Early palliative intervention in septic patients reduces healthcare utilization.

INTRODUCTION: While the role of palliative care in the emergency department is recognized, barriers against the effective integration of palliative interventions and emergency care remain. We examined the association between goals-of-care and palliative care consultations and healthcare utilization outcomes in older adult patients who presented to the emergency department (ED) with sepsis. METHODS: We performed a retrospective review of 197 patients aged 65 years and older who presented to the ED with sepsis or septic shock. Healthcare utilization outcomes were compared between patients divided into 3 groups: no palliative care consultation, palliative care consultation within 4 days of admission (i.e., early consultation), and palliative care consultation after 4 days of admission (i.e., late consultation). RESULTS: 51% of patients did not receive any palliative consultation, 39% of patients underwent an early palliative care consultation (within 4 days), and 10% of patients underwent a late palliative care consultation (after 4 days). Patients who received late palliative care consultation had a significantly increased number of procedures, total length of stay, ICU length of stay, and cost (p < .01, p < .001, p < .05, p < .001; respectively). Regarding early palliative care consultation, there were no statistically significant associations between this intervention and our outcomes of interest; however, we noted a trend towards decreased total length of stay and decreased healthcare cost. CONCLUSION: In patients aged 65 years and older who presented to the ED with sepsis, early palliative consultations were associated with reduced healthcare utilization as compared to late palliative consultations.

Clinical characteristics, medical service utilization, and expenditure for colorectal cancer in China, 2005 to 2014: Overall design and results from a multicenter retrospective epidemiologic survey.

BACKGROUND: Colorectal cancer (CRC) is the third most common cancer in China, however, publicly available, descriptive information on the clinical epidemiology of CRC is limited. METHODS: Patients diagnosed with primary CRC during 2005 through 2014 were sampled from 13 tertiary hospitals in 9 provinces across China. Data related to sociodemographic characteristics, the use of diagnostic technology, treatment adoption, and expenditure were extracted from individual medical records. RESULTS: In the full cohort of 8465 patients, the mean ± SD age at diagnosis was 59.3 ± 12.8 years, 57.2% were men, and 58.7% had rectal cancer. On average, 14.4% of patients were diagnosed with stage IV disease, and this proportion increased from 13.5% in 2005 to 20.5% in 2014 (P value for trend < .05). For diagnostic techniques, along with less use of x-rays (average, 81.6%; decreased from 90.0% to 65.7%), there were increases in the use of computed tomography (average, 70.4%; increased from 4.5% to 90.5%) and magnetic resonance imaging (average, 8.8%; increased from 0.1% to 20.4%) over the study period from 2005 to 2014. With regard to treatment, surgery alone was the most common (average, 50.1%), but its use decreased from 51.3% to 39.8% during 2005 through 2014; and the use of other treatments increased simultaneously, such as chemotherapy alone (average, 4.1%; increased from 4.1% to 11.9%). The average medical expenditure per patient was 66,291 Chinese Yuan (2014 value) and increased from 47,259 to 86,709 Chinese Yuan. CONCLUSIONS: The increasing proportion of late-stage diagnoses presents a challenge for CRC control in China. Changes in diagnostic and treatment options and increased expenditures are clearly illustrated in this study. Coupled with the recent introduction of screening initiatives, these data provide an understanding of changes over time and may form a benchmark for future related evaluations of CRC interventions in China.

Resource requirements for reintroducing elective surgery during the COVID-19 pandemic: modelling study.

BACKGROUND: The COVID-19 response required the cancellation of all but the most urgent surgical procedures. The number of cancelled surgical procedures owing to Covid-19, and the reintroduction of surgical acivirt, was modelled. METHODS: This was a modelling study using Hospital Episode Statistics data (2014-2019). Surgical procedures were grouped into four urgency classes. Expected numbers of surgical procedures performed between 1 March 2020 and 28 February 2021 were modelled. Procedure deficit was estimated using conservative assumptions and the gradual reintroduction of elective surgery from the 1 June 2020. Costs were calculated using NHS reference costs and are reported as millions or billions of euros. Estimates are reported with 95 per cent confidence intervals. RESULTS: A total of 4 547 534 (95 per cent c.i. 3 318 195 to 6 250 771) patients with a pooled mean age of 53.5 years were expected to undergo surgery between 1 March 2020 and 28 February 2021. By 31 May 2020, 749 247 (513 564 to 1 077 448) surgical procedures had been cancelled. Assuming that elective surgery is reintroduced gradually, 2 328 193 (1 483 834 - 3 450 043) patients will be awaiting surgery by 28 February 2021. The cost of delayed procedures is €5.3 (3.1 to 8.0) billion. Safe delivery of surgery during the pandemic will require substantial extra resources costing €526.8 (449.3 to 633.9) million. CONCLUSION: As a consequence of the Covid-19 pandemic, provision of elective surgery will be delayed and associated with increased healthcare costs.

