Reducing low-value interhospital transfers for mild traumatic brain injury.

BACKGROUND: The modified Brain Injury Guidelines (mBIG) were developed to stratify traumatic brain injuries (TBIs) and improve health care utilization by selectively requiring repeat imaging, intensive care unit admission, and neurosurgical (NSG) consultation. The goal of this study is to assess safety and potential resource savings associated with the application of mBIG on interhospital patient transfers for TBI. METHODS: Adult patients with TBI transferred to our Level I trauma center from January 2017 to December 2022 meeting mBIG inclusion criteria were retrospectively stratified into mBIG1, mBIG2, and mBIG3 based on initial clinicoradiological factors. At the time, our institution routinely admitted patients with TBI and intracranial hemorrhage (ICH) to the intensive care unit and obtained a repeat head computed tomography with NSG consultation, independent of TBI severity or changes in neurological examination. The primary outcome was progression of ICH on repeat imaging and/or NSG intervention. Secondary outcomes included length of stay and financial charges. Subgroup analysis on isolated TBI without significant extracranial injury was performed. RESULTS: Over the 6-year study period, 289 patients were classified into mBIG1 (61; 21.1%), mBIG2 (69; 23.9%), and mBIG3 (159; 55.0%). Of mBIG1 patients, 2 (2.9%) had radiological progression to mBIG2 without clinical decline, and none required NSG intervention. Of mBIG2, 2 patients (3.3%) progressed to mBIG3, and both required NSG intervention. More than 35% of transferred patients had minor isolated TBI. For mBIG1 and mBIG2, the median hospitalization charges per patient were $152,296 and $149,550, respectively, and the median length of stay was 4 and 5 days, respectively, with the majority downgraded from the intensive care unit within 48 hours. CONCLUSION: Clinically significant progression of ICH occurred infrequently in 1.5% of patients with mBIG1 and mBIG2 injuries. More than 35% of interfacility transfers for minor isolated TBI meeting mBIG1 and 2 criteria are low value and may potentially be safely deferred in an urban health care setting. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Pediatric Mild Traumatic Brain Injury: Who Can Be Managed at a Non-pediatric Trauma Center Hospital? A Systematic Review of the Literature.

BACKGROUND: Pediatric traumatic brain injury (TBI) affects about 475,000 children in the United States annually. Studies from the 1990s showed worse mortality in pediatric TBI patients not transferred to a pediatric trauma center (PTC), but did not examine mild pediatric TBI. Evidence-based guidelines used to identify children with clinically insignificant TBI who do not require head CT were developed by the Pediatric Emergency Care Applied Research Network (PECARN). However, which patients can be safely observed at a non-PTC is not directly addressed. METHODS: A systematic review of the literature was conducted, focusing on management of pediatric TBI and transfer decisions from 1990 to 2020. RESULTS: Pediatric TBI patients make up a great majority of preventable transfers and admissions, and comprise a significant portion of avoidable costs to the health care system. Majority of mild TBI patients admitted to a PTC following transfer do not require ICU care, surgical intervention, or additional imaging. Studies have shown that as high as 83% of mild pediatric TBI patients are discharged within 24 hrs. CONCLUSIONS: An evidence-based clinical practice algorithm was derived through synthesis of the data reviewed to guide transfer decision. The papers discussed in our systematic review largely concluded that transfer and admission was unnecessary and costly in pediatric patients with mild TBI who met the following criteria: blunt, no concern for NAT, low risk on PECARN assessment, or intermediate risk on PECARN with negative imaging or imaging with either isolated, nondisplaced skull fractures without ICH and/or EDH, or SDH <0.3 cm with no midline shift.

Futile trauma transfers: An infrequent but costly component of regionalized trauma care.

