Ankylosing spondylitis substantially increases health-care costs and length of hospital stay following total hip arthroplasty - National in-patient database study.

Introduction: The outcome following major arthroplasty surgeries in patients with ankylosing spondylitis (AS) has tremendously improved over the past decades, due to substantial amelioration in the medical therapies and sophistication of available surgical modalities. Although various studies have already demonstrated the complication rates and challenges faced in AS patients undergoing THA, there is a substantial paucity of data on the actual healthcare burden associated with this disease, and the diverse factors which may affect it. Methods: Using the National Inpatient Sample (NIS) database (on the basis of ICD-10 CMP codes), patients undergoing THA between the years 2016 and 2019 were identified. These patients were then classified into two categories: group A: patients with a known diagnosis of AS; and group N: those without. The details regarding demographical information, associated co-morbidities, data pertaining to patients' hospital admissions including expenditure incurred, length of stay and complications encountered, were compared. In addition, propensity-score matching was performed to identify a 1:1 matched sample of THA patients without AS. Results: Overall, 367,890 patients underwent THA; among whom, 501 (0.14%) were known AS patients (group A). Group A included a substantially higher proportion of patients belonging to younger age group (58.6 ± 13.4 versus 65.9 ± 11.4 years; p < 0.001), male sex (67.1% in group A vs 44.1% in group N; p < 0.001), and Asian ethnicity (p < 0.001). Group A patients had a substantially higher risk for longer duration of hospital stay (p < 0.03) and higher overall healthcare expenditure incurred (p < 0.001). As compared to group N, AS patients had a significantly higher risk for developing post-operative anemia [21.8% (group A) vs 11.8% (group N); p < 0.02]; and higher rate of periprosthetic infections [2.4% (group A) vs 1.0% (group N); p < 0.007]. Conclusion: Patients with AS require a significantly longer duration of hospital stay and higher admission-related expenditure following THA, as compared to the general population. These enhanced early health care-associated costs can be attributed to higher complication rates in AS patients. AS patients are prone to higher rates of anemia and peri-prosthetic infections during the early post-THA period.

Cost and Early Complication Analysis Following Total Hip Arthroplasty in Parkinson's Disease Patients: A Propensity-matched Database Study.

Background: Parkinson's Disease is a well-known neuromuscular disorder, which affects the stability and gait of elderly patients. With the progressive increase in the life span of patients with PD, the problem of degenerative arthritis and the consequent need for total hip arthroplasty (THA) in this cohort are rising. There is paucity of data in the existing literature regarding the healthcare costs and overall outcome following THA in PD patients. The current study was planned to assess the hospital expenditure, details regarding hospital stay, and complication rates for patients with PD, who underwent THA. Methods: We investigated the National Inpatient Sample data to identify PD patients, who underwent hip arthroplasty from 2016 to 2019. Using propensity score, PD patients were matched 1:1 to patients without PD by age, gender, non-elective admission, tobacco use, diabetes, and obesity. Chi-square and T-tests were used for analyzing categorical and non-categorical variables, respectively (Fischer-Exact test was employed for values<5). Results: Overall, 367,890 (1927 patients with PD) THAs were performed between 2016 and 2019. Before matching, PD group had significantly greater proportion of older patients, males, and non-elective admissions for THA (P<0.001). After matching, PD group had higher total hospital costs, longer hospital stay, greater blood loss anemia, and prosthetic dislocation (P<0.001). The in-hospital mortality was similar between the two groups. Conclusion: Patients with PD undergoing THA required greater proportion of emergent hospital admissions. Based on our study, the diagnosis of PD showed significant association with greater cost of care, longer hospital stay, and higher post-operative complications.

Cost and Complications in Rheumatoid Arthritis Patients Undergoing Primary Hip Arthroplasty: A National Inpatient Sample-Based Study.

INTRODUCTION: Rheumatoid arthritis (RA) is an autoimmune disease that affects multiple synovial joints in the body, including the hip. Hip involvement in RA patients is fairly common, but the current literature is lacking large-scale studies on the surgical outcomes of RA patients undergoing total hip arthroplasty (THA). The aim of the study is to examine the outcomes and hospital costs associated with THA in patients with RA and compare them to patients without RA using the National Inpatient Sample (NIS) database. METHODS: We analyzed the NIS database to identify patients undergoing THA between 2016 and 2019 using International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes. Multiple variables including demographics, medical comorbidities, total hospital costs, length of stay, and perioperative complication rates were then compared between patients with and without RA. Further, the two groups were matched for demographic differences, if any, using a 1:1 propensity match algorithm. RESULTS: Patients with RA undergoing THA were significantly younger and predominantly female when compared to patients without RA. There was also a lower incidence of obesity and the percentage of elective THA procedures were smaller in the RA group. The RA group had a longer length of stay and increased incidences of blood loss anemia, blood transfusion, and periprosthetic fractures. These differences persisted despite matching the two groups for demographic differences, elective procedures, diabetes, obesity, and tobacco usage. CONCLUSION: THA in RA is associated with an increased incidence of blood loss anemia, blood transfusion, and periprosthetic fractures, as well as a longer length of stay in THA patients.