Impact of Sinus Surgery on Hospital Utilization for Complications of Sinusitis.

BACKGROUND: Sinusitis complications are potentially lethal conditions that generally require extensive treatment and thus place a significant burden on the health-care system. The purpose of this study was to assess the impact of surgery on hospital utilization associated with treatment of sinusitis complications. METHODS: Retrospective cohort study using a national hospital database. The 2012 to 2013 National Inpatient Sample was queried for adult patients with sinusitis and complications. Patients were grouped based upon the presence or absence of sinus procedures. Patient demographics and health status, hospital characteristics, length of stay (LOS), and charges were determined. RESULTS: Of 1645 patients with sinusitis and associated complications, 232 (14%) underwent sinus procedures. These patients had higher LOS (8.0 ± 7.3 days vs 4.3 ± 5.2 days; P < .001) and charges (US$96 107 ± 108 089 vs US$30 661 ± 47 138; P < .001) than nonprocedure patients. Increased time to procedure in one operation patients (n = 209) of more than 2 days increased total LOS (11.4 ± 9.3 days vs 6.2 ± 5.5 days; P < .001) and charges (US$120 306 ± 112 748 vs US$76 923 ± 81 185; P = .005). Patients with multiple sinus procedures (n = 23) versus one had increased LOS and charges, despite no time difference from admission to first procedure (P = .35). On regression analysis, sinus procedure patients had excess LOS of 0.827 days and charges of US$36 949. CONCLUSION: Although often necessary, sinus procedures lead to increased LOS and charges. As prolonged time to sinus procedure and revision operations also increase charges, shorter trials of medical therapy and earlier surgical intervention may improve outcomes and reduce costs.

Direct economic burden of patients with autoimmune encephalitis in western China.

OBJECTIVE: To analyze the cost of autoimmune encephalitis (AE) in China for the first time. METHODS: Patients who were newly diagnosed with antibody-positive AE (anti-NMDA receptor [NMDAR], anti-γ aminobutyric acid type B receptor [GABABR], antileucine-rich glioma-inactivated 1 [LGI1], and anticontactin-associated protein-2 [CASPR2]) at West China Medical Center between June 2012 and December 2018 were enrolled, and a cost-of-illness study was performed retrospectively. Data on clinical characteristics, costs, and utilization of sources were collected from questionnaires and the hospital information system. RESULTS: Of the 208 patients reviewed, the mean direct cost per patient was renminbi (RMB) 94,129 (United States dollars [USD] 14,219), with an average direct medical cost of RMB 88,373 (USD 13,349). The average inpatient cost per patients with AE was RMB 86,810 (USD 13,113). The direct nonmedical cost was much lower than the direct medical cost, averaging RMB 5,756 (USD 869). The direct cost of anti-LGI1/CASPR2 encephalitis was significantly lower than that of anti-NMDAR encephalitis and anti-GABABR encephalitis. The length of stay in the hospital was significantly associated with the direct cost. CONCLUSIONS: The financial burden of AE is heavy for Chinese patients, and there are significant differences between different types of AE.

Effects of Virtual Exercise Rehabilitation In-Home Therapy Compared with Traditional Care After Total Knee Arthroplasty: VERITAS, a Randomized Controlled Trial.

