Analysis of treatment cost differences in patients undergoing femoral versus radial access in outpatient diagnostic cerebral arteriograms.

BACKGROUND: Outpatient diagnostic cerebral arteriograms are the most common procedure in neuroendovascular surgery, and the use of transradial access for these studies is growing. Although transradial access has been associated with lower hospital costs for elective diagnostic and interventional neuroendovascular procedures, no study has compared transfemoral access and transradial access costs for a homogenous population of patients undergoing outpatient diagnostic cerebral arteriogram. METHODS: In this single-center retrospective study, the Value Driven Outcomes database was used to evaluate treatment costs for patients who underwent outpatient diagnostic cerebral arteriogram from January 2019 to December 2022. Propensity-score matching was performed to reduce confounders. Costs from each encounter were subcategorized into imaging, supplies, pharmacy, procedures, labs, and facility costs. RESULTS: After matching, 337 patients each for transradial access and transfemoral access were available for analysis. A total of 118,992 cost data points were associated with all encounters. Overall, per-visit costs were 15.2% cheaper for patients who underwent transradial access versus transfemoral access (p < 0.001). Most of the cost difference was due to supplies (35.2% cost difference, p < 0.001) and procedure costs (9.3% cost difference, p < 0.001). No statistical differences were observed between the two approaches in imaging, pharmacy, labs, and facility costs (all p > 0.05). CONCLUSIONS: Costs for outpatient diagnostic cerebral arteriogram were lower in patients who underwent transradial access versus transfemoral access because of supply and procedure costs. Understanding reasons for cost differences in common procedures is important for creating strategies to reduce overall healthcare costs. Additionally, addressing the cost differences of newer techniques may increase the likelihood that they are more readily implemented by hospitals and providers.

Direct cost analysis of rapid MRI in the emergency department evaluation of patients suspected of having acute ischemic stroke*.

BACKGROUND: Abbreviated "rapid MRI" protocols have become more common for the evaluation of acute ischemic stroke (AIS). Prior research has not evaluated the effect of rapid MRIs on cost or hospital length of stay in AIS patients. METHODS: We retrospectively identified AIS patients who presented within 6 h of acute neurologic symptom onset to an emergency department (ED) and activated a "brain attack" code. We included sequential patients from January 2012 to September 2015, before rapid MRI was available, who had CT perfusion (CTP) and compared them to patients from October 2015 to May 2018 who had a rapid MRI. We used inverse-probability-weighting (IPW) to balance the cohorts. The primary outcomes were direct cost to our healthcare system and total hospital length of stay (LOS). RESULTS: We included 408 brain attack activations (mean ± SD age 62.1 ± 17.6 years, 47.8% male): 257 in the CTP cohort and 151 in the MRI cohort. Discharge diagnosis was ischemic stroke in 193/408 (47.3%). After patient matching, we found significant reductions for the MRI cohort in total cost (-18.7%, 95% CI -35.0, -2.4, p = 0.02) and hospital LOS (-17.0%, 95% CI -31.2, -2.8, p = 0.02), with no difference in ED LOS (p = 0.74) as compared to the CTP cohort. CONCLUSION: Although these results are preliminary and hypothesis-generating, we found that the use of a rapid MRI protocol in emergency department brain attacks was associated with a 18.7% reduction in total direct cost and 17% reduction in hospital length of stay.

Assessment of cell yield among different devices for endovascular biopsy to harvest vascular endothelial cells.

Endovascular biopsy can increase understanding of vascular disease by granting access to epigenetic data that are not normally attainable. This study compares biopsy yields among multiple devices used, examining differences in cell counts according to species, device type, sampling location and disease state. Chi-square analysis compared means of cells harvested with respect to these variables. Assessment of samples in 38 rabbits and 32 humans found no differences for species, location or pathology. Phenox clot retriever devices and retrievable stents yielded more cells (LR 64.2; p < 0.001) than other devices. Phenox clot retrievers and retrievable stents yield more cells than other device types. Further study of these devices for endovascular sampling is warranted to refine its use for this purpose.

Assessment of quantitative methods for enhancement measurement on vessel wall magnetic resonance imaging evaluation of intracranial atherosclerosis.

