Advantages of robotic arm-assisted total hip arthroplasty: a 90-day episode-of-care clinical utility and cost analysis.

Aim: Determine the clinical utility and economic differences over a 90-day period between robotic arm-assisted total hip arthroplasty (RATHA) and manual total hip arthroplasty (MTHA). Methods: Leveraging a nationwide commercial payer database, pre-covid THA procedures were identified. Following a 1:5 propensity score match, 1732 RATHA and 8660 MTHA patients were analyzed. Index costs, index lengths of-stay, and 90-day episode-of-care utilization and costs were evaluated. Results: Episode of care costs for RATHA was found to be $1573 lower compared with MTHA (p < 0.0001). Post-index hospital utilization was significantly less likely to occur for RATHA compared with MTHA. Total index costs were also significantly lower for RATHA versus MTHA (p < 0.0001). Conclusion: Index and post-index EOC hospital utilization and costs were lower for RATHA compared with MTHA.

A real-world comparison of the clinical and economic utility of OVA1 and CA125 in assessing ovarian tumor malignancy risk.

Aim: This largest-of-its-kind study evaluated the clinical utility of CA125 and OVA1, commonly used as ovarian tumor markers for assessing the risk of malignancy. The research focused on the ability and utility of these tests to reliably predict patients at low risk for ovarian cancer. Clinical utility endpoints were 12-month maintenance of benign mass status, reduction in gynecologic oncologist referral, avoidable surgical intervention and associated cost savings. Materials & methods: This was a multicenter retrospective review of data from electronic medical records and administrative claims databases. Patients receiving a CA125 or OVA1 test between October 2018 and September 2020 were identified and followed for 12 months using site-specific electronic medical records to assess tumor status and utilization outcomes. Propensity score adjustment was used to control for confounding variables. Payer allowed amounts from Merative MarketScan Research Databases were used to estimate 12-month episode-of-care costs per patient, including surgery and other interventions. Results: Among 290 low-risk OVA1 patients, 99.0% remained benign for 12 months compared with 97.2% of 181 low-risk CA125 patients. The OVA1 cohort exhibited 75% lower odds of surgical intervention in the overall sample of patients (Adjusted OR: 0.251, p ≤ 0.0001), and 63% lower odds of gynecologic oncologist utilization among premenopausal women (Adjusted OR: 0.37, p = 0.0390) versus CA125. OVA1 demonstrated significant savings in surgical interventions ($2486, p ≤ 0.0001) and total episode-of-care costs ($2621, p ≤ 0.0001) versus CA125. Conclusion: This study underscores the utility of a reliably predictive multivariate assay for assessing ovarian cancer risk. For patients assessed at low risk of ovarian tumor malignancy, OVA1 is associated with a significant reduction in avoidable surgeries and substantial cost savings per patient. OVA1 is also associated with a significant reduction in subspecialty referrals for low-risk premenopausal patients.

A 90-Day Episode-of-Care Analysis Including Computed Tomography Scans of Robotic-Arm Assisted versus Manual Total Knee Arthroplasty.

In this observational, retrospective study, we performed economic analyses between robotic arm-assisted total knee arthroplasty (RATKA) and manual total knee arthroplasty (MTKA). Specifically, we compared: (1) index costs including computed tomography (CT) scans; (2) 90-day postoperative health care utilization, (3) 90-day episode-of-care (EOC) costs, and (4) lengths of stay between CT scan-based robotically-assisted versus MTKAs. A large national database, Blue Health Intelligence (BHI), was used for RATKAs and MTKAs performed between April 1, 2017 and September 30, 2019. Based on strict inclusion-exclusion criteria, with propensity score matching, 4,135 RATKAs and 4,135 MTKAs were identified and analyzed. Index costs to the payer for RATKA patients were found to be less than those for MTKA patients ($29,984 vs. $31,280, p <0.0001). Overall, 90-day EOC costs for RATKA patients were found to be less than that for MTKA patients in the inpatient and outpatient settings. This also holds true for the use of skilled nursing facilities, pharmacies, or other services. In conclusion, the results from our study show that RATKA were associated with lower costs than MTKAs, even when including the cost of CT scans. These results are of marked importance given the emphasis to contain and reduce health care costs.

