The impact of different co-morbidities on clinical outcomes and resource utilization in critically ill burn and surgical patients: A population-based analysis of social determinants of health.

BACKGROUND: This study aims to establish the significance of social determinants of health and prevalent co-morbidities on multiple indicators for quality of care in patients admitted to the Burn and Surgical Intensive Care Unit (ICU). METHODS: We performed a retrospective analysis of population group data for patients admitted at the Burn and Surgical ICU from January 1, 2016, to November 18, 2019. The primary outcomes were length of hospital stay (LOS), mortality, 30-day readmission, and hospital charges. Pearson's chi-square test for categorical variables and t-test for continuous variables were used to compare population health groups. RESULTS: We analyzed a total of 487 burn and 510 surgical patients. When comparing ICU patients, we observed significantly higher mean hospital charges and length of stay (LOS) in BICU v. SICU patients with a history of mental health ($93,259.40 v. $50,503.36, p = 0.013 and 16.28 v. 9.16 days, p = 0.0085), end-stage-renal-disease (ESRD) ($653,871.05 v. $75,746.35, p = 0.0047 and 96.15 v. 17.53 days, p = 0.0104), sepsis ($267,979.60 v. $99,154.41, p = <0.001 and 39.1 v. 18.42 days, p = 0.0043), and venous thromboembolism (VTE) ($757,740.50 v. $117,816.40, p = <0.001 and 93.11 v. 20.21 days, p = 0.002). Also, higher mortality was observed in burn patients with ESRD, ST-Elevation Myocardial Infarction (STEMI), sepsis, VTE, and diabetes mellitus. 30-day-readmissions were greater among burn patients with a history of mental health, drug dependence, heart failure, and diabetes mellitus. CONCLUSIONS: Our study provides new insights into the variability of outcomes between burn patients treated in different critical care settings, underlining the influence of comorbidities on these outcomes. By comparing burn patients in the BICU with those in the SICU, we aim to highlight how differences in patient backgrounds, including the quality of care received, contribute to these outcomes. This comparison underscores the need for tailored healthcare strategies that consider the unique challenges faced by each patient group, aiming to mitigate disparities in health outcomes and healthcare spending. Further research to develop relevant and timely interventions that can improve these outcomes.

Financial toxicity among patients undergoing resectional surgery for inflammatory bowel disease in the United States.

AIM: Financial toxicity describes the financial burden and distress that patients experience due to medical treatment. Financial toxicity has yet to be characterized among patients with inflammatory bowel disease (IBD) undergoing surgical management of their disease. This study investigated the risk of financial toxicity associated with undergoing surgery for IBD. METHODS: This study used a retrospective analysis using the National Inpatient Sample from 2015 to 2019. Adult patients who underwent IBD-related surgery were identified using the International Classification of Diseases (10th Revision) diagnostic and procedure codes and stratified into privately insured and uninsured groups. The primary outcome was risk of financial toxicity, defined as hospital admission charges that constituted 40% or more of patient's post-subsistence income. Secondary outcomes included total hospital admission cost and predictors of financial toxicity. RESULTS: The analytical cohort consisted of 6412 privately insured and 3694 uninsured patients. Overall median hospital charges were $21 628 (interquartile range $14 758-$35 386). Risk of financial toxicity was 86.5% among uninsured patients and 0% among insured patients. Predictors of financial toxicity included emergency admission, being in the lowest residential income quartile and having ulcerative colitis (compared to Crohn's disease). Additional predictors were being of Black race or male sex. CONCLUSION: Financial toxicity is a serious consequence of IBD-related surgery among uninsured patients. Given the pervasive nature of this consequence, future steps to support uninsured patients receiving surgery, in particular emergency surgery, related to their IBD are needed to protect this group from financial risk.

Same day discharge colon surgery: is it financially worth it?

