Trends in treatment costs of U.S. emergency department visits.

BACKGROUND: Spending on emergency department (ED) services in recent years has increased faster than spending in any other area of healthcare. Analyzing growth rates of ED treatment costs by patient and hospital attributes may illuminate ways to reduce overall hospital cost growth. Prior studies have examined changes in ED visit charges and expenditures over time, but little research has focused on changes in ED treatment costs. METHODS: We analyzed trends in ED treatment costs by applying the Healthcare Cost and Utilization Project (HCUP) Cost-to-Charge Ratios for ED Files to the 2012-2019 HCUP Nationwide Emergency Department Sample. Specifically, we estimated treatment cost per ED visit, mean and total costs by patient and hospital characteristics, and compound annual growth rate in costs and patient volumes. RESULTS: During 2012-2019, ED treatment costs increased from $54 billion to $88 billion, a 5.4% annual growth rate-with 4.4 percentage points attributable to higher treatment cost per visit. Growth rates varied by patient and hospital attribute. CONCLUSIONS: By highlighting overall ED cost trends, as well as specific segments of the delivery system with the most rapidly increasing costs, this study provides important information for policymakers and hospital decisionmakers.

State variation in opioid treatment policies and opioid-related hospital readmissions.

BACKGROUND: State policy approaches designed to provide opioid treatment options have received significant attention in addressing the opioid epidemic in the United States. In particular, expanded availability of naloxone to reverse overdose, Good Samaritan laws intended to protect individuals who attempt to provide or obtain emergency services for someone experiencing an opioid overdose, and expanded coverage of medication-assisted treatment (MAT) for individuals with opioid abuse or dependence may help curtail hospital readmissions from opioids. The objective of this retrospective cohort study was to evaluate the association between the presence of state opioid treatment policies-naloxone standing orders, Good Samaritan laws, and Medicaid medication-assisted treatment (MAT) coverage-and opioid-related hospital readmissions. METHODS: We used 2013-2015 hospital inpatient discharge data from 13 states from the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project. We examined the relationship between state opioid treatment policies and 90-day opioid-related readmissions after a stay involving an opioid diagnosis. RESULTS: Our sample included 383,334 opioid-related index hospitalizations. Patients treated in states with naloxone standing-order policies at the time of the index stay had higher adjusted odds of an opioid-related readmission than did those treated in states without such policies; however, this relationship was not present in states with Good Samaritan laws. Medicaid methadone coverage was associated with higher odds of readmission among all insurance groups except Medicaid. Medicaid MAT coverage generosity was associated with higher odds of readmission among the Medicaid group but lower odds of readmission among the Medicare and privately insured groups. More comprehensive Medicaid coverage of substance use disorder treatment and a greater number of opioid treatment programs were associated with lower odds of readmission. CONCLUSIONS: Differences in index hospitalization rates suggest that states with opioid treatment policies had a higher level of need for opioid-related intervention, which also may account for higher rates of readmission. More research is needed to understand how these policies can be most effective in influencing acute care use.

Relative effectiveness of adjuvanted versus non-adjuvanted influenza vaccines in older adults with risk factors for influenza complications during the 2019-2020 U.S. influenza season.

This study estimated the relative vaccine effectiveness (rVE) of the MF59®-adjuvanted trivalent influenza vaccine (aTIV) versus standard-dose nonadjuvanted egg-based quadrivalent influenza vaccines (QIVe) for the prevention of influenza-related medical encounters (IRMEs), outpatient IRMEs, and influenza- and pneumonia-related hospitalizations during the 2019-2020 US influenza season among adults ≥65 years of age who had ≥1 high-risk condition. A secondary objective evaluated the rVE of aTIV versus QIVe in preventing these outcomes among older adults with specific high-risk conditions. This retrospective cohort study included US adults ≥65 years of age vaccinated with aTIV or QIVe between August 1, 2019, and January 31, 2020. Exposures, covariates, risk factors, and outcomes were captured from a linked dataset comprised of electronic health records (EHR) (Veradigm Network EHR) linked to insurance claims (Komodo Healthcare Map). A doubly robust approach was applied wherein multivariable-adjusted odds ratios were derived using inverse probability of treatment-weighted samples to calculate rVEs and 95 % confidence interval independently for individuals ≥1 high-risk condition and those with specific high-risk conditions. The study included 954,707 aTIV and 719,125 QIVe recipients. For all outcomes, aTIV was more effective than QIVe among adults ≥65 years of age who had ≥1 high-risk condition (any IMRE: 23.6 % [20.9 %-26.1 %]), outpatient IRME: 23.3 % [20.4 %-26.1 %], and influenza- or pneumonia-related hospitalizations: 19.0 % [16.3 %-21.6 %]), during the 2019-2020 influenza season. Similarly, aTIV was more effective than QIVe at preventing outcomes among individuals with specific high-risk conditions except for body mass index ≥40. This study demonstrated higher effectiveness of aTIV versus QIVe in preventing any IRMEs, outpatient IRMEs, and influenza- or pneumonia-related hospitalizations among adults ≥65 years of age who had ≥1 high-risk condition.

Relative Effectiveness of the MF59-Adjuvanted Influenza Vaccine Versus High-Dose Influenza Vaccine in Older Adults With Influenza Risk Factors During the 2019-2020 US Influenza Season.