BACKGROUND: Financial burden for patients, providers, and payers can reduce access to physical therapy (PT) after total knee arthroplasty (TKA). The purpose of the present study was to examine the effect of a virtual PT program on health-care costs and clinical outcomes as compared with traditional care after TKA. METHODS: At least 10 days before unilateral TKA, patients from 4 clinical sites were enrolled and randomized 1:1 to the virtual PT program (involving an avatar [digitally simulated] coach, in-home 3-dimensional biometrics, and telerehabilitation with remote clinician oversight by a physical therapist) or to traditional PT care in the home or outpatient clinic. The primary outcome was total health-care costs for the 12-week post-hospital period. Secondary (noninferiority) outcomes included 6 and 12-week Knee injury and Osteoarthritis Outcome Score (KOOS); 6-week knee extension, knee flexion, and gait speed; and 12-week safety measures (patient-reported falls, pain, and hospital readmissions). All outcomes were analyzed on a modified intent-to-treat basis. RESULTS: Of 306 patients (mean age, 65 years; 62.5% women) who were randomized from November 2016 to November 2017, 290 had TKA and 287 (including 143 in the virtual PT group and 144 in the usual care group) completed the trial. Virtual PT had lower costs at 12 weeks after discharge than usual care (median, $1,050 compared with $2,805; p < 0.001). Mean costs were $2,745 lower for virtual PT patients. Virtual PT patients had fewer rehospitalizations than the usual care group (12 compared with 30; p = 0.007). Virtual PT was noninferior to usual PT in terms of the KOOS at 6 weeks (difference, 0.77; 90% confidence interval [CI], -1.68 to 3.23) and 12 weeks (difference, -2.33; 90% CI, -4.98 to 0.31). Virtual PT was also noninferior to usual care at 6 weeks in terms of knee extension, knee flexion, and gait speed and at 12 weeks in terms of pain and hospital readmissions. Falls were reported by 19.4% of virtual PT patients and 14.6% of usual care patients (difference, 4.83%; 90% CI, -2.60 to 12.25). CONCLUSIONS: Relative to traditional home or clinic PT, virtual PT with telerehabilitation for skilled clinical oversight significantly lowered 3-month health-care costs after TKA while providing similar effectiveness. These findings have important implications for patients, health systems, and payers. Virtual PT with clinical oversight should be considered for patients managed with TKA. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Healthcare spending and utilization following antireflux surgery: examining costs and reasons for readmission.

BACKGROUND: While clinical outcomes have been reported for anti-reflux surgery (ARS), there are limited data on post-operative encounters, including readmission, and their associated costs. This study evaluates healthcare utilization during the 90-day post-operative period following ARS including fundoplication and/or paraesophageal hernia (PEH) repair. METHODS: Data were analyzed from the Truven Health MarketScan® Databases. Patients older than 16 years with an ICD-9 procedure code or Common Procedural Terminology (CPT) code for ARS and a primary diagnosis of GERD during 2012-2014 were selected. Healthcare spending and utilization on emergency department (ED) visits, performance of outpatient endoscopy, and readmission were examined. Reasons for readmission were classified based on ICD-9 code. RESULTS: A total of 40,853 patients were included in the cohort with a mean age of 49 years and females comprising 76.0%. Mean length of stay was 1.4 days, and 93.0% of patients underwent a laparoscopic approach. The mean cost of the index surgical admission was $24,034. Readmission occurred in 4.2% of patients, and of those, 26.3% required a surgical intervention. Patients requiring one or more related readmissions accrued additional costs of $29,513. Some of the most common reasons for readmission were related to nutritional, metabolic, and fluid and electrolyte disorders. Presentation to the ED occurred in 14.0% of patients, and outpatient upper endoscopy was required in 1.5% of patients, but with much lower associated costs as compared to readmission ($1175). CONCLUSION: The majority of patients undergoing ARS do not require additional care within 90 days of surgery. Patients who are readmitted accrue costs that almost double the overall cost of care compared to the initial hospitalization. Measures to attenuate potentially preventable readmissions after ARS may reduce healthcare utilization in this patient population.

A Population-Based Study of 90-Day Hospital Cost and Utilization Associated With Robotic Surgery in Colon and Rectal Cancer.

BACKGROUND: The role of robotic surgery in colorectal cancer remains contentious with most data arising from small, single-institution studies. METHODS: Stage I-III colorectal cancer resections from 2008 to 2014 were identified in New York State. Propensity score-adjusted negative binomial models were used to compare cost and utilization between robotic, laparoscopic, and open resections. RESULTS: A total of 12,218 patients were identified. For colectomy, the robotic-to-open conversion rate was 3%, and the laparoscopic-to-open conversion rate was 13%. For rectal resection, the robotic-to-open conversion rate was 7% and the laparoscopic-to-open conversion rate was 32%. In intention-to-treat analysis, there was no significant difference in cost across the surgical approaches, both in overall and stratified analyses. Both laparoscopic and robotic approaches were associated with decreased 90-d hospital utilization compared with open surgery in intention-to-treat analyses. CONCLUSIONS: Robotic and laparoscopic colorectal cancer resections were not associated with a hospital cost benefit after 90 d compared with open but were associated with decreased hospital utilization. Conversion to open resection was common, and efforts should be made to prevent them. Future research should continue to measure how robotic and laparoscopic approaches can add value to the health care system.

Healthcare resource use and costs of diabetic macular oedema for patients with antivascular endothelial growth factor versus a dexamethasone intravitreal implant in Korea: a population-based study.