AIM: Same day discharge (SDD) for colorectal surgery shows increasing promise in the era of enhanced recovery after surgery protocols and minimally invasive surgery. It has become increasingly relevant due to the constraints posed by the COVID-19 pandemic. The aim of this study was to compare SDD and postoperative day 1 (POD1) discharge to understand the clinical outcomes and financial impact on factors such as cost, charge, revenue, contribution margin and readmission. METHOD: A retrospective review of colectomies was performed at a single institution over a 2-year period (n = 143). Two populations were identified: SDD (n = 51) and POD1 (n = 92). Patients were selected by International Statistical Classification of Diseases and Related Health Problems-10 (ICD-10) and Diagnosis Related Grouper (DRG) codes. RESULTS: There was a statistically significant difference favouring SDD in total hospital cost (p < 0.0001), average direct costs (p < 0.0001) and average charges (p < 0.0016). SDD average hospital costs were $8699 (values in USD throughout) compared with $11 652 for POD 1 (p < 0.0001), and average SDD hospital charges were $85 506 compared with $97 008 for POD1 (p < 0.0016). The net revenue for SDD was $22 319 while for POD1 it was $26 173 (p = 0.14). Upon comparison of contribution margins (SDD $13 620 vs. POD1 $14 522), the difference was not statistically significant (p = 0.73). There were no identified statistically significant differences in operating room time, robotic console time, readmission rates or surgical complications. CONCLUSIONS: Amidst the pandemic-related constraints, we found that SDD was associated with lower hospital costs and comparable contribution margins compared with POD1. Additionally, the study was unable to identify any significant difference between operating time, readmissions, and surgical complications when performing SDD.

Hospital Prices for Physician-Administered Drugs for Patients with Private Insurance.

BACKGROUND: Hospitals can leverage their position between the ultimate buyers and sellers of drugs to retain a substantial share of insurer pharmaceutical expenditures. METHODS: In this study, we used 2020-2021 national Blue Cross Blue Shield claims data regarding patients in the United States who had drug-infusion visits for oncologic conditions, inflammatory conditions, or blood-cell deficiency disorders. Markups of the reimbursement prices were measured in terms of amounts paid by Blue Cross Blue Shield plans to hospitals and physician practices relative to the amounts paid by these providers to drug manufacturers. Acquisition-price reductions in hospital payments to drug manufacturers were measured in terms of discounts under the federal 340B Drug Pricing Program. We estimated the percentage of Blue Cross Blue Shield drug spending that was received by drug manufacturers and the percentage retained by provider organizations. RESULTS: The study included 404,443 patients in the United States who had 4,727,189 drug-infusion visits. The median price markup (defined as the ratio of the reimbursement price to the acquisition price) for hospitals eligible for 340B discounts was 3.08 (interquartile range, 1.87 to 6.38). After adjustment for drug, patient, and geographic factors, price markups at hospitals eligible for 340B discounts were 6.59 times (95% confidence interval [CI], 6.02 to 7.16) as high as those in independent physician practices, and price markups at noneligible hospitals were 4.34 times (95% CI, 3.77 to 4.90) as high as those in physician practices. Hospitals eligible for 340B discounts retained 64.3% of insurer drug expenditures, whereas hospitals not eligible for 340B discounts retained 44.8% and independent physician practices retained 19.1%. CONCLUSIONS: This study showed that hospitals imposed large price markups and retained a substantial share of total insurer spending on physician-administered drugs for patients with private insurance. The effects were especially large for hospitals eligible for discounts under the federal 340B Drug Pricing Program on acquisition costs paid to manufacturers. (Funded by Arnold Ventures and the National Institute for Health Care Management.).

Association of ICD-10 Clinical Modification Codes for Social Determinants of Health with Surgical Outcomes and Hospital Charges Among Cancer Patients.