Continuous Positive Airway Pressure Adherence and Treatment Cost in Patients With Obstructive Sleep Apnea and Cardiovascular Disease.

Objective: To determine whether continuous positive airway pressure (CPAP) adherence reduces health care-related costs or use in patients with obstructive sleep apnea (OSA) and comorbid cardiovascular disease (CVD). Patients: A total of 23 million patients with CVD were identified in the Medicare fee-for-service database. Of the 65,198 who completed a sleep study between January 2016 and September 2018, 55,125 were diagnosed as having OSA and 1758 were identified in the 5% Medicare durable medical equipment (DME) database. Methods: Patients with DME claims were categorized as adherent (AD, treatment evidenced ≥91 days after CPAP initiation; n=614) or nonadherent (nAD, n=242) to CPAP therapy. In addition, 9881 individuals with CVD who were not diagnosed as having OSA after sleep testing and without CPAP initiation were included as control patients. Propensity score matching balanced the groups for age, sex, and comorbidities (eg, diabetes mellitus), resulting in 241 participants per cohort. Dependent variables included total episode-of-care, inpatient, outpatient, skilled nursing, home health, and DME costs across 12 months. Results: Total episode-of-care costs of AD participants ($6825) were lower than those of nAD ($11,312; P<.05) and control ($8102) participants. This difference (Δ) was attributable to fewer outpatient expenses (Δ$2290; P<.05) relative to the nAD group and fewer inpatient expenses (Δ$745) relative to the control group because skilled nursing costs were comparable between groups (P=.73). Conclusion: Adherence to CPAP treatment reduces annual health care-related expenses by 40% in Medicare patients with CVD and OSA.

Health Care Utilization and Payer Cost Analysis of Robotic Arm Assisted Total Knee Arthroplasty at 30, 60, and 90 Days.

This study performed a health care utilization analysis between robotic arm assisted total knee arthroplasty (rTKA) and manual total knee arthroplasty (mTKA) techniques. Specifically, we compared (1) index costs and (2) discharge dispositions, as well as (3) 30-day (4) 60-day, and (5) 90-day (a) episode-of-care costs, (b) postoperative health care utilization, and (c) readmissions. The 100% Medicare Standard Analytical Files were used for rTKAs and mTKAs performed between January 1, 2016, and March 31, 2017. Based on strict inclusion-exclusion criteria and 1:5 propensity score matching, 519 rTKA and 2,595 mTKA patients were analyzed. Total episode payments, health care utilization, and readmissions, at 30-, 60-, and 90-day time points were compared using generalized linear model, binomial regression, log link, Mann-Whitney, and Pearson's chi-square tests. The rTKA versus mTKA cohort average total episode payment was US$17,768 versus US$19,899 (p < 0.0001) at 30 days, US$18,174 versus US$20,492 (p < 0.0001) at 60 days, and US$18,568 versus US$20,960 (p < 0.0001) at 90 days. At 30 days, 47% fewer rTKA patients utilized skilled nursing facility (SNF) services (13.5 vs. 25.4%; p < 0.0001) and had lower SNF costs at 30 days (US$6,416 vs. US$7,732; p = 0.0040), 60 days (US$6,678 vs. US$7,901, p = 0.0072), and 90 days (US$7,201 vs. US$7,947, p = 0.0230). rTKA patients also utilized fewer home health visits and costs at each time point (p < 0.05). Additionally, 31.3% fewer rTKA patients utilized emergency room services at 30 days postoperatively and had 90-day readmissions (5.20 vs. 7.75%; p = 0.0423). rTKA is associated with lower 30-, 60-, and 90-day postoperative costs and health care utilization. These results are of marked importance given the emphasis to contain and reduce health care costs and provide initial economic insights into rTKA with promising results.

Clinical and economic burden of colorectal and bariatric anastomotic leaks.