Background: This study estimated the relative vaccine effectiveness (rVE) of the MF59-adjuvanted trivalent influenza vaccine (aTIV) versus high-dose trivalent inactivated influenza vaccine (HD-TIV) for prevention of influenza-related medical encounters (IRMEs) during the 2019-2020 United States (US) influenza season stratified by the cumulative number of influenza risk factors. A secondary objective evaluated outpatient IRMEs and influenza- and pneumonia-related hospitalizations. Methods: This retrospective cohort study included US adults ≥65 years old vaccinated with aTIV or HD-TIV between 1 August 2019 and 31 January 2020. Electronic health records linked to claims were used to ascertain exposure, covariates, risk factors, and outcomes. Multivariable adjusted odds ratios (ORs) were derived using inverse probability of treatment-weighted samples to calculate rVEs independently for individuals with 0, ≥1, 1-2, or ≥3 risk factors. Results: The study included 1 115 725 aTIV and 2 561 718 HD-TIV recipients. For the primary outcome of any IRME, the analysis found comparable effectiveness between aTIV and HD-TIV (rVE, 5.2% [95% confidence interval {CI}, -5.9% to 15.1%]) among those with 0 risk factors, whereas aTIV was more effective than HD-TIV among patients with ≥1, 1-2, or ≥3 risk factors (12.5% [95% CI, 10.0%-15.0%], 18.4% [95% CI, 13.7%-22.9%], and 10.4% [7.4%-13.3%], respectively). The same trends were observed for the secondary outcomes. Conclusions: This study demonstrated comparable effectiveness of aTIV and HD-TIV among individuals with no identified risk factors and higher effectiveness of aTIV compared with HD-TIV in preventing any IRMEs, outpatient IRMEs, and influenza- or pneumonia-related hospitalizations among those with at least 1 or multiple high-risk factors in adults ≥65 years old.

Relative Vaccine Effectiveness of Cell- vs Egg-Based Quadrivalent Influenza Vaccine Against Test-Confirmed Influenza Over 3 Seasons Between 2017 and 2020 in the United States.

Background: Influenza vaccine viruses grown in eggs may acquire egg-adaptive mutations that may reduce antigenic similarity between vaccine and circulating influenza viruses and decrease vaccine effectiveness. We compared cell- and egg-based quadrivalent influenza vaccines (QIVc and QIVe, respectively) for preventing test-confirmed influenza over 3 US influenza seasons (2017-2020). Methods: Using a retrospective test-negative design, we estimated the relative vaccine effectiveness (rVE) of QIVc vs QIVe among individuals aged 4 to 64 years who had an acute respiratory or febrile illness and were tested for influenza in routine outpatient care. Exposure, outcome, and covariate data were obtained from electronic health records linked to pharmacy and medical claims. Season-specific rVE was estimated by comparing the odds of testing positive for influenza among QIVc vs QIVe recipients. Models were adjusted for age, sex, geographic region, influenza test date, and additional unbalanced covariates. A doubly robust approach was used combining inverse probability of treatment weights with multivariable regression. Results: The study included 31 824, 33 388, and 34 398 patients in the 2017-2018, 2018-2019, and 2019-2020 seasons, respectively; ∼10% received QIVc and ∼90% received QIVe. QIVc demonstrated superior effectiveness vs QIVe in prevention of test-confirmed influenza: rVEs were 14.8% (95% CI, 7.0%-22.0%) in 2017-2018, 12.5% (95% CI, 4.7%-19.6%) in 2018-2019, and 10.0% (95% CI, 2.7%-16.7%) in 2019-2020. Conclusions: This study demonstrated consistently superior effectiveness of QIVc vs QIVe in preventing test-confirmed influenza over 3 seasons characterized by different circulating viruses and degrees of egg adaptation.

Methods for estimating the cost of treat-and-release emergency department visits.

OBJECTIVE: To evaluate and compare approaches to estimating the service delivery cost of emergency department (ED) visits from total charge data only. DATA SOURCES: The 2013-2017 Healthcare Cost and Utilization Project's (HCUP) State Emergency Department Databases (SEDD) and the Centers for Medicare and Medicaid Services Healthcare Cost Report Information System (HCRIS) public use files. STUDY DESIGN: Compare a baseline approach (requiring cost-center-level charge detail) and four alternative methods (relying on total charges only) for estimating ED visit costs. Estimation errors are calculated after applying each method to a sample of ED visits, treating estimates from the baseline approach as the "true" cost. Performance metrics are calculated at the visit and hospital levels. DATA COLLECTION/EXTRACTION METHODS: The charges, revenue center codes, and patient/hospital characteristics were extracted from the SEDD. Detailed costs and charges were extracted from HCRIS public use files. PRINCIPAL FINDINGS: Baseline ("true") ED visit costs increased from $383 to $420 per visit between 2013 and 2017. Three methods performed comparatively well estimating mean cost per visit. The method using an overall cost-to-charge ratio (CCR) for all ancillary cost centers without regression adjustment (ANC-CCR) performed the worst, overestimating "true" costs by $63-$113 per visit. The other three methods, which used CCRs computed from selected cost centers, exhibited much smaller bias, with two of the methods yielding estimates within $2 of the "true" cost in 2017. Compared with ANC-CCR, the other three methods had more compact estimation error distributions. The estimated mean visit costs from all four methods have relatively small statistical variance, with 95% confidence intervals for mean cost in a hospital with 25,000 ED visits ranging between $4 and $7. CONCLUSIONS: When cost-center-level charge detail for ED visits is unavailable, alternative methods relying on total ED charges can estimate ED service costs for patient and hospital segments.