INTRODUCTION: We sought to characterize the impact of social determinants of health (SDOH)-related codes on outcomes among patients with a cancer diagnosis. METHODS: Patients diagnosed with lung, pancreas, colon, or rectal cancer between 2017 and 2020 were identified in the California Department of Healthcare Access and Information Patient Discharge Database. Data on concomitant SDOH-related codes (International Classification of Diseases, Tenth Revision [ICD-10] Z55-Z65) designating health hazards related to socioeconomic and psychosocial circumstances were obtained. The association of these SDOH codes with postoperative outcomes was evaluated. RESULTS: Among 10,421 patients who underwent an operation from 2017 to 2020, median age was 66 years (interquartile range [IQR] 56-75) and nearly half of the cohort was male (n = 551,252.9%). In total, 102 (1%) patients had a concurrent ICD-10 SDOH diagnosis. After controlling for competing risk factors, the risk-adjusted probability of in-hospital death was 4.1% (95% confidence interval [CI] 1.0-7.2) among patients with an SDOH diagnosis compared with 2.9% (95% CI 2.5-3.2) among patients without an SDOH diagnosis (odds ratio [OR] 1.52, 95% CI 0.63-3.66; p = 0.258); postoperative complications were 27.0% (95% CI 20.0-34.1) compared with 24.9% (95% CI 24.1-25.6) among patients without an SDOH diagnosis (OR 1.15, 95% CI 0.73-1.82; p = 0.141), and length of stay was 10.6 days (95% CI 10.0-11.2) compared with 9.4 days (95% CI 9.3-9.5) among patients without an SDOH diagnosis. Patients with an SDOH diagnosis had a 5.19 (95% CI 3.23-8.34; p < 0.005) higher odds of being discharged to a skilled nursing facility versus patients without an SDOH diagnosis. CONCLUSION: Uptake and utilization of ICD-10 SDOH was 1% among California patients with lung, pancreas, colon, or rectal cancer. Patients with a concomitant ICD-10 SDOH code had longer length of stay and had higher odds of being discharged to a skilled nursing facility.

The Variation of Chargemaster Price Listings for Urogynecologic Procedures.

IMPORTANCE: A 2018 Executive Order calling for price transparency required hospitals to publicly provide chargemasters, which are detailed lists of standard price listings for billable medical procedures. OBJECTIVES: The objective of this study was to evaluate price listing variations in common urogynecology procedures. STUDY DESIGN: This was a cross-sectional study of chargemasters obtained between February and April 2020 from hospitals across 5 states chosen to reflect the diversity of health systems in the United States. Hospital characteristic and quality metric data were obtained from the Homeland Infrastructure Foundation, U.S. Department of Agriculture, and U.S. Centers for Medicare & Medicaid Services websites. Current Procedural Terminology codes and procedure names for 9 urogynecologic procedures were used to search each chargemaster and extract price listings. Price listings were compared with data on quality, population demographics, and hospital characteristics to determine if any significant relationships existed. RESULTS: Eight hundred thirty-four chargemasters were identified. Price listings for most procedures differed significantly across the 5 states, including colpocleisis, cystoscopy with chemodenervation, diagnostic cystoscopy, diverticulectomy, sacral neuromodulation, midurethral sling, and sacrospinous ligament fixation. Price listings were significantly higher in urban hospitals than rural hospitals for 6 procedures. No significant association was seen with price listing and quality measures for most procedures. CONCLUSIONS: Listed prices varied for several urogynecologic procedures. Some of this variation is associated with hospital characteristics such as urban setting. However, notably, price listing was not associated with quality. Further investigation of chargemaster price listings with hospital characteristics and quality metrics and with what is actually paid by patients is imperative for patients to navigate charges.

Ongoing Challenges With Price Transparency in Hospital Charges for Hand Procedures.

In 2020, the Centers for Medicare & Medicaid Services issued a historic rule on price transparency that aimed to better inform Americans about their health care costs by requiring hospitals to publicly provide pricing information on their items and services. In this review article, we describe the current gaps in transparency that persist after the implementation of the rule, from incomplete pricing files to noncompliance despite the issuance of monetary penalties by Centers for Medicare & Medicaid Services. Price transparency is vital for hand and upper extremity procedures, given their cost variation and patient desire for more financial discussions with their physicians regarding these procedures. Further improvements and interventions by various stakeholders are necessary to improve the current state of hospital price transparency and cost information for these patients and for anyone who seeks to make informed health care decisions. Policymakers should enforce stronger financial interventions and penalties and promote the use of bundled payments to facilitate better compliance by hospitals through a more expanded and accessible display of health care service costs. To help increase health care financial literacy among consumers, hand surgeons and hospital staff should engage in more dialog regarding health care prices and financial considerations with their patients.

Laser enucleation of the prostate (LEP) vs. simple prostatectomy: an analysis of hospital charges and comparison of practice trends.