BACKGROUND: Anastomotic leaks cause a significant clinical and economic burden on patients undergoing bariatric and colorectal surgeries. Current literature shows a wide variation in incidence of anastomotic leaks and a significant gap in associated economic metrics. This analysis utilized claims data to quantify the full episode-of-care cost burden of leaks following colorectal and bariatric surgeries. METHODS: Medicare Fee-for-Service and commercial claims data from a large U.S.-based health plan were queried for cost and utilization of members that underwent bariatric and colorectal surgical procedures between January 1, 2013 and August 31, 2015. Outcomes were collected for members with anastomotic leaks versus those without leaks during the initial hospital stay (index) and within 30 days of the procedure. These outcomes included leak frequency, payer reimbursement, and length of stay (LOS). RESULTS: The colorectal Medicare analysis identified 239,350 patients undergoing colorectal surgery. For patients with a leak compared to those without, index admission costs were $30,670 greater ($48,982 vs. $18,312; p < 0.0001) and the index LOS was 12 days longer (19 vs. 7 days; p < 0.0001). This finding was similar for the bariatric patients (n = 62,292) where cost was $30,885 higher ($43,918 vs. $13,033; p < 0.0001) and LOS was 15 days longer (17 vs. 2 days; p < 0.0001). Furthermore, readmissions and associated costs were also substantially higher for those with an index leak. The commercial analysis of both the bariatric and colorectal populations trended similarly to the Medicare population in regards to all outcomes measured. CONCLUSION: Patients experiencing anastomotic leaks during and after bariatric and colorectal surgery have significantly higher costs and longer LOS both at the initial stay and within 30 days of the procedure. It is important that providers and hospitals understand the economic consequences of these procedures and implement technologies and techniques to prevent/reduce anastomotic leaks.

Leading Change in Academic Pharmacy: Report of the 2018-2019 AACP Academic Affairs Committee.

EXECUTIVE SUMMARYThe Committee was charged with the responsibility for examining the need for change in pharmacy education and the models of leadership that would enable that change to occur across the academy. They also examined the question of faculty wellbeing in a time of change and made several recommendations and suggestions regarding both charges. Building upon the work of the previous Academic Affairs Committee, the 2018-19 AAC encourages the academy to implement new curricular models supporting personalized learning that creates engaged and lifelong learners. This will require transformational leadership and substantial investments in faculty development and new assessment strategies and resources. Recognizing that the magnitude of the recommended change will produce new stress on faculty, the committee identified the need for much additional work on student, faculty and leaders' wellbeing, noting the limited amount of empirical evidence on pharmacy related to stress and resilience. That said, if faculty and administrators are not able to address personal and community wellbeing, their ability to support their students' wellbeing will be compromised.

Budget Impact Analysis to Estimate the Cost Dynamics of Treating Refractory Gastroesophageal Reflux Disease With Radiofrequency Energy: a Payer Perspective.

PURPOSE: A minimally invasive endoscopic treatment that utilizes radio-frequency energy (RFE) has received increased attention as an appropriate middle-ground approach in the treatment of refractory gastroesophageal reflux disease (GERD) and as an alternative to complicated and invasive surgical procedures. The objective of this study was to develop a longitudinal budget impact analysis from the payer perspective to estimate the direct medical costs of treatment for the refractory GERD patient population and to estimate the budgetary impact of further extending the RFE treatment option to other target populations. DESIGN AND METHODOLOGY: A retrospective analysis of claims designed to assess the longitudinal costs and budget impact on payer expenditures associated with managing and treating GERD surgically (Nissen fundoplication [NF]), endoscopically (RFE), or medically was performed. Both Medicare and commercially insured claims databases were interrogated for such population-level analyses. RESULTS: At current adoption rates (less than 1% of procedures), RFE demonstrated overall cost savings ranging from 7.3% to 50.5% in the 12-month time period following the index procedure (inclusive of procedure costs) when compared to medical management and fundoplication across the commercial and Medicare patient populations. Increasing the total number of RFE procedures to 2% of total cases performed generated per-member, per-month (PMPM) savings of $0.28 in the Medicare population and $0.37 in the commercially insured population. Further increases yielded higher PMPM savings. CONCLUSION: Adding to the clinical importance of RFE in filling the gap between medical and surgical management, this economic analysis demonstrates to payers that the adoption of RFE can create notable savings to their plans when compared to surgery or medical management.