OBJECTIVES: To estimate the costs and healthcare resources of patients with diabetic macular oedema (DME) who received intravitreal antivascular endothelial growth factor (anti-VEGF) agents or a dexamethasone intravitreal implant (DEX-implant) in Korea. DESIGN: Retrospective cohort study. SETTING: The Korean National Health Insurance claim data from 1 January 2015 to 30 June 2017 were retrieved from the Health Insurance Review and Assessment Service. PARTICIPANTS: Adult patients with DME who were diagnosed with diabetic retinopathy or DME and received ranibizumab, aflibercept or a DEX-implant in conjunction with intravitreal injection were included. Patients whose primary diagnoses were age-related macular degeneration or retinal vein occlusion were excluded. MAIN OUTCOME MEASURES: Healthcare resource utilisation and costs related to DME in the 12-month postindex period. RESULTS: During the study period, 182 patients and 414 patients were identified in the anti-VEGF and DEX-implant groups, respectively, and there was no significant difference in the demographic characteristics between the two groups. The outpatient eye care-related medical costs were US$3002.33 for the anti-VEGF group vs US$2250.35 for the DEX-implant group (p<0.0001). After adjusting the relevant covariates based on the generalised linear model, the estimated outpatient eye care-related medical costs were 33% higher in the anti-VEGF group than in the DEX-implant group (p<0.0001, 95% CI 22% to 45%). The utilisation pattern of the two groups showed no significant difference except for the number of intravitreal injections, which was higher in the anti-VEGF group (2.69±2.29) than in the DEX-implant group (2.09±1.37, p<0.001). CONCLUSION: The average annual eye-related medical cost of the DEX-implant group was significantly lower than that of the anti-VEGF group during the study period, which was mainly due to decreased utilisation of eye care-related injections. Further long-term studies are needed.

Feasibility of Bundled Payments in Anterior, Middle, and Posterior Cranial Fossa Skull Base Meningioma Surgery: MarketScan Analysis of Health Care Utilization and Outcomes.

BACKGROUND: The aim of our study was to compare the health care utilization and outcomes after surgery for anterior cranial fossa skull base meningioma (AFM), middle cranial fossa skull base meningioma (MFM), and posterior cranial fossa skull base meningioma (PFM) across the United States. METHODS: We queried the MarketScan database using International Classification of Diseases, Ninth Revision and Current Procedural Terminology 4, from 2000 to 2016. We included adult patients who had at least 24 months of enrollment after the surgical procedure. The outcome of interest was length of hospital stay, disposition, complications, and reoperation after the procedure. RESULTS: A cohort of 1191 patients was identified from the database. Less than half of patients (43.66%) were in the AFM cohort, 32.24% were in the MFM cohort, and only 24.1% were in the PFM cohort. Patients who underwent surgery for PFM had longer hospital stay (P = 0.0009), high complication rate (P = 0.0011), and less likely to be discharged home (P = 0.0013) during index hospitalization. There were no differences in overall payments at 12 months and 24 months among the cohorts. There was no significant difference in 90-day median payments among the groups ($66,212 [AFM] vs. $65,602 [MFM] and $71,837 [PFM]; P = 0.198). Male gender, commercial insurance (compared with Medicare), and higher comorbidity scores (score 3 compared with score 0) were associated with higher 90-day payments in the PFM cohort. CONCLUSIONS: Overall payments (at 12 months and 24 months) and 90-day payments were not different among the cohorts. Patients with PFM had longer hospital stay and higher complication rate and were less likely to be discharged home with higher utilization of outpatient services at 12 months and 24 months.

Revision Total Hip Arthroplasty for the Treatment of Fracture: More Expensive, More Complications, Same Diagnosis-Related Groups: A Local and National Cohort Study.

BACKGROUND: Revision total hip arthroplasty (revision THA) occurs for a wide variety of indications and in the United States it is coded under Diagnosis-Related Groups (DRGs) 466, 467, and 468, which do not account for revision etiology, a potentially substantial driver of cost. This study investigates revision THA costs and 30-day complications by indication, both locally and nationally. METHODS: Hospitalization costs and complication rates for 1,422 aseptic revision THAs performed at a high-volume center between 2009 and 2014 were retrospectively reviewed. Additionally, charges for 28,133 revision THAs in the National Inpatient Sample (NIS) were converted to costs using the Healthcare Cost and Utilization Project cost-to-charge ratios, and 30-day complication rates for 3,224 revision THAs were obtained with use of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Costs and complications were compared between revision THAs performed for fracture, wear/loosening, and dislocation/instability with use of simultaneous and pairwise comparisons and a multivariable model accounting for American Society of Anesthesiologists (ASA) score, age, and sex. RESULTS: Local hospitalization costs for fracture (median, $25,672) were significantly higher than those for wear/loosening ($20,228; p < 0.001) or dislocation/instability ($17,911; p < 0.001), with differences remaining significant even after adjusting for patient comorbidities (p < 0.001). NIS costs for fracture (median, $27,596) were higher than those for other aseptic indications (wear/loosening: $21,176, p < 0.001; dislocation/instability: $16,891, p< 0.001). Local 30-day orthopaedic complication rates for fracture (20.7%) were higher those than for dislocation/instability (9.0%; p = 0.007) and similar to those for wear/loosening (17.6%; p = 0.434). Nationally, combined medical and surgical complication rates for fracture (71.3% of patients with ≥1 complication) were significantly higher than those for wear/loosening (35.2%; p < 0.001) or dislocation/instability (35.1%; p < 0.001). CONCLUSIONS: Hospitalization costs for revision THA for fracture were 33% to 48% higher than for all other aseptic revision THAs, both locally and nationally. This increased cost persisted even after multivariable comorbidity adjustment, the current DRG basis for stratifying revision THA reimbursement. Additionally, 30-day complication rates suggest that increased resource utilization for fracture patients continues even after discharge. Indication-specific coding and reimbursement systems are necessary to maintain sustainable access to revision THA for all patients. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Same Day Discharge after Robotic Radical Prostatectomy.

