Urinary catheter monitoring of intra-abdominal pressure after major abdominal surgery, a cost-benefit analysis.

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.

Modeling the economic value of Ceribell Rapid Response EEG in the inpatient hospital setting.

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.

Computerized prescriber order entry and opiate prescription in ambulatory care visits.

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.

Neurophysiological monitoring during cervical spine surgeries: Longitudinal costs and outcomes.

OBJECTIVES: Well-designed longitudinal studies assessing effectiveness of intraoperative neurophysiologic monitoring (IONM) are lacking. We investigate IONM effects on cost and administrative markers for health outcomes in the year after cervical spine surgery. METHODS: We identified single-level cervical spine surgeries in commercial claims. We constructed linear regression models estimating the effect of IONM (controlling for patient demographics, pre-operative health, services during index admission) on total spending, neurological complications, readmissions, and outpatient opiate usage in the year following index surgery. RESULTS: IONM was associated with increased spending during index admission of $1229 (p = 0.001), but decreased spending post-discharge of $1615 (p = 0.010), for a net - $386 (p = 0.608) for the year after surgery. Shorter length of stay (0.116 days, p = 0.004) and fewer readmissions (20.5 per thousand, p = 0.036) accounted for some post-discharge savings. IONM was associated with decreased rates of nervous system complications (4/1000, p = 0.048) and post-discharge opiate use (17 prescriptions/1000, p = 0.050) in the year after index admission. CONCLUSIONS: IONM was associated with administrative markers suggesting improved health outcomes after cervical spine surgery without greater costs for the year. SIGNIFICANCE: This study suggests IONM may have lasting health and cost benefits.

The Business Case for Expanded Clozapine Utilization.

OBJECTIVE: In most settings, less than 25% of patients with treatment-resistant schizophrenia receive clozapine, the only medication proven effective for treatment-resistant schizophrenia. Therefore, a business case analysis was conducted to assess whether increasing clozapine utilization for treatment-resistant schizophrenia in a health care system would result in direct health care cost savings. METHODS: Veterans with treatment-resistant schizophrenia who were treated in the Veterans Health Administration (VHA) were studied. Treatment response, suicides, adverse drug reactions (and associated mortality), and effects on inpatient hospitalization related to clozapine were derived from a systematic review of published studies. A one-factor sensitivity analysis and a probabilistic sensitivity analysis (PSA) with Monte Carlo simulation were conducted to calculate the cost-benefits of increased clozapine utilization. RESULTS: Despite monitoring costs, in the base case analysis, the VHA would save $22,444 per veteran with treatment-resistant schizophrenia over the first year of clozapine therapy, primarily from 18.6 fewer inpatient days per patient. If current utilization was doubled, and 50% of those veterans continued clozapine treatment for one year, VHA would save an estimated $80 million. Cost savings were most sensitive to the proportion of treatment-resistant patients who received clozapine, decrease in inpatient days, cost of inpatient stays, clozapine response rate, and number of patients with treatment-resistant schizophrenia. In the PSA, initiation of clozapine for all VHA patients with treatment-resistant schizophrenia who were not currently treated with clozapine would save at least $290 million in 95% of simulations. CONCLUSIONS: Increased clozapine utilization would result in net cost savings for the VHA.

Does intraoperative neurophysiologic monitoring matter in noncomplex spine surgeries?

OBJECTIVES: To determine associations between intraoperative neurophysiologic monitoring (IOM) for spinal decompressions and simple fusions with neurologic complications, length of stay, and hospitalization charges. METHODS: Adult discharges in the Nationwide/National Inpatient Sample (NIS) (2007-2012) with spinal decompressions and simple spinal fusions were included. Revision surgeries, instrumentations, complicated approaches, and tumor- and trauma-related surgeries were excluded. Extracted data included patient demographics, medical comorbidities, primary spinal surgery type, and hospital characteristics. Bivariate and multiple regression analyses using NIS survey design variables correlated IOM use with neurologic complications, hospital charges, and length of stay. RESULTS: IOM was reported in 4.9% of an estimated 1.1 million discharges in the weighted sample. Discharges reporting IOM were more often privately insured (61% vs 57%, p < 0.001) and had slightly more comorbidities (25% vs 24% with 3+ comorbidities, p = 0.01). Spinal fusions more often reported IOM than decompressions. The IOM group had fewer neurologic complications (0.8% vs 1.4% of controls) with no difference in length of stay (3.0 days for each group), but increased hospital charges (39% greater). Multiple regression adjustment showed significant associations of IOM with fewer neurologic complications (odds ratio 0.60, 95% confidence interval [CI] 0.47, 0.76, p < 0.001), while the estimated percentage of hospital charges was sizably diminished from the unadjusted analysis (IOM effect +9%, 95% CI +4%, +13%, p < 0.001), and length of stay was reduced (IOM effect -0.26 days, 95% CI -0.42, -0.11, p < 0.001). CONCLUSIONS: IOM was associated with better clinical outcomes and some increased hospital charges among discharges of simple spinal fusions and laminectomies in a large, multiyear, nationally representative dataset.

Comparative effectiveness analyses of intraoperative neurophysiological monitoring in spinal surgery.

Intraoperative neurophysiological monitoring for surgeries of the spine has been performed in clinical practice for several decades, but recent alterations in reimbursement schemes by third party payers have raised issues of the value of these procedures. Decision modeling using comparative effectiveness techniques holds the promise of evidence-based assessment of both cost and meaningful outcomes. In this article, we review the elements of comparative effectiveness analyses followed by a critical appraisal of the small but growing body of cost-effectiveness literature for intraoperative neurophysiological monitoring in spine.

Association of polypharmacy and statin new-user adherence in a Veterans Health Administration population: a retrospective cohort study.

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.

Cost-benefit analysis: intraoperative neurophysiological monitoring in spinal surgeries.

PURPOSE: To construct a cost-benefit model for intraoperative neurophysiological monitoring (IOM) in spinal surgeries. METHODS: Decision model was based on sensitivity, specificity, IOM cost, prevention rate given an IOM alert, and spinal procedure neurologic complication rates in pooled estimates from the published literature with outcome of lifetime costs after neuromonitored versus unmonitored spinal surgeries. Lifetime cost of neurologic injury was the sum of direct health care costs and lost wages and benefits. Results from Monte Carlo simulation with 10,000 replications were analyzed for cost outcomes and relationship of input variables to outcomes. RESULTS: IOM saved $23,189 (P < 0.001) for the reference case of 50-year-olds with neurologic complication rate of 5%, 2009 Medicare reimbursement of IOM at $1,535 per operation, 52.4% prevention rate given an IOM alert at 94.3% sensitivity and 95.6% specificity, assuming incomplete (nonplegic) motor injury. The baseline risk of surgery, lifetime costs after neurologic deficit, and ability to prevent neurologic deficits after an IOM alert were most correlated with cost outcomes. In linear prediction models, IOM remained cost-saving when neurologic complication rate from surgery exceeded 0.3% (P < 0.001) and prevention rate after IOM alert was greater than 14.2%(P = 0.02). CONCLUSIONS: Intraoperative monitoring is cost-saving for spinal surgeries in a theoretical model based on the current published literature.

Polyglandular autoimmunity with macrophagic myofasciitis.

We report a man with chronic fatigue, multiple autoimmune disorders, and a muscle biopsy consistent with macrophagic myofasciitis. This rare and recently described muscle disorder is seen in patients exposed to vaccinations with aluminum hydroxide adjuvant. This case highlights the relationship between macrophagic myofasciitis and autoimmunity.