del Sistema Nervioso , Neurología , Niño , Humanos , Estados Unidos/epidemiología , Anciano , Estudios Transversales , Estudios Retrospectivos , Enfermedades del Sistema Nervioso/epidemiología , Enfermedades del Sistema Nervioso/terapia , Encuestas de Atención de la Salud , Sistema de Registros , Atención AmbulatoriaRESUMEN
OBJECTIVE: To estimate costs and benefits associated with measurement of intra-abdominal pressure (IAP). METHODS: We built a cost-benefit analysis from the hospital facility perspective and time horizon limited to hospitalization for patients undergoing major abdominal surgery for the intervention of urinary catheter monitoring of IAP. We used real-world data estimating the likelihood of intra-abdominal hypertension (IAH), abdominal compartment syndrome (ACS), and acute kidney injury (AKI) requiring renal replacement therapy (RRT). Costs included catheter costs (estimated $200), costs of additional intensive care unit (ICU) days from IAH and ACS, and costs of CRRT. We took the preventability of IAH/ACS given early detection from a trial of non-surgical interventions in IAH. We evaluated uncertainty through probabilistic sensitivity analysis and the effect of individual model parameters on the primary outcome of cost savings through one-way sensitivity analysis. RESULTS: In the base case, urinary catheter monitoring of IAP in the perioperative period of major abdominal surgery had 81% fewer cases of IAH of any grade, 64% fewer cases of AKI, and 96% fewer cases of ACS. Patients had 1.5 fewer ICU days attributable to IAH (intervention 1.6 days vs. control of 3.1 days) and a total average cost reduction of $10,468 (intervention $10,809, controls $21,277). In Monte Carlo simulation, 86% of 1,000 replications were cost-saving, for a mean cost savings of $10,349 (95% UCI $8,978, $11,720) attributable to real-time urinary catheter monitoring of intra-abdominal pressure. One-way factor analysis showed the pre-test probability of IAH had the largest effect on cost savings and the intervention was cost-neutral at a prevention rate as low as 2%. CONCLUSIONS: In a cost-benefit model using real-world data, the potential average in-hospital cost savings for urinary catheter monitoring of IAP for early detection and prevention of IAH, ACS, and AKI far exceed the cost of the catheter.
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Lesión Renal Aguda , Hipertensión Intraabdominal , Lesión Renal Aguda/etiología , Lesión Renal Aguda/prevención & control , Análisis Costo-Beneficio , Humanos , Unidades de Cuidados Intensivos , Hipertensión Intraabdominal/diagnóstico , Hipertensión Intraabdominal/etiología , Hipertensión Intraabdominal/prevención & control , Catéteres UrinariosRESUMEN
OBJECTIVE: To estimate the cost savings associated with a pedometer-based, web-mediated physical activity intervention in a cohort of US veterans with chronic obstructive pulmonary disease (COPD). STUDY DESIGN: Economic analysis. METHODS: We constructed a decision tree from the health care system perspective incorporating adjusted relative risk of a pedometer-based, web-mediated intervention for COPD-related acute exacerbations, acute exacerbation-related costs (ie, emergency department visits and hospitalizations), and intervention-related costs. Total COPD-related costs were estimated per patient across 12 months. Probabilistic sensitivity analysis with Monte Carlo simulation was used to estimate uncertainty in the model findings. RESULTS: In the deterministic (base case) model, the model estimated costs to be $4236 per participant who used the pedometer-based, web-mediated intervention compared with $7913 per participant in the control group (estimated $3677 saved in 1 year compared with the control group). The model findings were robust to probabilistic sensitivity analysis, with a difference in mean costs of $4582 (95% probability interval, $4084-$5080; P < .001). Cost savings in the model were driven by the adjusted relative risk of the web-based intervention, probability of a COPD-related acute exacerbation, rate of hospitalization, probability of hospitalization, and cost of hospitalization. CONCLUSIONS: A pedometer-based, web-mediated physical activity intervention yielded substantial cost savings. Increased implementation of the intervention could markedly reduce the economic burden of COPD for payers and patients.