PURPOSE: The typical mean length of stay following robot-assisted laparoscopic prostatectomy is 24 to 48 hours. We began routinely offering same day discharge from the hospital after robot-assisted laparoscopic prostatectomy. We evaluated the success rate, safety and cost implications in what is to our knowledge the only large series of same day discharge to date. MATERIALS AND METHODS: Beginning in September 2016 all patients were given the option of same day discharge without it being mandated. After allowing 3 months to solidify the protocol we evaluated our prospective database for the next 500 patients. RESULTS: Of the 500 consecutive men who underwent robot-assisted laparoscopic prostatectomy performed by 1 surgeon in 18 months 246 (49.2%) were discharged home the day of surgery and all of the remaining 254 were discharged the next day for a mean 0.51-day length of stay. Mean patient age was 62 years (range 42 to 81) and mean body mass index was 29.7 kg/m2 (range 20 to 53). Of the patients 34 (6.8%) had a Clavien-Dindo grade I-III complication within 90 days but there were no grade IV-V complications. Only 5 patients (1%) required an emergency department visit and only 8 (1.6%) required readmission. Only 1 of the patients who elected same day discharge was rehospitalized and only 1 presented to the emergency department. The estimated charge for an overnight stay at our institution is $2,109. The approximate reduction in charges was $518,814 during 18 months ($345,876 per year) with no increased cost due to emergency department visits or hospital readmissions compared with that of overnight patients. In the most recent 100 patients the rate of same day discharge improved to 65%. CONCLUSIONS: Same day discharge following robot-assisted laparoscopic prostatectomy can be safely routinely offered with no increase in readmissions or emergency visits. It may lead to significant savings in health care costs.

The disproportionate cost of operation and congenital anomalies in infancy.

BACKGROUND: Congenital anomalies are the leading cause of infant death and pediatric hospitalization, but existing estimates of the associated costs of health care are either cross-sectional surveys or economic projections. We sought to determine the percent of total hospital health care expenditures attributable to major anomalies requiring surgery within the first year of life. METHODS: Utilizing comprehensive California statewide data from 2008 to 2012, cohorts of infants undergoing major surgery, with birth defects and with surgical anomalies, were constructed alongside a referent group of newborns with no anomalies or operations. Cost-to-charge and physician fee ratios were used to estimate hospital and professional costs, respectively. For each cohort, costs were broken down according to admission, birth episode, and first year of life, with additional stratifications by birth weight, gestational age, and organ system. RESULTS: In total, 68,126 of 2,205,070 infants (3.1%) underwent major surgery (n = 32,614) or had a diagnosis of a severe congenital anomaly (n = 57,793). These accounted for $7.7 billion of the $18.9 billion (40.7%) of the total health care costs/expenditures of the first-year-of-life hospitalizations, $7.0 billion (48.6%) of the costs for infants with comparatively long birth episodes, and $5.2 billion (54.7%) of the total neonatal intensive care unit admission costs. Infants with surgical anomalies (n = 21,264) totaled $4.1 billion (21.7%) at $80,872 per infant. Cardiovascular and gastrointestinal diseases accounted for most admission costs secondary to major surgery or congenital anomalies. CONCLUSION: In a population-based cohort of infant births compared with other critically ill neonates, surgical congenital anomalies are disproportionately costly within the United States health care system. The care of these infants, half of whom are covered by Medi-Cal or Medicaid, stands as a particular focus in an age of reform of health care payments.

Impact of body mass index on utilization of selected hospital resources for four common surgical procedures.