Incidence of Non-variceal Upper Gastrointestinal Bleeding Worsens Outcomes with Acute Coronary Syndrome: Result of a National Cohort.

INTRODUCTION: Upper gastrointestinal bleeding (UGIB) is a feared complication of acute coronary syndrome (ACS) and has been shown to increase morbidity and mortality. Our aim was to assess the incidence of non-variceal UGIB in patients with ACS in a national cohort and its impact on in-hospital mortality, length of stay (LOS), and cost of hospitalization. METHODS: This was a retrospective cohort study analyzing the 2016 Nationwide Inpatient Sample (NIS) utilizing ICD 10 CM codes. Principal discharge diagnoses of ACS (STEMI, NSTEMI, and UA) in patients over 18 years old were included. Non-variceal UGIB with interventions including endoscopy, angiography, and embolization were also evaluated. Primary outcome was the national incidence of concomitant non-variceal UGIB in the setting of ACS. Secondary outcomes included in-hospital mortality, length of stay, and cost of stay. RESULTS: A total of 661,404 discharges with principal discharge diagnosis of ACS in 2016 were analyzed. Of the included cohort, 0.80% (n = 5324) were complicated with non-variceal UGIB with increased frequency in older patients (OR 1.03, 95% CI 1.03-1.04; p = 0.0001). Despite endoscopic evaluation, 17.35% (n = 744) underwent angiography. After adjustment of confounders, inpatient mortality was significantly higher in patients with UGIB (OR 2.07, 95% CI 1.63-2.63, p = 0.0001). Non-variceal UGIB also led to significantly longer LOS (10.38 days vs 4.37 days, p = 0.0001) and cost of stay ($177,324 vs $88,468, p = 0.0001). DISCUSSION: Our study shows that the national incidence of non-variceal UGIB complicating ACS is low at less than 1%, but resulted in significantly higher inpatient mortality, LOS, and hospitalization charges.

Breast MRI screening for average-risk women: A monte carlo simulation cost-benefit analysis.

BACKGROUND: Screening high-risk women for breast cancer with MRI is cost-effective, with increasing cost-effectiveness paralleling increasing risk. However, for average-risk women cost is considered a major limitation to mass screening with MRI. PURPOSE: To perform a cost-benefit analysis of a simulated breast cancer screening program for average-risk women comparing MRI with mammography. STUDY TYPE: Population simulation study. POPULATION/SUBJECTS: Five million (M) hypothetical women undergoing breast cancer screening. FIELD STRENGTH/SEQUENCE: Simulation based primarily on Kuhl et al8 study utilizing 1.5T MRI with an axial bilateral 2D multisection gradient-echo dynamic series (repetition time / echo time 250/4.6 msec; flip angle, 90°) with a full 512 × 512 acquisition matrix and a sensitivity encoding factor of two, performed prior to and four times after bolus injection of 0.1 mmol of gadobutrol per kg of body weight (Gadovist; Bayer, Germany). An axial T2 -weighted fast spin-echo sequence with identical anatomic parameters was also included. ASSESSMENT: A Monte Carlo simulation utilizing Medicare reimbursement rates to calculate input variable costs was developed to compare 5M women undergoing breast cancer screening with either triennial MRI or annual mammography, 2.5M in each group, over 30 years. STATISTICAL TESTS: Expected recall rates, BI-RADS 3, BI-RADS 4/5 cases and cancer detection rates were determined from published literature with calculated aggregate costs including resultant diagnostic/follow-up imaging and biopsies. RESULTS: Baseline screening of 2.5M women with breast MRI cost $1.6 billion (B), 3× higher than baseline mammography screening ($0.54B). With subsequent screening, MRI screening is more cost-effective than mammography screening in 24 years ($13.02B vs. $13.03B). MRI screening program costs are largely driven by cost per MRI exam ($549.71). A second simulation model was performed based on MRI Medicare reimbursement trends using a lower MRI cost ($400). This yielded a cost-effective benefit compared to mammography screening in less than 6 years ($3.41B vs. $3.65B), with over a 22% cost reduction relative to mammography screening in 12 years and reaching a 38% reduction in 30 years. DATA CONCLUSION: Despite higher initial cost of a breast MRI screening program for average-risk women, there is ultimately a cost savings over time compared with mammography. This estimate is conservative given cost-benefit of additional/earlier breast cancers detected by breast MRI were not accounted for. LEVEL OF EVIDENCE: 3 Technical Efficacy Stage: 6 J. Magn. Reson. Imaging 2019.