PURPOSE: Laser enucleation of the prostate (LEP) and simple prostatectomy (SP) are surgical treatment options for large gland Benign Prostatic Hyperplasia. While multiple studies compare clinical outcomes of these procedures, there are limited data available comparing hospital charges in the United States. Here, we present current practice trends and a hospital charge analysis on a national level using an annual insurance claims data repository. METHODS: The Healthcare Cost and Utilization Project National Inpatient Sample and Nationwide Ambulatory Surgery Sample databases for 2018 were queried. CPT and ICD-10PCS codes identified patients undergoing LEP or SP, who were then compared for practice setting, total hospital charges, and payor. Laser type for LEP and surgical approach for SP could not be differentiated. RESULTS: The median hospital charge of 5782 LEPs and 973 SPs is $26,689 and $51,250 (p < 0.001), respectively. LEP independently predicts a decreased hospital charge of $16,464 (p < 0.001) per case. Medicare is the primary payor for both procedures. More LEP procedures are completed in the outpatient setting (87.8%) vs. SPs (5.7%, p < 0.001). Median length of stay is longer for SP (LEP: 0, IQR: 0; SP: 3, IQR: 2-4; p < 0.001). In the Western region, LEP is least commonly performed (184, p < 0.001), most expensive ($43,960; p < 0.001), and has longer length of stay (2, p < 0.001). CONCLUSIONS: LEP should be considered a cost-effective alternative to SP. Regions of the U.S. that perform more LEPs have shorter length of stay and lower hospital charges associated with the procedure.

Financial analysis of minimally invasive sacrocolpopexy compared with native tissue vaginal repair with concomitant hysterectomy.

INTRODUCTION: Minimally invasive sacrocolpopexy (MISCP) is increasingly used for uterovaginal prolapse, but comparative cost data of MISCP versus native tissue vaginal repair (NTR) are lacking. The objective was to determine the cost difference, from a hospital perspective, between MISCP and NTR performed with hysterectomy for uterovaginal prolapse. METHODS: This was a retrospective cohort study at a tertiary care center of women who underwent NTR or MISCP with concomitant hysterectomy in 2021. Hospital charges, direct and indirect costs, and operating margin (revenue minus costs) were obtained from Strata Jazz and compared using SPSS. RESULTS: A total of 82 women were included, 33 MISCP (25 robotic, 8 laparoscopic) versus 49 NTR. Demographic and surgical data were similar, except that MISCP had younger age (50.5 vs 61.1 years, p<0.01). Same-day discharge and estimated blood loss were similar, but operative time was longer for MISCP (204 vs 161 min, p<0.01). MISCP total costs were higher (US$17,422 vs US$13,001, p<0.01). MISCP had higher direct costs (US$12,354 vs US$9,305, p<0.01) and indirect costs (US$5,068 vs US$3,696, p<0.01). Consumable supply costs were higher with MISCP (US$4,429 vs US$2,089, p<0.01), but the cost of operating room time and staff was similar (US$7,926 vs US$7,216, p=0.07). Controlling for same-day discharge, anti-incontinence procedures and smoking, total costs were higher for MISCP (adjusted beta = US$4,262, p<0.01). Mean charges (US$102,060 vs US$97,185, p=0.379), revenue (US$22,214 vs US$22,491, p=0.929), and operating margin (US$8,719 vs US$3,966, p=0.134) were not statistically different. CONCLUSION: Minimally invasive sacrocolpopexy had higher costs than NTR; however, charges, reimbursement, and operating margins were not statistically significantly different between the groups.

The Divergence Between Hospital Charges and Reimbursements For Primary 1-2-level Lumbar Fusion Has Increased Over Time: A Medicare Administrative Claims Analysis.