BACKGROUND: Evidence about the impact of obesity on surgical resource consumption in the Australian setting is equivocal. Our objectives were to quantify the prevalence of obesity in four frequently performed surgical procedures and explore the association between body mass index (BMI) and hospital resource utilization including procedural duration, length of stay (LOS) and costs. METHODS: A retrospective cohort study of patients undergoing four surgical procedures at a tertiary referral centre in New South Wales, between 1 January 2016 and 31 December 2016, was conducted. The four surgical procedures were total hip replacement, laparoscopic appendectomy, laparoscopic cholecystectomy and hysteroscopy with dilatation and curettage. Surgical groups were stratified according to BMI category. RESULTS: A total of 699 patients were included in the study. The prevalence of obesity was significantly higher than local and national population estimates for all procedures except appendectomy. BMI was not associated with increased hospital resource utilization (procedural, anaesthetic or intensive care stay duration) in any of the four surgical procedures examined after controlling for age, gender and complexity. For other outcomes of hospital resource utilization (LOS and cost), the relationship was inconsistent across the four procedures examined. A high BMI was positively associated with higher LOS, medical costs and allied health costs in those who underwent an appendectomy, and critical care costs in those who underwent laparoscopic cholecystectomy. CONCLUSION: Obesity was common in patients undergoing four frequently performed surgical procedures. The relationship between BMI and hospital resource utilization appears to be complex and varies across the four procedures examined.

[Every week counts: Use of health services and related costs of a community-based cohort of people with advanced chronic diseases]. / Cada semana cuenta: uso de dispositivos sanitarios y costes relacionados de una cohorte comunitaria de personas con enfermedades crónicas avanzadas.

OBJECTIVE: To describe the use of health resources of people with advanced chronicity, quantifying and characterizing its cost to suggest improvements in health care models. DESIGN: Observational, analytical and prospective study during 3 years of a cohort of people with advanced chronicity. LOCATION: Three primary care teams (EAP) of Osona, Cataluña. PARTICIPANTS: 224 people identified as advanced patients through a systematic population strategy. MAIN MEASUREMENTS: Age, sex, type of home, end-of-life trajectory; use, type and cost of resources in primary care, emergencies, palliative teams or hospitalization (in acute or intermediate care). RESULTS: Patients made an average of 1.1 admissions per year (average stay=6 days), 74% in intermediate care hospitals. They lived in the community 93.4% of time, carrying out 1 weekly contact with the EAP (45.1% home care). The average daily cost was 19.4euros, the main chapters were intermediate care hospitalizations (36.5%), EAP activity (29.4%) and admissions in acute hospitals (28.6%). Factors determining a potential lower cost are frailty/dementia as trajectory (p<0.001), living in a nursing-home facility (p<0.001) and over-aging (p<0.001). There are certain differences in the behavior of the EAP related to the global cost and to community resources (p<0.05). CONCLUSIONS: Consumption in intermediate hospitalization and primary care is more relevant than stays in acute care centers. Nursing-homes and home-care strategies are important to attend effectively and efficiently, especially when primary care teams get ready for it.

Surgical treatment of early-onset idiopathic scoliosis in the United States: a trend analysis of 15 years (1997-2012).

