Quantification of patient-level costs in outpatient total shoulder arthroplasty.

BACKGROUND: Patient-level costs of inpatient and outpatient total shoulder arthroplasty (TSA) irrespective of payer status are seldom reported. The purpose of this study was to compare patient-level costs of primary elective TSA between inpatient and outpatient surgery centers. METHODS: By use of the Texas Health Care Information Collection database, inpatient and outpatient TSAs performed between 2010 and 2015 were identified according to billing codes. Patient-level costs (total charges and itemized charges) were analyzed according to type of surgery center (inpatient vs outpatient) and inpatient volume (high volume vs low volume). Statistical comparisons were performed using 1-way analysis of variance and 2-sample independent t tests. Mixed-model analysis of variance was used to compare the rate of cost change between inpatient and outpatient TSAs from 2010-2015. P < .05 represented statistical significance. RESULTS: A total of 21,331 inpatient TSAs and 1542 outpatient TSAs were performed from 2010-2015 in the state of Texas. Inpatient TSA costs were significantly higher than outpatient TSA costs ($76,109 [standard deviation (SD), $48,981] vs $22,907 [SD, $13,599]; P < .001). After exclusion of inpatient-specific charges, inpatient TSA remained 41.1% more expensive than outpatient TSA ($32,330 [SD, $24,221] vs $22,907 [SD, $13,599]; P < .0001). High-volume inpatient TSA was less expensive than low-volume inpatient TSA; however, high-volume inpatient TSA remained 33.4% more costly than outpatient TSA even after exclusion of inpatient-specific charges ($30,579 [SD, $23,233] vs $22,907 [SD, $13,599]; P < .0001). CONCLUSIONS: In the state of Texas, the patient-level costs of primary elective inpatient TSA were significantly higher than those of the equivalent outpatient procedure. This difference persisted after exclusion of low-volume inpatient TSA centers and inpatient-specific ancillary charges.

Challenges of Managing Type 3c Diabetes in the Context of Pancreatic Resection, Cancer and Trauma.

Type 3c diabetes mellitus (T3cDM), also known as pancreatogenic or pancreoprivic diabetes, is a specific type of DM that often develops as a result of diseases affecting the exocrine pancreas, exhibiting an array of hormonal and metabolic characteristics. Several pancreatic exocrine diseases and surgical procedures may cause T3cDM. Diagnosing T3cDM remains difficult as the disease characteristics frequently overlap with clinical presentations of type 1 DM (T1DM) or type 2 DM (T2DM). Managing T3cDM is likewise challenging due to numerous confounding metabolic dysfunctions, including pancreatic endocrine and exocrine insufficiencies and poor nutritional status. Treatment of pancreatic exocrine insufficiency is of paramount importance when managing patients with T3cDM. This review aims to consolidate the latest information on surgical etiologies of T3cDM, focusing on partial pancreatic resections, total pancreatectomy, pancreatic cancer and trauma.

A Geographic Population-level Analysis of Access to Total Shoulder Arthroplasty in the State of Texas.

INTRODUCTION: Managing costs and improving access to care are two important goals of healthcare policy. The purposes of this study were to (1) evaluate the changes in distribution of total shoulder arthroplasty (TSA) cases in the state of Texas from 2010 to 2015 and (2) to evaluate patient access to TSA surgery centers as measured by driving miles. METHODS: Inpatient (IP) and outpatient (OP) records were obtained from 2010 to 2015 from the Texas Department of State Health Services. All primary elective anatomic or reverse TSAs for patients with Texas-based home residence zip codes were included. Driving miles between patient zip codes and their chosen TSA surgery centers were estimated, and the results were compared between IP (high-volume [HV-IP] or low-volume [LV-IP]) and OP centers. Paired student t-tests, multivariate regressions, and mixed-model analysis of variance (ANOVA) were performed for volume comparisons, interactions between TSA centers types, and yearly trend data, respectively. RESULTS: Between 2010 and 2015, a total of 21,092 TSA procedures were performed across 321 surgery centers in the state of Texas (19,629 IP [93.1%] and 1,463 OP [6.9%]). During this time, the cumulative volume of IP TSA per 100,000 Texas residents increased by 109.1%, whereas the cumulative volume of OP TSA increased by 143.7%. Approximately 85.5% of included patients resided within 50 miles of any TSA surgery center; however, only 47.0% of the total Texas population resided within 50 miles of any TSA surgery center. This relationship remained true at every time point irrespective of their volume designations (OP, IP, HV-IP, and LV-IP). CONCLUSION: Despite the overall increase in TSA volume over time, the majority all TSA utilization in the state of Texas occurred in patients who resided within 50 miles of a TSA center. Increasing volume seems to reflect concentration of care into HV-IP and OP centers. Strategies to improve access to TSA care for underserved areas should be considered. LEVEL OF EVIDENCE: Level II.