STUDY DESIGN: A retrospective cohort study was performed for patients undergoing 1-2-level lumbar fusion (1-2LF) from 2005 to 2014 using an administrative claims database. OBJECTIVE: The objective of this study was to determine changes in: (1) annual charges; (2) annual reimbursement rates; and (3) annual difference (charges minus reimbursements) in patients undergoing 1-2LF. SUMMARY OF BACKGROUND DATA: With implementation of value-based care in orthopaedics, coupled with the rise in number of patients undergoing 1-2LF, understanding the discordance in hospital charges and reimbursements is needed. The difference in hospital charges to reimbursements specifically for 1-2LF for degenerative disc disease has not been studied. MATERIALS AND METHODS: A Medicare administrative claims database was queried for patients undergoing primary lumbar fusion using ICD-9 procedural code 81.04-81.08. Patients specifically undergoing 1-2LF were filtered from this cohort using ICD-9 procedural code 81.62. The query yielded 547,067 patients who underwent primary 1-2LF. Primary outcomes analyzed included trends in charges, reimbursement rates, and net difference in cost over time and per annual basis. Linear regression evaluated the change in costs over time with a P -value less than 0.05 considered significant. RESULTS: From 2005 to 2014, total charges increased from $6,085,838,407 to $19,621,979,956 and total reimbursements increased from $1,677,764,831 to $4,656,702,685 (all P <0.001). Per patient charges increased 92.10% from 2005 to 2014 for patients undergoing primary 1-2LF from $129,992 to $249,697 ( P <0.001). Similarly, an increase in reimbursement per patient of 65.35% from $35,836 to $59,258 ( P <0.001) was noted. The annual difference in charges to reimbursements increased 102.26% during the study interval from $94,155 to $190,439 ( P <0.001). CONCLUSIONS: Per patient charges and reimbursements both increased over the study period; however, charges increased 30% more than reimbursements. Further breakdown of hospital, surgeon, and anesthesiologist reimbursements for 1-2LF is needed. LEVEL OF EVIDENCE: Level III.

Is Hospital Hospice Service Associated with Efficient Healthcare Utilization in Deceased Lung Cancer Patients? Hospital Charges at Their End of Life.

In July 2015, South Korea began applying National Health Insurance reimbursement to inpatient hospice service. It is now appropriate and relevant to evaluate how hospice care is associated with healthcare utilization in terminal lung cancer patients. We used nationwide NHI claims data of lung cancer patients from 2008-2018 and identified a sample of patients deceased after July 2016. We transposed the dataset into a retrospective cohort design where a unit of analysis was each lung cancer patients' healthcare utilization. The differences in hospital charges per day were investigated depending on the patient's use of hospice service before death with the Generalized Linear Model (GLM) analysis. Additionally, subgroup analysis and the propensity score matching method were used to validate the model using the claims information of 25,099 patients. About 17.0% of patients used hospice services (N = 4260). With other variables adjusted, hospice service utilization by deceased lung cancer patients was associated with statistically significant lower hospital charges per day at the end of life (1 month, 3 months, and 6 months before death) compared to non-users. A similar trend was found in the propensity score matching model analysis. We found lower end-of-life hospital charges per day among lung cancer patients who received hospice services near death. The ever-expanding aging population requires health policymakers and the National Health Insurance program to expand hospice services for terminal cancer patients in underserved regions and hospitals that do not provide hospice.

Utilization Trends, Cost, and Payments for Adult Spinal Deformity Surgery in Commercial and Medicare-Insured Populations.

BACKGROUND: Previous studies have characterized utilization rates and cost of adult spinal deformity (ASD) surgery, but the differences between these factors in commercially insured and Medicare populations are not well studied. OBJECTIVE: To identify predictors of increased payments for ASD surgery in commercially insured and Medicare populations. METHODS: We identified adult patients who underwent fusion for ASD, 2007 to 2015, in 20% Medicare inpatient file (n = 21 614) and MarketScan commercial insurance database (n = 38 789). Patient age, sex, race, insurance type, geographical region, Charlson Comorbidity Index, and length of stay were collected. Outcomes included predictors of increased payments, surgical utilization rates, total cost (calculated using Medicare charges and hospital-specific charge-to-cost ratios), and total Medicare and commercial payments for ASD. RESULTS: Rates of fusion increased from 9.0 to 8.4 per 10 000 in 2007 to 20.7 and 18.2 per 10 000 in 2015 in commercial and Medicare populations, respectively. The Medicare median total charges increased from $88 106 to $144 367 (compound annual growth rate, CAGR: 5.6%), and the median total cost increased from $31 846 to $39 852 (CAGR: 2.5%). Commercial median total payments increased from $58 164 in 2007 to $64 634 in 2015 (CAGR: 1.2%) while Medicare median total payments decreased from $31 415 in 2007 to $25 959 in 2015 (CAGR: -2.1%). The Northeast and Western regions were associated with higher payments in both populations, but there is substantial state-level variation. CONCLUSION: Rate of ASD surgery increased from 2007 to 2015 among commercial and Medicare beneficiaries. Despite increasing costs, Medicare payments decreased. Age, length of stay, and BMP usage were associated with increased payments for ASD surgery in both populations.