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Intervención basada en la Internet , Enfermedad Pulmonar Obstructiva Crónica , Ahorro de Costo , Ejercicio Físico , Costos de la Atención en Salud , HumanosRESUMEN
BACKGROUND AND OBJECTIVES: Previous studies have shown gender disparities in physician pay in various specialties. This retrospective, cross-sectional study evaluated data from the American Academy of Neurology (AAN) Compensation and Productivity Survey for differences in neurologist compensation by gender. METHODS: Of the 3,268 completed surveys submitted, 2,719 were from neurologists and 1,466 had sufficient data for analysis (551 women, 951 men respondents). We calculated an hourly wage from full-time equivalent (FTE) status and weeks worked per year. We evaluated differences in men and women neurologist compensation with multivariable generalized linear models adjusting for race, ethnicity, geographic region, practice setting, years in practice, call status, leadership role, straight salary, and subspecialty. RESULTS: Baseline characteristics for men and women neurologists were similar with the exception of subspecialty distribution. More men were practicing in higher-wage subspecialties compared to women (p < 0.05). Mean FTE annual salary for all neurologists was $280,315, and mean standardized hourly compensation was $131. Estimated annual salary for women was 10.7% less (p ≤ 0.001, 95% confidence interval -4% to -16%) after controlling for race, region, years of practice, practice setting, call status, leadership role, and subspecialty-wage category. FTE annual salary for women neurologists in high-compensation specialties ($281,838) was lower than the mean annual salary for men neurologists in both high-compensation ($365,751) and low-compensation subspecialties ($282,813). When broken down by years of practice, the highest earning women neurologists' mean hourly wage (11-20 years of practice, $128/h) was less than that of all men neurologists except those with 0 to 5 years of practice ($125/h). DISCUSSION: This study, using convenience sample data, adds to the existing body of evidence demonstrating that, despite adjustment for multiple confounding variables, ongoing disparities exist in physician compensation. Despite efforts by professional societies such as the AAN, ongoing systemic issues and barriers exist. Further research into underlying causes and mitigation strategies is recommended; use of probability sampling methods in future research will be important to decrease potential bias and to increase generalizability.
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Neurólogos , Salarios y Beneficios , Estudios Transversales , Femenino , Humanos , Masculino , Estudios Retrospectivos , Factores Sexuales , Estados UnidosRESUMEN
BACKGROUND AND OBJECTIVES: - To determine gender differences in headache types diagnosed, sociodemographic characteristics, military campaign and exposures, and healthcare utilization among United States (U.S.) Veterans in the Veterans Health Administration (VHA). METHODS: - This study employed a retrospective cohort design to examine VHA Electronic Health Record (EHR) data. This cohort includes Veterans who had at least one visit for any headache between fiscal years 2008 and 2019. Headache diagnoses were classified into eight categories using International Classification of Disease, Clinical Modification codes. Demographics, military-related exposures, comorbidities, and type of provider(s) consulted were extracted from the EHR, and compared by gender. Age-adjusted incidence and prevalence rates of medically diagnosed headache disorders were calculated separately for each type of headache. RESULTS: - Of the 1,524,960 Veterans with headache diagnoses included in the cohort, 82.8% were men. Compared with women, men were more often white (70.4% vs 56.7%), older (52.0±16.8 vs 41.9±13.0 years), with higher rates of traumatic brain injury (2.9% vs 1.1%) and post-traumatic stress disorder (23.7% vs 21.7%), and lower rates of military sexual trauma (3.2% vs 33.7%; p<0.001 for all). Age adjusted incidence rate of headache of any type was higher among women. Migraine and trigeminal autonomic cephalalgias rates were most stable over time. Men were more likely than women to be diagnosed with headache not-otherwise-specified (77.4% vs 67.7%) and have higher incidence rates of headaches related to trauma (3.4% vs 1.9% [post-traumatic]; 5.5% vs 5.1% [post-whiplash]; p <0.001 for all). Men also had fewer headache types diagnosed (mean ± standard deviation; 1.3 ± 0.6 vs 1.5 ± 0.7), had fewer encounters for headache/year (0.8 ± 1.2 vs 1.2 ± 1.6) and fewer visits to headache specialists (20.8% vs 27.4% p <0.001 for all), compared to women. Emergency Department utilization for headache care was high for both genders and higher for women compared to men (20.3% vs 22.9%; p<0.001). DISCUSSION: - Among Veterans with headache diagnoses, important gender differences exist for men and women Veterans receiving headache care within VHA regarding sociodemographic characteristics, headache diagnoses, military exposure, and headache healthcare utilization. The findings have potential implications for providers and the healthcare system caring for Veterans living with headache.