BACKGROUND: Appropriate interfacility transfers are a key component of highly functioning trauma systems but transfer of unsalvageable patients can overburden the resources of higher-level centers. We sought to identify the occurrence and associated reasons for futile transfers within our trauma system. METHODS: Using prospectively collected data from our system database, a retrospective cohort study was conducted to identify patients who underwent interfacility transfer to our American College of Surgeons level I center. Adult patients from June 2017 to June 2019 who died, had comfort measures implemented, were discharged, or went to hospice care within 48 hours of admission without significant operation, procedure, or radiologic intervention were examined. Futility was defined as resulting in death or hospice discharge within 48 hours of transfer without major operative, endoscopic, or radiologic intervention. RESULTS: A total of 1,241 patients transferred to our facility during the study period. Four hundred seven patients had a length of stay less than or equal to 48 hours. Eighteen (1.5%) met the criteria for futility. The most common reason for transfer in the futile population was traumatic brain injury (56%) and need for neurosurgical capabilities (62%). Futile patients had a median age and Injury Severity Score of 75 and 21. The main transportation method was ground 9 (50%) with 8 (44.4%) being transported by helicopter and 1 (5.6%) being transported by both. Combining transport costs with hospital charges, each futile transfer was estimated to cost US $56,396 (interquartile range, 41,889-106,393) with a total cost exceeding US $1.7 million. With an estimated 33,000 interfacility transfers annually for trauma in the United States, the cost of futile transfers to the American trauma system would exceed 27 million dollars each year. CONCLUSION: Futile transfers represent a small but costly portion transfer volume. Identification of patients whose conditions preclude the benefit of transfer due to futility and development of appropriate support for referral will significantly improve appropriate allocation of health care resources. LEVEL OF EVIDENCE: Economic; Care management, level IV.

Effect of statewide reduction in extended care facility use after joint replacement on hospital readmission.

BACKGROUND: Extended care facility use is a primary driver of variation in hospitalization-associated health care payments and is increasingly a focus for savings under episode-based payment. However, concerns remain that extended care facility limits could incur rising readmissions, emergency department use, or other costs. We analyzed the effects of a statewide value improvement initiative to decrease extended care facility use after lower extremity arthroplasty on extended care facility use, readmission, emergency department use, and payments. METHODS: We performed a retrospective cohort study using complete claims from the Michigan Value Collaborative for patients undergoing lower extremity joint replacement. We compared the change in extended care facility use before (2012-2013) and after (2016-2017) the aforementioned statewide initiative with 90-day postacute care, readmission, and emergency department rates and payments using t tests. RESULTS: Of the patients included, 68,537 underwent total knee arthroplasty; 27,131 underwent total hip arthroplasty. Statewide, extended care facility use and postacute care payments decreased (extended care facility: 27.5% before vs 18.1% after, payments: $4,999 vs $3,832, P < .0001) without increased readmission rates (8.0% vs 7.6%, P = .10) or payments ($1,087 vs $1,026, P = .14). Emergency department use increased (7.8% vs 8.9%, P < .0001). Per hospital, there was no association between extended care facility use change and readmission rate change (r = 0.05). Hospital change in extended care facility use ranged from +2.3% (no extended care facility decrease group) to -16.6% (large extended care facility decrease group) and was associated with lower total episode payments without differences in change in readmission rate/payments or emergency department use. CONCLUSION: Despite decreased use of extended care facilities, there was no compensatory increase in readmission rate or payments. Reducing excess use of extended care facilities after joint replacement may be an important opportunity for savings in episode-based reimbursement.

Stop Flying the Patients! Evaluation of the Overutilization of Helicopter Transport of Trauma Patients.

INTRODUCTION: Helicopter transport is a resource intensive and expensive method for transportation of patients by helicopter. The primary objective of this study was to evaluate the appropriateness of helicopter transport determined by procedural care within 1-h of transfer at an urban level I trauma center. METHODS: All trauma patients transported by helicopter from January 2015-December 2017 to an urban level I trauma center from referring hospitals or the scene were retrospectively analyzed. A subgroup analysis was performed evaluating patients that required a procedure or operation within 1-h of transport compared with the remainder of the patient cohort who were transported via helicopter. RESULTS: A total of 1590 patients were transported by helicopter. Thirty-nine percent of patients (n = 612) were admitted directly to the floor from the trauma bay and 16% (n = 249) of patients required only observation or were discharged home after helicopter transfer. Approximately one-third of the entire study cohort (36%, n = 572) required any procedure, with a median time to procedure of 31.5 h (interquartile range 54.4). Only 13% (n = 74) required a procedure within 1-h of helicopter transport. The average distance (in miles) if the patient had been driven by ground transport rather than helicopter was 67.0 miles (SD ± 27.9) and would take an estimated 71.5 min (±28.4) for patients who required a procedure within 1-h compared with 61.6 miles (SD ± 30.9) with an estimated 66.1 min (SD ± 30.8) for the remainder of the cohort (P value 0.899 and 0.680, respectively). CONCLUSIONS: This analysis demonstrates that helicopter transport was not necessary for the vast majority of trauma patients transported via helicopter.