BACKGROUND CONTEXT: Early-onset scoliosis is a challenging problem that is defined as a curvature of the spine of more than 10 degrees identified in a child less than 10 years. Early-onset idiopathic scoliosis (EOIS) can cause substantial morbidity and may require surgical intervention. PURPOSE: The aim of the present study was to identify the trends of EOIS type of surgeries, length of hospital stay, in-hospital complications, and total inpatient admission charges over a 15-year study period in the United States from 1997 to 2012. STUDY DESIGN/SETTING: This retrospective study used the ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) codes from the Healthcare Cost and Utilization Project (HCUP) Kids Inpatient's Database (KID) for a 15-year period (1997-2012). PATIENT SAMPLE: We identified a total of 897 patients with EOIS over the 15-year study period. OUTCOME MEASURES: The present study determines the current trends for EOIS surgeries. METHODS: The present study had no funding sources or any potential conflicts of interest associated biases. Idiopathic scoliosis patients with ages between 0 and <10 years were identified from the Kids' Inpatient Database with ICD-9-CM code 737.30. Posterior, anterior, and combined spinal surgeries were identified in EOIS through the procedure codes. Patients' gender, discharge diagnosis (comorbidities), hospital length of stay (LOS), mortality rates, hospital charges, and in-hospital complication rate data were collected between 1997 and 2012. The primary grouping variable of the study was the type of surgery (posterior, anterior, and combined). The trends of each variable (female gender, mortality rates, in-hospital complications rates, discharge diagnosis, LOS, and total hospital charges) were assessed for each surgical group separately. Cost inflation of hospital charges was adjusted for the year 2012. An analysis of variance test was used to analyze continuous variables and a chi-square test was used for categorical variables. A linear regression test was used to assess the trend of changes. p≤.05 was considered statistically significant. RESULTS: The study identified 897 patients, with 546 (61%) of them requiring surgery. Spine deformity surgery rates significantly decreased in patients with EOIS over time from 75% in 1997 to 47% in 2012, p=.019. In the surgery cohort, the male to female distribution was 37% and 63%, respectively. The overall mortality rate was 0.1%. The average length of hospital stay was 8 days and the average number of discharge diagnosis was 5.3. Aggregated complications were seen in 6% of the patients. The total mean hospital charge (per 2012 US dollars) was $119,613, which increased significantly for all types of surgeries. Over the 15-year study period, 62% (n=342) of the patients had posterior surgeries, 13% (n=71) of the patients had anterior surgeries, and 24% (n=133) of the patients had combined (anterior and posterior) surgeries. Posterior surgeries increased significantly from 33% in 1997 to 91% in 2012 (p<.004). Combined surgeries saw a significant decline from 50% to 4.3% (0<0.001). Anterior surgeries also decreased from 17% to 4.3% (p<.126), but this did not reach statistical significance. CONCLUSIONS: From 1997 to 2012 (15 years) study period of patients with EOIS, posterior-based surgeries significantly increased. The overall surgery rate has significantly decreased for these patients. A significant increase in hospital charges were noticed in posterior, anterior, and combined surgeries.

Resource use and cost of annual health checks in primary care for people with intellectual disabilities.

BACKGROUND: The annual health check (AHC) programme, as part of a Directed Enhanced Service, offers an incentive to general practitioners in England to conduct health checks for people with intellectual disabilities (IDs). The aim of this analysis was to estimate the impact on health care costs of AHCs in primary care to the National Health Service in England by comparing adults with ID who did or did not have AHCs using data obtained from The Health Improvement Network. METHODS: Two hundred eight records of people with ID from The Health Improvement Network database were analysed. Baseline health care resource use was captured at the time the first AHC was recorded (i.e. index date), or the earliest date after 1 April 2008 for those without an AHC. We examined the volume of resource use and associated costs that occurred at the time AHCs were performed, as well as before and after the index date. We then estimated the impact of AHCs on health care costs. RESULTS: The average cost of AHC was estimated at £142.57 (95%CI £135.41 to £149.74). Primary, community and secondary health care costs increased significantly after the index date in the no AHC group owing to higher increase in resource utilisation. Regression analysis showed that the expected health care cost for those who have an AHC is 56% higher than for those who did not have an AHC. Age and gender were also associated with increase in expected health care cost. CONCLUSION: The level of resource utilisation increased in both (AHC and no AHC) groups after the index date. Although the level of resource use before index date was lower in the no AHC group, it increased after the index date up to almost reaching the level of resource utilisation in the AHC group. Further research is needed to explore if the AHCs are effective in reducing health inequalities.

Impact of Complications on Resource Utilization During 90-Day Coronary Artery Bypass Graft Bundle for Medicare Beneficiaries.

BACKGROUND: The study reports the impact of adverse events during the index coronary artery bypass graft surgery (CABG) on Medicare reimbursement for the index hospitalization and a 90-day follow-up period. METHODS: This retrospective study used 2014 Medicare claims files for hospitals, skilled nursing services, rehabilitation facilities, long-term care facilities, home health services, and outpatient visits. The study sample is 37,106 Medicare beneficiaries that survived an index CABG in a US hospital during the first three quarters of 2014. Adverse events included acute renal failure, new onset hemodialysis, postoperative respiratory failure, any infection (postoperative infection, or sepsis), postoperative shock and hemorrhage, postoperative stroke, and reoperation during index hospitalization. RESULTS: Total average Medicare reimbursement for all services consumed during index CABG hospitalization and the 90-day postdischarge period was $42,063 ± $23,284. The index CABG hospitalization accounted for $32,544 ± $14,406, 77.4% of the bundle. Medicare beneficiaries having at least one adverse event had significantly higher total average Medicare reimbursement by $15,941 ($54,280 versus $38,339) for the bundle compared with Medicare beneficiaries not having an adverse event. The risk-adjusted incremental Medicare reimbursement for the entire 90-day bundle exceeded $20,000 for four adverse events: new-onset hemodialysis, $33,250; septicemia, $32,063; postoperative stroke, $24,117; and postoperative infection, $23,801. CONCLUSIONS: Medicare beneficiaries who have adverse events during their index CABG hospitalization will significantly affect that hospital's financial risk. The challenge under the voluntary CABG bundled payment program will be to monitor and reduce adverse events and manage the services consumed by Medicare beneficiaries having adverse events delivered at all the venues of care.