Nationwide Readmission Rates and Hospital Charges for Patients With Surgical Evacuation of Nontraumatic Subdural Hematomas: Part 1-Craniotomy.

BACKGROUND: Despite patients experiencing high recurrence and readmission rates after surgical management of nontraumatic subdural hematomas (SDHs), few studies have examined the causes and predictors of unplanned readmissions in this population on a national scale. OBJECTIVE: To analyze independent factors predicting 30-day hospital readmissions after surgical treatment of nontraumatic SDH in patients who survived their index surgery and evaluate hospital readmission rates and charges. METHODS: Using the Nationwide Readmissions Database, we identified patients who underwent craniotomy for nontraumatic SDH evacuation (2010-2015) using a retrospective cohort observational study design. National estimates and variances within the cohort were calculated after stratifying, hospital clustering, and weighting variables. RESULTS: Among 49 013 patients, 10 643 (21.7%) had at least 1 readmission within 30 days of their index treatment and 38 370 (78.3%) were not readmitted. Annual readmission rates did not change during the study period ( P = .74). The most common primary causes of 30-day readmissions were recurrent SDH (n = 3949, 37.1%), venous thromboembolism (n = 1373, 12.9%), and delayed hyponatremia and syndrome of inappropriate antidiuretic hormone secretion (n = 1363, 12.8%). Comorbidities that independently predicted readmission included congestive heart failure, chronic obstructive pulmonary disease, coagulopathy, diabetes mellitus, liver disease, lymphoma, fluid and electrolyte disorders, metastatic cancer, peripheral vascular disease, psychosis, and renal failure ( P ≤ .03). Household income in the 51st to 75th percentile was associated with a decreased risk of readmission. CONCLUSION: National trends in 30-day readmission rates after nontraumatic SDH treatment by craniotomy provide quality benchmarks that can be used to drive quality improvement efforts on a national level.

Sharing the Operating Room: A Descriptive Study of Combined and Collaborative Plastic Surgery Cases.

BACKGROUND: Plastic surgeons are often asked for intraoperative assistance by other surgical services. Improvement of a plastic surgery service has been shown to improve patient outcomes, decrease length of stay, and increase hospital revenue, yet plastic surgery's contribution to a hospital tends to be undervalued. The purpose of this study was to quantify the multidisciplinary role the plastic surgery service plays within a single, large pediatric institution. METHODS: Surgical cases involving both plastic surgery and at least one other team were identified from 2016 to 2019. Each case was categorized as either "combined" or "collaborative" based on whether the two teams worked separately on separate problems or together on the same problem, respectively. Data points collected included combined and collaborative cases, operating room hours, and total hospital charges billed. RESULTS: Of the 7564 total plastic surgery cases performed, multidisciplinary cases made up a minority of total cases (16 percent) but required 32 percent of the operating room hours and provided 49 percent of the total charges billed. Collaborative cases alone accounted for 20 percent of the service's operating room hours and 39 percent of total charges billed, while making up only 8 percent of total cases. CONCLUSIONS: Relative to cases where plastic surgery operates alone, combined and collaborative cases account for a disproportionately high number of operating room hours and provide a disproportionately high amount of charges billed.

Geographic Financial Analysis of Craniosynostosis Surgery in the United States.

BACKGROUND: The purpose of this study was to investigate the financial implications of demographic and socioeconomic factors upon the cost of surgical procedures for craniosynostosis. METHODS: A retrospective cohort study was conducted of admissions for craniosynostosis surgery in the United States from 2015 through 2020 using the Pediatric Health Information System. Patient demographics, case volume, and surgical approach were analyzed in context of hospital charges. RESULTS: During the study interval, 3869 patients were admitted for surgery for craniosynostosis. In multivariate regression accounting for demographic and socioeconomic factors, hospital admission charges were significantly higher in patients with longer hospital length of stay ( P < 0.001), longer ICU length of stay ( P < 0.001), living in an underserved area ( P = 0.046), preoperative risk factors ( P = 0.016), and those undergoing open procedures ( P < 0.001); hospital admission charges were significantly lower in patients with White race ( P = 0.020) and those treated at high-volume centers ( P < 0.001). In multivariate regression, ICU length of stay was significantly higher in patients with preoperative risk factors ( P < 0.001), undergoing open procedures ( P < 0.001), government insurance ( P = 0.018), and not treated at high-volume centers ( P = 0.005). There were significant differences in admission charges ( P < 0.001), charge-to-cost ratios ( P < 0.001), and likelihood of being treated at high-volume craniofacial centers ( P < 0.001) across geographic regions of the country. CONCLUSIONS: In the United States, there is significant sociodemographic variability in charges for craniosynostosis care, with increased hospital charges independently associated with non-White race, preoperative risk factors, and living in an underserved area.