Are cost advantages from a modern Indian hospital transferable to the United States?

BACKGROUND: Multiple modern Indian hospitals operate at very low cost while meeting US-equivalent quality accreditation standards. Though US hospitals face intensifying pressure to lower their cost, including proposals to extend Medicare payment rates to all admissions, the transferability of Indian hospitals' cost advantages to US peers remains unclear. METHODS: Using time-driven activity-based costing methods, we estimate the average cost of personnel and space for an elective coronary artery bypass graft (CABG) surgery at two American hospitals and one Indian hospital (NH). All three hospitals are Joint Commission accredited and have reputations for use of modern performance management methods. Our case study applies several analytic steps to distinguish transferable from non-transferable sources of NH's cost savings. RESULTS: After removing non-transferable sources of efficiency, NH's residual cost advantage primarily rests on shifting tasks to less-credentialed and/or less-experienced personnel who are supervised by highly-skilled personnel when perceived risk of complications is low. NH's high annual CABG volume facilitates such supervised work "downshifting." The study is subject to limitations inherent in case studies, does not account for the younger age of NH's patients, or capture savings attributable to NH's negligible frequency of re-admission or post-acute care facility placement. CONCLUSIONS: Most transferable bases for a modern Indian hospital's cost advantage would require more flexible American states' hospital and health professional licensing regulations, greater family participation in inpatient care, and stronger support by hospital executives and clinicians for substantially lowering the cost of care via regionalization of complex surgeries and weekend use of costly operating rooms.

Are all trauma centers created equal? Level 1 to level 1 trauma center patient transfers in the setting of rapid trauma center proliferation.

BACKGROUND: Level 1 trauma centers should provide definitive care for every aspect of injury. However, in environments that have experienced trauma center proliferation, not all level 1 centers may have the resources or expertise needed for every patient, necessitating transfer to another trauma center. The purpose of this study was to assess the incidence of such transfers and associated impact on patient outcome and burden on the receiving level 1 center. METHODS: In a metropolitan area experiencing trauma center proliferation, we performed a 5.5-year review of patient transfers to an established level 1 (index center) from other state designated level 1 centers. American College of Surgeons verification level was identified for each facility. Comparisons were performed between the cohort of transferred patients and patients with similar demographics, injury patterns, and severity managed at the index center using propensity score matching. RESULTS: A total of 104 patients were received from other state level 1 centers (39% American College of Surgeons level 2, 61% American College of Surgeons level 1). Nearly 70% of patients were transferred for definitive evaluation and/or management of brain, spine, or cerebrovascular injury. For 76% of this subgroup, specialty consultation was available, but the injury was deemed beyond their capability. Comparison of the transfer cohort propensity score matched to the control cohort (93 vs. 558 patients) demonstrated increased length of stay (6.5 days vs. 4.6 days, p = 0.001) and cost (US $36,027 vs. US $30,654, p = 0.033) associated with the transfer cohort, with similar mortality (12.1% vs. 9.7%, p = 0.492). CONCLUSION: The number of level 1 to level 1 transfers observed imply a disparity in resources and capability among level 1 trauma centers in the region. The majority of transfers were for neurosurgical care, suggestive of a deficit of adequate neurosurgical coverage in the setting of trauma center proliferation. Both patients and established trauma centers bear the burden for these transfers with respect to increased cost and length of stay. LEVEL OF EVIDENCE: Care management, level IV.

Characteristics of Pediatric Patient Transferred From Hospital-Based General Emergency Departments to Acute-Care Facilities: An Analysis of the Healthcare Cost and Utilization Project Nationwide Emergency Department Sample.