Ethnic Difference in Proximal Aortic Stiffness: An Observation From the Dallas Heart Study.

OBJECTIVES: This study aims to compare ethnic difference in proximal aortic pulse wave velocity (PWV) and characteristic impedance (Zc). BACKGROUND: Increased aortic stiffness is an independent predictor of target organ damage, incident hypertension, and all-cause mortality. However, previous studies have not directly assessed proximal aortic function in Blacks, the ethnic population with disproportionately high risk for incident hypertension and target organ complications. METHODS: We evaluated the multiethnic, population-based DHS (Dallas Heart Study) participants (N = 2,544, 54.2% women, 49.7% Black) who underwent cardiac magnetic resonance at 1.5-T. Aortic stiffness and Zc were determined from aortic arch PWV and lumen area measurements. Linear regression was used to evaluate ethnic differences in proximal aortic wall stiffness using aortic arch PWV and Zc as dependent variables with and without adjustment for traditional cardiovascular risk factors. Because cardiac output was significantly higher in Blacks compared to Whites and Hispanics, additional comparisons of PWV and Zc were performed after adjustment for cardiac output and peripheral vascular resistance. RESULTS: Compared with Whites, both Blacks and Hispanics had higher levels of aortic arch PWV (4.25, 95% confidence interval [CI]: 4.15 to 4.35 m/s, vs. 4.72, 95% CI: 4.64 to 4.81 m/s, vs. 4.48, 95% CI: 4.33 to 4.63 m/s, respectively, both p < 0.05 vs. White), and Zc (64.9, 95% CI: 63.3 to 66.6 dyne·s/cm5, vs. 75.6, 95% CI: 74.0 to 77.2 dyne·s/cm5, vs. 70.1, 95% CI: 67.6 to 72.8 dyne·s/cm5, respectively, both p < 0.01 vs. White) after adjustment for age, age squared, sex, body mass index, height, mean arterial blood pressure, antihypertensive treatment, heart rate, total cholesterol, diabetes mellitus, and smoking. Compared with Hispanics, Blacks also had higher level of both PWV and Zc (both p < 0.01). Ethnic differences in PWV and Zc persisted after adjustment for cardiac output and peripheral vascular resistance. CONCLUSIONS: In a multiethnic population-based-sample, Blacks and Hispanics had higher proximal aortic stiffness compared with Whites independent of blood pressure and relevant risk factors.

Dislocation rates following primary total hip arthroplasty have plateaued in the Medicare population.

The purpose of this study was to determine if the use of larger femoral head diameters, in combination with recent practice including enhanced soft tissue choices and various operative exposure choices has led to any further decline in dislocation rates. 51,901 patients undergoing primary THA were identified from 5% Medicare Part B (physician/carrier) claims between January 1, 1997 and December 31, 2011. Dislocation rate at 6 months following THA was 2.84% over the study period (1997-2011). From 2005 to 2011, dislocation rates following primary THA have plateaued in the United States at approximately 2%. This suggests that the full benefits using large femoral head sizes are now realized. For further improvement in dislocation rates, a greater emphasis will be required on patient selection, surgical technique and component alignment.

Making new vaccines affordable: a comparison of financing processes used to develop and deploy new meningococcal and pneumococcal conjugate vaccines.

Mechanisms to increase access to health products are varied and controversial. Two innovative mechanisms have been used to accelerate the development of low-price supply lines for conjugate vaccines. The Meningitis Vaccine Project is a so-called push mechanism that facilitated technology transfer to an Indian company to establish capacity to manufacture a vaccine. The Advanced Market Commitment for pneumococcal vaccines is a so-called pull mechanism that guarantees companies a supplement paid in addition to the purchase price for vaccines for a specific period. We compare these approaches, identifying key dimensions of each and considering their potential for replication. We also discuss issues that the Global Alliance for Vaccines and Immunisation (GAVI) face now that these new vaccines are available. Progress towards GAVI's strategic aims is needed and funding is crucial. Approaches that decrease the financial pressure on GAVI and greatly increase political and financial engagement by low-income countries should also be considered.