RESUMO
Importance: Postoperative neurocognitive disorders (PNDs) after surgical procedures are common and may be associated with increased health care expenditures. Objective: To quantify the economic burden associated with a PND diagnosis in 1 year following surgical treatment among older patients in the United States. Design, Setting, and Participants: This retrospective cohort study used claims data from the Bundled Payments for Care Improvement Advanced Model from 4285 hospitals that submitted Medicare Fee-for-service (FFS) claims between January 2013 and December 2016. All Medicare patients aged 65 years or older who underwent an inpatient hospital admission associated with a surgical procedure, did not experience a PND before index admission, and were not undergoing dialysis or concurrently enrolled in Medicaid were included. Data were analyzed from October 2019 and May 2020. Exposures: PND, defined as an International Classification of Diseases, Ninth or Tenth Revision, diagnosis of delirium, mild cognitive impairment, or dementia within 1 year of discharge from the index surgical admission. Main Outcomes and Measures: The primary outcome was total inflation-adjusted Medicare postacute care payments within 1 year after the index surgical procedure. Results: A total of 2â¯380â¯473 patients (mean [SD] age, 75.36 (7.31) years; 1â¯336â¯736 [56.1%] women) who underwent surgical procedures were included, of whom 44â¯974 patients (1.9%) were diagnosed with a PND. Among all patients, most were White (2â¯142â¯157 patients [90.0%]), presenting for orthopedic surgery (1â¯523â¯782 patients [64.0%]) in urban medical centers (2â¯179â¯893 patients [91.6%]) that were private nonprofits (1â¯798â¯749 patients [75.6%]). Patients with a PND, compared with those without a PND, experienced a significantly longer hospital length of stay (mean [SD], 5.91 [6.01] days vs 4.29 [4.18] days; P < .001), were less likely to be discharged home (9947 patients [22.1%] vs 914â¯925 patients [39.2%]; P < .001), and had a higher incidence of mortality at 1 year after treatment (4580 patients [10.2%] vs 103â¯767 patients [4.4%]; P < .001). After adjusting for patient and hospital characteristics, the presence of a PND within 1 year of the index procedure was associated with an increase of $17â¯275 (95% CI, $17â¯058-$17â¯491) in cost in the 1-year postadmission period (P < .001). Conclusions and Relevance: The findings of this cohort study suggest that among older Medicare patients undergoing surgical treatment, a diagnosis of a PND was associated with an increase in health care costs for up to 1 year following the surgical procedure. Given the magnitude of this cost burden, PNDs represent an appealing target for risk mitigation and improvement in value-based health care.
Assuntos
Efeitos Psicossociais da Doença , Transtornos Neurocognitivos , Complicações Cognitivas Pós-Operatórias , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Idoso , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Medicare/economia , Avaliação das Necessidades , Transtornos Neurocognitivos/diagnóstico , Transtornos Neurocognitivos/economia , Transtornos Neurocognitivos/epidemiologia , Transtornos Neurocognitivos/etiologia , Complicações Cognitivas Pós-Operatórias/economia , Complicações Cognitivas Pós-Operatórias/epidemiologia , Complicações Cognitivas Pós-Operatórias/etiologia , Melhoria de Qualidade , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Anterior compartment prolapse is the most common pelvic organ prolapse (POP) with a range of surgical treatment options available. OBJECTIVES: To compare the clinical effectiveness and cost-effectiveness of surgical treatments for the repair of anterior POP. METHODS: We conducted a systematic review of randomised controlled trials comparing surgical treatments for women with POP. Network meta-analysis was possible for anterior POP, same-site recurrence outcome. A Markov model was used to compare the cost-utility of surgical treatments for the primary repair of anterior POP from a UK National Health Service perspective. MAIN RESULTS: We identified 27 eligible trials for the network meta-analysis involving eight surgical treatments tested on 3194 women. Synthetic mesh was the most effective in preventing recurrence at the same site. There was no evidence to suggest a difference between synthetic non-absorbable mesh, synthetic partially absorbable mesh, and biological mesh. The cost-utility analysis, which incorporated effectiveness, complications and cost data, found non-mesh repair to have the highest probability of being cost-effective. The conclusions were robust to model inputs including effectiveness, costs and utility values. CONCLUSIONS: Anterior colporrhaphy augmented with mesh appeared to be cost-ineffective in women requiring primary repair of anterior POP. There is a need for further research on long-term effectiveness and the safety of mesh products to establish their relative cost-effectiveness with a greater certainty. TWEETABLE ABSTRACT: New study finds mesh cost-ineffective in women with anterior pelvic organ prolapse.