STUDY OBJECTIVE: The objective of this study was to analyze the characteristics of pediatric patients transferred from a hospital-based general emergency department (ED) to an acute care facility. METHODS: Study data were abstracted from the 2010 Healthcare Cost and Utilization Project Nationwide Emergency Department Sample database. A multivariate logistic regression was constructed for pediatric patients (<18 years old) who require a transfer to an acute care facility from a general ED. Independent variables included in the model were age (<1, 1-4, 5-9, 10-14, 15-17 age in years), sex, insurance/payment method, and diseases/body systems using International Classification of Diseases, Ninth Revision, coding. RESULTS: In the Healthcare Cost and Utilization Project/Nationwide Emergency Department Sample, 5.5 million ED visits were for children less than 18 years. About 1.5% of visits resulted in transfer. Children younger than 1 year had higher transfer rates as compared with 15 to 17 year old group (odds ratio [OR], 1.17; 95% confidence interval [CI], 1.089-1.146). Patients with Medicaid and self-pay compared with private insurance/health maintenance organization had 4% (OR, 0.96; 95% CI, 0.944-0.976) and 9% (OR, 0.91; 95% CI, 0.886-0.945), respectively, lower likelihood of being transferred. Patients with circulatory (OR, 8.43; 95% CI, 7.8-9.1), endocrine (OR, 5.9; 95% CI, 5.6-6.2), mental (OR, 5.44; 95% CI, 5.3-5.6), nervous system (OR, 5.2; 95% CI, 4.9-5.5), congenital anomalies (OR, 5.14; 95% CI, 4.5-5.9), hematology-oncology (OR, 4.49; 95% CI, 4.2-4.8), digestive, (OR, 1.52; 95% CI, 1.5-1.6), and other disorders (OR, 1.33; 95% CI, 1.3-1.4) had a higher odds of being transferred as compared with trauma/injury and poisoning, whereas patients with disorders related to genitourinary (OR, 0.96; 95% CI, 0.91-1.0), respiratory (OR, 0.79; 95% CI, 0.77-0.81), musculoskeletal (OR, 0.63; 95% CI, 0.58-0.68), skin (OR, 0.47; 95% CI, 0.45-0.50), infectious and parasitic (OR, 0.23; 95% CI, 0.22-0.25), and eyes/ears/nose/throat (OR, 0.09; 95% CI, 0.079-0.094) had a lower odds of being transferred as compared with trauma/injury and poisoning. CONCLUSIONS: Children younger than 1 year had relatively higher transfer rates. Patients covered by Medicaid and self-pay had the lowest likelihood of transfer. Transfer rates varied significantly by condition and the high-transfer diagnostic categories were related to circulatory, endocrine, nervous, hematology-oncology, and mental disorders as well as congenital anomalies, which may be related to a lack of ED or inpatient resources to care for children with problems that require more complex care.

Impact of transitioning inpatient chemotherapy regimens to the outpatient setting.

BACKGROUND: Chemotherapy regimens historically have required admission of the patient to the hospital for extended infusions running over multiple days to complete each cycle of therapy. With the evolution of monitoring strategies readily available, a renaissance in patient care and healthcare cost utilization is necessary as transitioning the administration of these agents to the outpatient setting is seemingly achievable and is potentially more cost-effective. PURPOSE: This evaluation sought to primarily measure cost-savings for an institution by transitioning inpatient chemotherapy regimens to the outpatient setting. Secondary outcomes evaluated the effect of this transition on overall patient length of stay, prevalence of adverse effects, and overall chemotherapy schedule adherence as a result of implementing transitions in sites of care. Barriers to receiving care in the outpatient setting were assessed by evaluating the acuity of performance status as well as distance from the hospital. METHODS: This single-center retrospective, quantitative chart and expense analysis evaluated patients receiving rituximab, etoposide, prednisone, vincristine, cyclophosphamide and doxorubicin (R-EPOCH) or rituximab, ifosfamide, carboplatin, and etoposide (R-ICE) chemotherapy regimens based on treatment setting at a single institution. Included patients were treated at the University of Chicago Medical Center. Those receiving inpatient-only management as compared with patients who received therapy in outpatient settings were compared in a matched cohort analysis. The control group was matched from the period before transition of therapy was instituted between November 2014 and November 2015, with those patients transitioned to outpatient therapy (December 2015 to November 2016), using demographic, diagnostic, treatment, and clinical status data to assure group similarity. Mean cost of therapy was compared between inpatient and outpatient regimens. Descriptive and demographic categorical data were compared using the Fisher's exact test. Continuous data were evaluated using the Student's t test. A significance level of alpha <0.05 was used for all analysis. RESULTS: The cost of R-EPOCH therapy represented a significant difference across groups. R-ICE therapy similarly saw significant cost differences between inpatient and outpatient groups. If this was made standard of care for qualifying patients a retrospective annualized estimation of $466,507.85 with R-EPOCH therapy and $205,977.60 for R-ICE therapy could have been saved if this was utilized for patients who previously received their therapy as an inpatient. CONCLUSION: The population of patients cared for at the University of Chicago Medicine during this time-period qualified for outpatient treatment for those treated with R-EPOCH and R-ICE regimens with no significantly identifiable prohibitive barriers between groups. As no significant complications manifested, it is reasonable to continue transitioning patients receiving these regimens to the outpatient setting where appropriate. R-EPOCH and R-ICE therapies were shown to be reasonable outpatient therapy while providing significant cost-savings for the institution.