PURPOSE: Quantitative measures of vessel wall magnetic resonance imaging (vwMRI) for the evaluation of intracranial atherosclerotic disease (ICAD) offers standardization not available with previously used qualitative approaches that may be difficult to replicate. METHODS: vwMRI studies performed to evaluate ICAD that had caused a stroke were analyzed. Two blinded reviewers qualitatively rated culprit lesions for the presence of enhancement on T1 delay alternating with nutation for tailored excitation (DANTE) SPACE images. At least 3 months later, quantitative analysis was performed of the same images, comparing lesion enhancement to reference structures. Cohen's kappa and intraclass correlation coefficients were calculated to assess agreement. Ratios of enhancement of lesions to references were compared to qualitative ratings. RESULTS: Studies from 54 patients met inclusion criteria. A mean of 49 (90.7%) lesions were qualitatively rated as enhancing, with good inter-rater agreement (κ = 0.783). Among reference structure candidates, low infundibulum demonstrated the highest inter-rater agreement on pre- and post-contrast imaging. The ratio of percentage increase in plaque signal following contrast to the same measure in low infundibulum demonstrated the highest agreement with qualitative assessment, with highest agreement seen with a ratio of 0.8 set as a threshold (κ = 0.675). CONCLUSION: Quantitative metrics can yield objective data to better standardize techniques and acceptance of vwMRI evaluation of ICAD. The low infundibulum had the highest inter-rater agreement on both pre- and post-contrast images and is best suited as a normally enhancing reference structure. Such quantitative techniques should be implemented in future research of vwMRI for the evaluation of ICAD.

Pediatric trauma center verification improves quality of care and reduces resource utilization in blunt splenic injury.

PURPOSE: We sought to evaluate value impact of transition from an adult trauma center treating children (ATC) to a verified pediatric trauma center (PTC) in children with blunt splenic injury (BSI). METHODS: Children with BSI from FY 2005 to FY 2017 were extracted from the hospital trauma registry. February 2009 distinguished "ATC" treated children from "PTC" treated children. Cohorts were subcategorized into "isolated injury" and "multisystem injury". Quality and financial characteristics were statistically compared. Analysis of covariance was used to evaluate changes in quality and financial trends over the transition period. A multiple linear regression was performed to identify variables independently predictive of hospital and professional charges. RESULTS: 126 children with BSI were identified (ATC, n = 56; PTC, n = 70). Splenic procedure rates and hospital charges decreased. Quality and cost metrics for isolated BSI remained unchanged while multisystem BSI children experienced improvements. PTC designation, ISS, splenic procedure, isolated BSI, average hospital LOS, and mortality were all independently predictive of hospital and professional charges. CONCLUSIONS: PTC verification improves the value of BSI management, but the associated decrease in operative rate is only partially responsible. Multisystem injury children experience the greatest value benefit from PTC verification. TYPE OF STUDY: Treatment and cost-effectiveness study. LEVEL OF EVIDENCE: Level III.

Acute care surgery practice model: Targeted growth for fiscal success.

PURPOSE: Acute care surgery (ACS) remains in its infancy as a defined surgical specialty within hospital systems. Little has been published regarding the financial impact of this method of care delivery to hospital systems and departments when combining trauma, surgical critical care, emergent, and elective general surgery into a single practice model. We sought to compare hospital net income and divisional clinical productivity measures of a newly formed, university division of ACS based on patient type-trauma, emergency general surgery, and elective surgery-to determine the best avenues by which to focus on programmatic growth. METHODS: Single calendar year, retrospective review of hospital system income and divisional fiscal productivity of specific patient visits by patient type (trauma, emergent, or elective) admitted to or discharged by the acute care surgeons. Demographic data, payor mix, patient volumes, and operative rates were determined for each patient type. Fiscal contribution by patient type to both hospital and clinical productivity were measured by hospital net income and divisional work relative value units (wRVU) production respectively. The Chi-square test for independence compared payor mix and analysis of variance was used for comparison of fiscal performance between patient types. RESULTS: We included 1,492 patients in the analysis of calendar year 2010; 1,056 trauma (67% male; mean age, 41.9; range, 0-102), 346 emergent (53% male; mean age, 44.6; range, 15-91), and 90 elective (51% male; mean age, 46; range, 16-87) patient encounters met criteria for analysis. There were no differences in payor mix between patient types. Significant differences were seen in average per patient encounter hospital net income, divisional wRVU production and duration of stay. The ACS team (n = 3) operated on 12% of trauma patients compared with 52% of emergent and 100% of elective surgery encounters. Hospital net income per patient was greatest for trauma encounters, whereas divisional clinical productivity per patient encounter was greatest for emergent patients. Elective encounters contributed negatively to hospital margins. CONCLUSION: Per-patient hospital system income and a majority of clinical wRVU productivity remains greatest for the care of injured patients in our ACS practice model; emergent general surgical encounters demonstrate the greatest per-patient rates of divisional clinical productivity.