Trends in Health Care Costs and Utilization Associated With Untreated Hearing Loss Over 10 Years.

Importance: Nearly 38 million individuals in the United States have untreated hearing loss, which is associated with cognitive and functional decline. National initiatives to address hearing loss are currently under way. Objective: To determine whether untreated hearing loss is associated with increased health care cost and utilization on the basis of data from a claims database. Design, Setting, and Participants: Retrospective, propensity-matched cohort study of persons with and without untreated hearing loss based on claims for health services rendered between January 1, 1999, and December 31, 2016, from a large health insurance database. There were 154 414, 44 852, and 4728 participants at the 2-, 5-, and 10-year follow-up periods, respectively. The study was conceptualized and data were analyzed between September 2016 and November 2017. Exposures: Untreated hearing loss (ie, hearing loss that has not been treated with hearing devices) was identified via claims measures. Main Outcomes and Measures: Medical costs, inpatient hospitalizations, total days hospitalized, 30-day hospital readmission, emergency department visits, and days with at least 1 outpatient visit. Results: Among 4728 matched adults (mean age at baseline, 61 years; 2280 women and 2448 men), untreated hearing loss was associated with $22 434 (95% CI, $18 219-$26 648) or 46% higher total health care costs over a 10-year period compared with costs for those without hearing loss. Persons with untreated hearing loss experienced more inpatient stays (incidence rate ratio, 1.47; 95% CI, 1.29-1.68) and were at greater risk for 30-day hospital readmission (relative risk, 1.44; 95% CI, 1.14-1.81) at 10 years postindex. Similar trends were observed at 2- and 5-year time points across measures. Conclusions and Relevance: Older adults with untreated hearing loss experience higher health care costs and utilization patterns compared with adults without hearing loss. To further define this association, additional research on mediators, such as treatment adherence, and mitigation strategies is needed.

Patient Risk Factors Do Not Impact 90-Day Readmission and Emergency Department Visitation After Total Ankle Arthroplasty: Implications for the Comprehensive Care for Joint Replacement (CJR) Bundled Payment Plan.

BACKGROUND: The Comprehensive Care for Joint Replacement (CJR) model provides bundled payments for in-hospital care and care within 90 days following discharge for Medicare beneficiaries undergoing lower-extremity joint replacement involving the hip, knee, or ankle (total hip arthroplasty, total knee arthroplasty, or total ankle arthroplasty [TAA]). The study hypothesis was that patient comorbidities are associated with readmissions, emergency department (ED) utilization, and subspecialist wound-healing consultation, which are examples of costly contributors to postoperative health-care spending. METHODS: The medical records for 1,024 patients undergoing TAAs between June 2007 and December 2016 at a single academic center in the southeastern United States were reviewed for the outcomes of readmissions, ED visitations, and subspecialist wound-healing consultation within the 90-day post-discharge period. All patients undergoing TAA (n = 1,365) were eligible. Of the 1,037 patients who consented to participation in the study and underwent TAA, 1,024 (98.7%) completed the study. Medical comorbidities according to the Elixhauser and Charlson-Deyo comorbidity indices that were present prior to TAA were recorded. Univariate and multivariable tests of significance were used to relate patient and operative characteristics to outcomes. RESULTS: Four hundred and ninety-six (48.4%) of the 1,024 patients were female, and 964 (94.1%) were white/Caucasian, with an average age (and standard deviation) of 63 ± 10.5 years. Hypertension, obesity, solid tumor, depression, rheumatic disease, cardiac arrhythmia, hypothyroidism, diabetes mellitus, and chronic pulmonary disease had a prevalence of >10%. Fifty-three (5.2%) of the 1,024 patients were readmitted for any cause. Thirty-six (3.5%) of the 1,024 returned to the ED but were not admitted to the hospital. Readmission or ED visitation was most commonly for a wound complication, followed by deep venous thrombosis (DVT) and pulmonary embolism (PE) evaluation, while urgent medical evaluations composed the majority of non-TAA-related ED visitations. No patient comorbidities were significantly associated with 90-day readmission, ED visitation, or wound complications in multivariable models. CONCLUSIONS: Patient comorbidities were not associated with 90-day hospital readmissions or ED visitation for patients undergoing TAA. Readmissions were dominated by evaluation of wound compromise as well as DVT and PE. These data suggest that there may be considerable differences between TAA and total hip arthroplasty or total knee arthroplasty that cause surgeons to question the inclusion of TAA in CJR bundled payment models. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.