Dynamic Electronic Tracking and Escalation to reduce Critical care Transfers (DETECT): the protocol for a stepped wedge mixed method study to explore the clinical effectiveness, clinical utility and cost-effectiveness of an electronic physiological surveillance system for use in children.

BACKGROUND: Active monitoring of hospitalised adults, using handheld electronic physiological surveillance systems, is associated with reduced in-patient mortality in the UK. Potential also exists to improve the recognition and response to deterioration in hospitalised children. However, the clinical effectiveness, the clinical utility, and the cost-effectiveness of this technology to reduce paediatric critical deterioration, have not been evaluated in an NHS environment. METHOD: This is a non-randomised stepped-wedge prospective mixed methods study. Participants will be in-patients under the age of 18 years, at a tertiary children's hospital. Day-case, neonatal surgery and Paediatric Intensive Care Unit (PICU) patients will be excluded. The intervention is the implementation of Careflow Vitals and Connect (System C) to document vital signs and sepsis screening. The underpinning age-specific Paediatric Early Warning Score (PEWS) risk model calculates PEWS and provides associated clinical decision support. Real-time data of deterioration risk are immediately visible to the entire clinical team to optimise situation awareness, the chronology of the escalation and response are captured with automated reporting of the organisational safety profile. Baseline data will be collected prospectively for 1 year preceding the intervention. Following a 3 month implementation period, 1 year of post-intervention data will be collected. The primary outcome is unplanned transfers to critical care (HDU and/or PICU). The secondary outcomes are critical deterioration events (CDE), the timeliness of critical care transfer, the critical care interventions required, critical care length of stay and outcome. The clinical effectiveness will be measured by prevalence of CDE per 1000 hospital admissions and per 1000 non-PICU bed days. Observation, field notes, e-surveys and focused interviews will be used to establish the clinical utility of the technology to healthcare professionals and the acceptability to in-patient families. The cost-effectiveness will be analysed using Health Related Group costs per day for the critical care and hospital stay for up to 90 days post CDE. DISCUSSION: If the technology is effective at reducing CDE in hospitalised children it could be deployed widely, to reduce morbidity and mortality, and associated costs. TRIAL REGISTRATION: Current Controlled Trials ISRCTN61279068 , date of registration 03.06.19, retrospectively registered.

The Effects of Medicaid Expansion on Triage and Regional Transfer After Upper-Extremity Trauma.

PURPOSE: Underinsured hand trauma patients are more likely to be transferred to quaternary care centers, which burdens these patients and centers. By increasing insurance coverage, care for less severe upper-extremity injuries may be available closer to patients' homes. We evaluated whether the 2014 expansion of Medicaid in Maryland under the Affordable Care Act decreased the number of uninsured upper-extremity trauma patients and the volume of unnecessary emergency trauma visits at our hand center. METHODS: We identified all upper-extremity trauma patients between 2010 and 2017 at our hand trauma referral center. Injury severity was classified based on the need for subspecialty care. Bivariate relations between insurance status and demographic covariates, including injury type and distance, both before and after Medicaid expansion were evaluated. We used patient-level and multinomial logistic regression models to evaluate changes in payer and transfer appropriateness. RESULTS: We studied 12,009 acute upper-extremity trauma patients. With Medicaid expansion, the percentage of trauma patients with Medicaid coverage increased from 15% to 24%, with a decrease in uninsured from 31% to 24%. After Medicaid expansion, non-transfer patient appropriateness decreased and appropriateness of transfers remained consistent across all payers. The average distance patients traveled for care remained similar before and after expansion. CONCLUSIONS: Medicaid expansion significantly decreased the proportion of uninsured upper-extremity trauma patients. We identified no significant changes in the distances these patients traveled for specialized care. In addition, the appropriateness of transferred patients did not change significantly after expansion, whereas appropriateness of nontransferred patients actually declined after Medicaid expansion. CLINICAL RELEVANCE: This study indicates no notable change in adherence to transfer guidelines after expansion, and a possible increase in use of emergency services by newly insured patients.

Factors Associated With the Interhospital Transfer of Emergency General Surgery Patients.