Novel Predictive Models for High-Value Care Outcomes Following Glioblastoma Resection.

BACKGROUND: Treating patients with glioblastoma (GBM) requires extensive medical infrastructure. Individualized risk assessment for extended length of stay (LOS), nonroutine discharge disposition, and increased total hospital charges is critical to optimize delivery of care. Our study sought to develop predictive models identifying independent risk factors for these outcomes. METHODS: We retrospectively reviewed patients undergoing GBM resection at our institution between January 2017 and September 2020. Extended LOS and elevated hospital charges were defined as values in the upper quartile of the cohort. Nonroutine discharge was defined as any disposition other than to home. Multivariate models for each outcome included covariates demonstrating P ≤ 0.10 on bivariate analysis. RESULTS: We identified 265 patients undergoing GBM resection, with an average age of 58.2 years. 24.5% of patients experienced extended LOS, 22.6% underwent nonroutine discharge, and 24.9% incurred elevated total hospital charges. Decreasing Karnofsky Performance Status (KPS) (P = 0.004), increasing modified 5-factor frailty (mFI-5) index (P = 0.012), lower surgeon experience (P = 0.005), emergent surgery (P < 0.0001), and larger tumor volume (P < 0.0001) predicted extended LOS. Independent predictors of nonroutine discharge included older age (P = 0.02), decreasing KPS (P < 0.0001), and emergent surgery (P = 0.048). Nonprivate insurance (P = 0.011), decreasing KPS (P = 0.029), emergent surgery (P < 0.0001), and larger tumor volume (P = 0.004) predicted elevated hospital charges. These models were incorporated into an open-access online calculator (https://neurooncsurgery3.shinyapps.io/gbm_calculator/). CONCLUSIONS: Several factors were independent predictors for at least 1 high-value care outcome, with lower KPS and emergent admission associated with each outcome. These models and our calculator may help clinicians provide individualized postoperative risk assessment to glioblastoma patients.

Differences in hospital length of stay and total hospital charge by income level in patients hospitalized for hip fractures.

This study examines the difference in length of stay and total hospital charge by income quartile in hip fracture patients. The length of stay increased in lower income groups, while total charge demonstrated a U-shaped relationship, with the highest charges in the highest and lowest income quartiles. INTRODUCTION: Socioeconomic factors have an impact on outcomes in hip fracture patients. This study aims to determine if there is a difference in hospital length of stay (LOS) and total hospital charge between income quartiles in hospitalized hip fracture patients. METHODS: National Inpatient Sample (NIS) data from 2016 to 2018 was used to determine differences in LOS, total charge, and other demographic/clinical outcomes by income quartile in patients hospitalized for hip fracture. Multivariate regressions were performed for both LOS and total hospital charge to determine variable impact and significance. RESULTS: There were 860,045 hip fracture patients were included this study. With 222,625 in the lowest income quartile, 234,215 in the second, 215,270 in the third, and 190,395 in the highest income quartile. LOS decreased with increase in income quartile. Total charge was highest in the highest quartile, while it was lowest in the middle two-quartiles. Comorbidities with the largest magnitude of effect on both LOS and total charge were lung disease, kidney disease, and heart disease. Time to surgery post-admission also had a large effect on both outcomes of interest. CONCLUSION: The results demonstrate that income quartile has an effect on both hospital LOS and total charge. This may be the result of differences in demographics and other clinical variables between quartiles and increased comorbidities in lower income levels. The overall summation of these socioeconomic, demographic, and medical factors affecting patients in lower income levels may result in worse outcomes following hip fracture.

Open Repair Versus Closed Repair: A Cost-Analysis of the Two Surgical Approaches for the Treatment of Craniosynostoses.