RESUMEN
AIMS: Potentially life-threatening diagnosis of non-convulsive status epilepticus (NCSE) can only be confirmed with electroencephalography (EEG). When access to EEG is limited, physicians may empirically treat, risking unnecessary sedation and intubation, or not treat, increasing risk of refractory seizures. Either may prolong hospital length of stay (LOS). The current study aimed to examine the effect of a new EEG system (Ceribell Rapid Response EEG, Rapid-EEG) on hospital costs by enabling easy access to EEG and expedited seizure diagnosis and treatment. MATERIALS AND METHODS: We built a two-armed decision-analytic cost-benefit model comparing Rapid-EEG with clinical suspicion alone for NCSE. Diagnostic parameters were informed by a multicenter clinical trial (DECIDE, NCT03534258), while LOS and cost parameters were from public US inpatient data, published literature, and Center for Medicare and Medicaid Services fee schedules. We calculated reference case estimates from mean values, while uncertainty was assessed using 95% prediction intervals (PI) generated by probabilistic sensitivity analysis (PSA) and ANCOVA sum of squares. All costs were indexed to 2019 US$. RESULTS: Each use case of Rapid-EEG saved $3,971 to $17,290 as it led to reduction in the hospital LOS by 1.2 days (6.1 vs. 7.4 days) and ICU LOS by 0.4 days (1.5 vs. 1.9 days). Using PSA, Rapid-EEG saving was $5,633 per use case (95% PI: $($4,649 to $6,617), as it led to diminished hospital LOS by 1.1 days (95% PI: 0.9-1.4 days) and reduced ICU LOS by 0.5 days (95% PI: 0.4-0.6 days). Cost-savings were demonstrated in 75% of replications. Sixty-four percent of variance in total costs was attributable to LOS for persons incorrectly diagnosed with seizures. LIMITATIONS: Results were obtained from the analysis of existing data and not a prospective outcome trial. CONCLUSIONS: Rapid-EEG alters the treatment course for patients with suspected seizures and will result in cost savings per patient.
Asunto(s)
Pacientes Internos , Estado Epiléptico , Anciano , Electroencefalografía , Hospitales , Humanos , Medicare , Estados UnidosRESUMEN
Importance: After the emergence of COVID-19, studies reported a decrease in hospitalizations of patients with ischemic stroke (IS), but there are little to no data regarding hospitalizations for the remainder of 2020, including outcome data from a large cohort of patients with IS and comorbid COVID-19. Objective: To assess hospital discharge rates, demographic factors, and outcomes of hospitalization associated with the COVID-19 pandemic among US patients with IS before vs during the COVID-19 pandemic. Design, Setting, and Participants: This retrospective cohort study used data from the Vizient Clinical Data Base on 324â¯013 patients with IS at 478 nonfederal hospitals in 43 US states between January 1, 2019, and December 31, 2020. Patients were eligible if they were admitted to the hospital on a nonelective basis and were not receiving hospice care at the time of admission. A total of 41 166 discharged between January and March 2020 were excluded from the analysis because they had unreliable data on COVID-19 status, leaving 282 847 patients for the study. Exposure: Ischemic stroke and laboratory-confirmed COVID-19. Main Outcomes and Measures: Monthly counts of discharges among patients with IS in 2020. Demographic characteristics and outcomes, including in-hospital death, among patients with IS who were discharged in 2019 (control group) were compared with those of patients with IS with or without comorbid COVID-19 (COVID-19 and non-COVID-19 groups, respectively) who were discharged between April and December 2020. Results: Of the 282 847 patients included in the study, 165 912 (50.7% male; 63.4% White; 26.3% aged ≥80 years) were allocated to the control group; 111 418 of 116 935 patients (95.3%; 51.9% male; 62.8% White; 24.6% aged ≥80 years) were allocated to the non-COVID-19 group and 5517 of 116 935 patients (4.7%; 58.0% male; 42.5% White; 21.3% aged ≥80 years) to the COVID-19 group. A mean (SD) of 13â¯846 (553) discharges per month among patients with IS was reported in 2019. Discharges began decreasing in February 2020, reaching a low of 10â¯846 patients in April 2020 before returning to a prepandemic level of 13â¯639 patients by July 2020. A mean (SD) of 13â¯492 (554) discharges per month was recorded for the remainder of 2020. Black and Hispanic patients accounted for 21.4% and 7.0% of IS discharges in 2019, respectively, but accounted for 27.5% and 16.0% of those discharged with IS and comorbid COVID-19 in 2020. Compared with patients in the control and non-COVID-19 groups, those in the COVID-19 group were less likely to smoke (16.0% vs 17.2% vs 6.4%, respectively) and to have hypertension (73.0% vs 73.1% vs 68.2%) or dyslipidemia (61.2% vs 63.2% vs 56.6%) but were more likely to have diabetes (39.8% vs 40.5% vs 53.0%), obesity (16.2% vs 18.4% vs 24.5%), acute coronary syndrome (8.0% vs 9.2% vs 15.8%), or pulmonary embolus (1.9% vs 2.4% vs 6.8%) and to require intubation (11.3% vs 12.3% vs 37.6%). After adjusting for baseline factors, patients with IS and COVID-19 were more likely to die in the hospital than were patients with IS in 2019 (adjusted odds ratio, 5.17; 95% CI, 4.83-5.53; National Institutes of Health Stroke Scale adjusted odds ratio, 3.57; 95% CI, 3.15-4.05). Conclusions and Relevance: In this cohort study, after the emergence of COVID-19, hospital discharges of patients with IS decreased in the US but returned to prepandemic levels by July 2020. Among patients with IS between April and December 2020, comorbid COVID-19 was relatively common, particularly among Black and Hispanic populations, and morbidity was high.