BACKGROUND: Transferred emergency general surgery (EGS) patients constitute a highly vulnerable, acutely ill population. Guidelines to facilitate timely, appropriate EGS transfers are lacking. We determined patient- and hospital-level factors associated with interhospital EGS transfers, a critical first step to identifying which patients may require transfer. METHODS: Adult EGS patients (defined by American Association for the Surgery of Trauma International Classification of Diseases, Ninth Revision diagnosis codes) were identified within the 2008-2013 Nationwide Inpatient Sample (n = 17,175,450). Patient- and hospital-level factors were examined as predictors of transfer to another acute care hospital with a multivariate proportional cause-specific hazards model with a competing risk analysis to assess the effect of risk factors for transfer. RESULTS: 1.8% of encounters resulted in a transfer (n = 318,286). Transferred patients were on average 62 y old and most commonly had Medicare (52.9% [n = 168,363]), private (26.7% [n = 84,991]), or Medicaid insurance (10.8% [n = 34,279]). 67.7% were white. The most common EGS diagnoses among transferred patients were related to hepatic-pancreatic-biliary (n = 90,989 [28.6%]) and upper gastrointestinal tract (n = 60,088 [18.9%]) conditions. Most transferred patients (n = 269,976 [84.8%]) did not have a procedure before transfer. Transfer was more likely if patients were in small (hazard ratio 2.52, 95% confidence interval 2.28-2.79) or medium (1.32, 1.21-1.44) versus large facilities, government (1.19, 1.11-1.28) versus private facilities, and rural (4.58, 3.98-5.27) or urban nonteaching (1.89, 1.70-2.10) versus urban teaching facilities. Patient-level factors were not strong predictors of transfer. CONCLUSIONS: We identified that hospital-level characteristics more strongly predicted the need for transfer than patient-related factors. Consideration of these factors by providers as care is delivered in the context of the resources and capabilities of local institutions may facilitate transfer decision-making.

Palliative Care in Gynecologic Oncology.

The integration of palliative care and hospice into standard gynecologic oncology care is associated with cost-savings, longer survival, lower symptom burden, and better quality of life for patients and caregivers. Consequently, this comprehensive approach is formally recognized and endorsed by the Society of Gynecologic Oncology, the National Comprehensive Cancer Network, and the American Society of Clinical Oncology. This article reviews the background, benefits, barriers, and most practical delivery models of palliative care. It also discusses management of common symptoms experienced by gynecologic oncology patients.

Cost Burden and Mortality in Rural Emergency General Surgery Transfer Patients.

BACKGROUND: Recent articles have suggested regionalization of some emergency general surgery (EGS) problems to tertiary referral centers. We sought to characterize the clinical and cost burden of such transfers to our tertiary referral center. MATERIALS AND METHODS: Data were collected retrospectively for nine EGS diagnoses for patients admitted to the EGS service during calendar years 2015 and 2016. Patients were grouped as inpatient transfers (IPTs), Emergency Department transfers (EDTs), or local admissions (LAs). Demographic data, length of stay at originating site, insurance status, Charlson Comorbidity Index, and all relevant financial data were obtained. RESULTS: Six hundred sixty-three patients were reviewed: 93 IPTs, 343 EDTs, and 227 LAs. IPTs required longer lengths of stay (7.0 d compared to 4.0 d for EDTs and 3.0 d for LAs), higher median direct costs, and higher case mix index, which produced a higher median revenue but averaged a median net loss (-$264 compared to +$2436 for EDTs and +$3125 for LAs). The IPTs had higher median comorbidities (Charlson Comorbidity Index 3.5 versus 2.9 for EDTs and 2.0 for LAs), age (62 y versus 58 for EDTs and 52 for LAs), and mortality rate (7.5% versus 2.3% for EDTs and 0.4% for LAs). CONCLUSIONS: Patients who present to a tertiary care EGS service as an IPT from another hospital have more comorbidities, higher mortality rate, and result in a financial loss. These data suggest the need for adequate risk adjustment in quality assessment of tertiary referral center outcomes and the need for increased financial reimbursement for the care of these patients.

Variation in postacute care utilization after complex surgery.