PURPOSE: The purpose of this study was to quantify the hospitalization charges of the 2 general surgical approaches in the treatment of craniosynostosis and determine if there was a significant difference between the 2. Several studies compared them side-by-side according to specific variables, such as success rates, postoperative complications, blood loss, and length of stay, but were limited by small sample sizes. METHODS: This is a retrospective cohort study that was conducted using the Kids' Inpatient Database (KID). All patients diagnosed with craniosynostosis (Q75.0) were identified. The procedures were grouped according to the approach taken, whether it was a traditional, open approach, or a closed, minimally invasive approach. The primary predictor variable was the surgical approach (open vs closed). The outcome variables were the hospital charges (US dollars) and length of stay (days). Statistical analyses were based on the univariate and multivariate linear regression models, and P value less than .05 marked the significance level. RESULTS: Among a sample of 2,585 cases, an open approach was employed in 2,353 cases and a closed approach in 232 cases. Race, payer information, hospital region, admission status (elective vs not elective), patient location, and surgical approach (open vs closed) were all significant predictors (P < .15) of increased hospitalization charges. Relative to white patients, being in the 'other' racial class added $10,987 in hospital charges (P < .05). Relative to the Northeast, being a patient in the West added $33,459 in hospital charges (P < .01). Not being admitted electively added $72,572 (P < .01) relative to elective admissions. Finally, open repair added $59,539 (P < .01) in charges relative to closed repair. CONCLUSIONS: The traditional open approach added nearly $60,000 to the cost of the procedure when compared with the closed, endoscopic approach. The scope and invasiveness of the open approach demand greater surgical services, hospital services, supplies, and equipment, ultimately contributing to this increased cost.

Price Transparency and Compliance With Federal Regulation for Pediatric Tonsillectomy.

OBJECTIVE: To improve hospital price transparency, the Centers for Medicare & Medicaid Services (CMS) requires, as of January 2021, that all hospitals reveal charges for specific items and services. This analysis investigates whether otolaryngology residency-affiliated hospitals have complied with this new regulation, and it evaluates the variability in hospital-reported charges for pediatric tonsillectomy. STUDY DESIGN: Cross-sectional analysis. SETTINGS: Subset of hospitals affiliated with otolaryngology residency programs. METHODS: Hospital websites were searched to determine compliance rates with CMS guidelines by posting a price transparency tool and specific charges for Current Procedural Terminology code 42820 (tonsillectomy and adenoidectomy, <12 years old). Various charges were collected: gross charge, discounted cash price, deidentified minimum and maximum negotiated charges, hospital fees, and physician fees. RESULTS: Overall 104 unique hospitals were analyzed: 81 (78%) provided pricing data, but only 28 (27%) complied with CMS guidelines. The median reported total gross charge was $13,239 (range, $600-$41,957); deidentified minimum negotiated charge, $9222 (range, $337-$25,164); and deidentified maximum negotiated charge, $17,355 (range, $1002-$54,987). Hospital fees (median, $11,900; range, $2304-$38,831) were consistently higher than physician fees (median, $1827; range, $420-$5063). All estimates included a disclaimer stating that values likely underrepresent true prices. CONCLUSION: Hospital compliance with the new regulation remains low, which limits efforts toward improved price transparency. There is wide variability in reported charges for pediatric tonsillectomy and adenoidectomy.

Charges, length of stay, and complication associations with trauma center ownership in adult patients with mild to moderate trauma.

BACKGROUND: For-profit (FP) trauma centers (TCs) charge more for trauma care than not-for-profit (NFP) centers. We sought to determine charges, length of stay (LOS), and complications associations with TC ownership status (FP, NFP, and government) for three diagnoses among patients with overall low injury severity. METHODS: Adult patients treated at TCs with an International Classification of Diseases-based injury severity score (ICISS) survival probability ≥ 0.85 were identified. Only those who with a principal diagnosis of femur, tibial or rib fractures were included. RESULTS: Total charges were significantly higher at FP centers than NFP and lower at government centers (89.6% and -12.8%, respectively). FP TCs had a 12.5% longer LOS and government TCs had a 20.4% longer LOS than NFP TCs. CONCLUSION: Patients presenting to FP TCs with mild/moderate femur, tibial, or rib fractures experienced higher charges and increased LOS compared with government or NFP centers. There was no difference in overall complication rates.