BACKGROUND: Variation in use of postacute care (PAC), including skilled nursing facilities and inpatient rehabilitation, accounts for 73% of regional variation in Medicare spending. Studies of hospital variation in PAC use have typically focused on nonsurgical patients or have been limited to Medicare data. Consequently, there is no nationally representative data on how rates of postoperative discharge to PAC differ between hospitals. The purpose of this study was to explore hospital-level variation in PAC utilization after cardiovascular and abdominal surgery. MATERIALS AND METHODS: We evaluated 3,487,365 patients from the Nationwide Inpatient Sample and 60,666 from the Veterans Affairs health system, who had colorectal surgery, hepatectomy, pancreatectomy, coronary bypass, aortic aneurysm repair, and peripheral vascular bypass from 2008 to 2011. For each hospital, we calculated unadjusted and risk-adjusted observed-to-expected ratios for discharge to PAC facilities (skilled nursing or inpatient rehabilitation). RESULTS: A total of 631,199 (18%) non-veterans and 4744 (8%) veterans were discharged to PAC facilities. For veterans, 32% were ≥70 y old, and 98% were men. For non-veterans, 39% were ≥70, and 60% were men. Hospital rates of discharge to PAC facilities varied from 1% to 36% for veterans hospitals and from 1% to 59% for non-veteran hospitals. Risk-adjusted observed-to-expected ratios ranged from 0.10 to 4.15 for veterans and from 0.11 to 4.3 for non-veteran hospitals. CONCLUSIONS: There is substantial variation in PAC utilization and rates of home discharge after abdominal and cardiovascular surgery. To reduce variation, further research is needed to understand health systems factors that influence PAC utilization.

Correlation of payor status and pediatric transfer for acute appendicitis.

BACKGROUND: Tertiary referral centers provide specialty and critical care for patients presenting to hospitals that lack these resources. There is a notion among tertiary centers that outside hospitals are more likely to transfer uninsured or underinsured patients. We examined funding status of patients transferred to our tertiary pediatric hospital for surgical management of appendicitis, hypothesizing that transferred patients were more likely to have unfavorable coverage. MATERIALS AND METHODS: The electronic medical record was queried for all cases of laparoscopic appendectomy at our hospital between 2011 and 2015. Insurance was grouped into three categories: commercial, Medicaid/Children's Health Insurance Plan, or none. Transferred patients were compared to patients who presented directly. RESULTS: A total of 5758 patients underwent laparoscopic appendectomy during the study period, of which 1683 (29.2%) were transfer patients. Transfer patients were more likely to be older, with a median age of 10.5 y versus 9.8 y in nontransferred patients (P ≤ 0.0001), and were more likely to be identified as non-Hispanic (50.0% versus 36.5%; P ≤ 0.0001). Insurance coverage was similar between groups. However, subgroup analysis of the hospitals that most frequently used our transfer services revealed a trend to transfer a higher proportion of Medicaid/Children's Health Insurance Plan patients. CONCLUSIONS: Overall, pediatric patients transferred for laparoscopic appendectomy had similar insurance coverage to patients admitted directly, but subgroup analysis shows that not all centers follow this trend. Transfer patients were more frequently older and non-Hispanic. This builds upon the existing literature regarding the correlation of funding and transfer practices and highlights the need for additional research in this area.

Cost-effectiveness development for the postoperative care of craniotomy patients: a safe transitions pathway in neurological surgery.

OBJECTIVE The authors' institution is in the top 5th percentile for hospital cost in the nation, and the neurointensive care unit (NICU) is one of the costliest units. The NICU is more expensive than other units because of lower staff/patient ratio and because of the equipment necessary to monitor patient care. The cost differential between the NICU and Neuro transitional care unit (NTCU) is $1504 per day. The goal of this study was to evaluate and to pilot a program to improve efficiency and lower cost by modifying the postoperative care of patients who have undergone a craniotomy, sending them to the NTCU as opposed to the NICU. Implementation of the pilot will expand and utilize neurosurgery beds available on the NTCU and reduce the burden on NICU beds for critically ill patient admissions. METHODS Ten patients who underwent craniotomy to treat supratentorial brain tumors were included. Prior to implementation of the pilot, inclusion criteria were designed for patient selection. Patients included were less than 65 years of age, had no comorbid conditions requiring postoperative intensive care unit (ICU) care, had a supratentorial meningioma less than 3 cm in size, had no intraoperative events, had routine extubation, and underwent surgery lasting fewer than 5 hours and had blood loss less than 500 ml. The Safe Transitions Pathway (STP) was started in August 2016. RESULTS Ten tumor patients have utilized the STP (5 convexity meningiomas, 2 metastatic tumors, 3 gliomas). Patients' ages ranged from 29 to 75 years (median 49 years; an exception to the age limit of 65 years was made for one 75-year-old patient). Discharge from the hospital averaged 2.2 days postoperative, with 1 discharged on postoperative day (POD) 1, 7 discharged on POD 2, 1 discharged on POD 3, and 1 discharged on POD 4. Preliminary data indicate that quality and safety for patients following the STP (moving from the operating room [OR] to the neuro transitional care unit [OR-NTCU]) are no different from those of patients following the traditional OR-NICU pathway. No patients required escalation in level of nursing care, and there were no readmissions. This group has been followed for greater than 1 month, and there were no morbidities. CONCLUSIONS The STP is a new and efficient pathway for the postoperative care of neurosurgery patients. The STP has reduced hospital cost by $22,560 for the first 10 patients, and there were no morbidities. Since this pilot, the authors have expanded the pathway to include other surgical cases and now routinely schedule craniotomy patients for the (OR-NTCU) pathway. The potential cost reduction in one year could reach $500,000 if we reach our potential of 20 patients per month.

Comparisons of the surgical outcomes and medical costs between transferred and directly admitted patients diagnosed with intestinal obstruction in an American tertiary referral center.

PURPOSE: Intestinal obstruction is a leading cause of patient mortality and the most common reason for emergent operation in colorectal surgery. The influence of inter-hospital transfer on patients' outcomes varies greatly in different diseases. We aimed to compare the surgical outcomes and medical costs between transferred and directly admitted patients diagnosed with intestinal obstruction in an American tertiary referral center. METHODS: All intestinal obstruction patients operated in Cleveland Clinic from Jan 2012 to Dec 2016 were collected from a prospectively maintained database. Preoperative characteristics; surgical outcomes, including intraoperative complication, postoperative complication, readmission, reoperation, and postoperative 30-day mortality; and medical cost were collected. All parameters were compared between two groups before and after propensity score match. Multivariate logistic analysis was used to explore risk factors of surgical outcomes. RESULTS: A total of 576 patients were included, with 75 in the transferred group and 501 in the directly admitted group. Before match, the transferred patients had longer waiting interval from admission to surgery (p < 0.001), more contaminated or infected wounds (p = 0.02), different surgical procedures (p = 0.02), and similar surgical outcomes and total medical cost (all p > 0.05), compared with the directly admitted group. Multivariate analysis showed that inter-hospital transfer was not an independent predictor of any surgical outcome. After matching to balance the preoperative characteristics between two groups, no significant differences were identified in all surgical outcomes and total medical cost between two groups (all p > 0.05). CONCLUSIONS: Compared with directly admitted patients, transferred intestinal obstruction patients are associated with similar surgical outcomes and similar medical costs.

Early Treatment at a Referral Center Improves Outcomes for Patients with Acute Vascular Disease.

BACKGROUND: Patients with acute vascular disease frequently need specialized management that may require transfer to a vascular referral center. Although transfer may be medically necessary, it can delay definitive care and is an indicator of incorrect triage to the initial hospital. Regionalization of acute vascular care could improve patient triage and subsequent outcomes. To evaluate the potential benefit from regionalization, we analyzed outcomes of patients treated for acute vascular disease at vascular referral centers. METHODS: Using a statewide database capturing all inpatient admissions in Maryland during 2013-2015, patients undergoing noncardiac vascular procedures on an acute basis were identified. Patients admitted to a vascular referral center were stratified by admission status as direct or transfer. The primary outcome was inpatient mortality, and the secondary outcome was resource use. Patient groups were compared by univariable analyses, and the effect of admission status on mortality was assessed by multivariable logistic regression. RESULTS: Of 4,873 patients with acute vascular disease managed at vascular referral centers, 2,713 (56%) were admitted directly, whereas 2,160 (44%) were transferred. Transfers to referral centers accounted for 71% of all interhospital transfers. The transfer-group patients were older, had more comorbidities, and higher illness severities. Patients who were transferred had higher mortality (14% vs. 9%, P < 0.0001), longer hospital lengths of stay, greater critical care-resource utilization, and higher costs. After adjusting for demographics, comorbidities, and illness severity, transfer status was independently associated with higher inpatient mortality. CONCLUSIONS: Primary treatment at a referral center is independently associated with improved outcomes for patients with acute vascular disease. Direct admission or earlier triage to a specialty center may improve patient and system outcomes and could be facilitated by standardization and regionalization of complex acute vascular care.