Health economics of percutaneous hemodynamic support in the treatment of high-risk cardiac patients: a systematic appraisal of the literature.

This article systematically appraises the findings and conclusions derived from six recent studies of the economic impact and relative value of using percutaneous ventricular assist devices to render short-term hemodynamic support to high-risk patients with particular attention to the settings of cardiogenic shock and percutaneous coronary interventions. Although the extant body of literature is still growing, these studies offer evidence and insight regarding the health economics of traditional and emerging technologies in this treatment domain, and generally find the latter to be cost-effective in the long term. As the incidence of heart disease rises and the attendant economic burden of healthcare climbs, technologies for mitigating cardiovascular illness will be the target for more robust empirical evidence to justify the comparative value of minimally invasive hemodynamic support interventions in the armamentarium of treatment options available to physicians.

Economic and operational implications of a standardized approach to hemodynamic support therapy using percutaneous cardiac assist devices.

OBJECTIVE: Impella 2.5 has been shown to reduce major adverse events for patients undergoing elective high-risk percutaneous coronary intervention. We performed a single-center retrospective study to compare the costs and resource use of Impella 2.5 and intra-aortic balloon pump (IABP) support. METHODS: All high-risk patients who received Impella 2.5 (n = 35) and IABP (n = 295) support from December 2008 to July 2011 were included. Propensity score matching identified a balanced 1:1 matched cohort (35 Impella vs 35 IABP) based on indications for implantation, preimplantation hemodynamics, and age. Diagnostic, procedural, financial, and resource use data were collected. RESULTS: As compared with IABP, Impella offered a more predictable course of treatment/resource consumption and was not associated with any extreme cost outliers (17.1% vs 0.0%, respectively; P = 0.025). The mean admission and 90-day episode of care total costs for Impella were 5.5% ($67,681 vs $71,608, P = 0.79) and 4.2% ($70,680 vs $73,476, P = 0.85) lesser than that for IABP, respectively. Although not statistically significant, Impella patients had a trend toward lower rehospitalization rates (11.4% vs 20%), lesser mean index length of hospital stay (11.2 vs 13.7), and 90-day (11.7 vs 14.2) episode of care length of hospital stay. CONCLUSIONS: Impella support was associated with consistent course of treatment/resource consumption with significantly fewer 90-day extreme cost outliers than was IABP. The lower index and 90-day follow-up cost trends observed for Impella were driven by shorter length of hospital stay and fewer rehospitalizations. As providers strive to improve quality of care by reducing variability, these findings have implications for the development of hemodynamic support algorithms.

Percutaneous cardiac assist devices compared with surgical hemodynamic support alternatives: cost-effectiveness in the emergent setting.

UNLABELLED: This study evaluates the cost-effectiveness of percutaneous cardiac assist device (pVAD) therapy in the emergent setting compared with traditional surgical hemodynamic support alternatives. BACKGROUND: Previous research has demonstrated the cost-effectiveness of pVAD hemodynamic support for patients undergoing high-risk percutaneous coronary intervention. For patients in cardiogenic shock (CS), use of pVAD therapy has been shown to reduce length of stay (LOS). METHODS: National utilization and outcome data from the 2010-2011 MedPAR and state-sponsored all-payer databases were collected for patients with an acute myocardial infarction complicated by CS who were treated with either a pVAD (n = 883) or with traditional surgical hemodynamic support alternatives (ECMO and extracorporeal VAD) (n = 305). RESULTS: Discharge survival was greater with pVADs than with surgical alternatives (56% vs. 42%, P < 0.001) and was achieved with a strong trend toward reduced LOS (13.2 and 17.9 days, respectively, P = 0.055) and a significantly lower cost of the index admission ($90,929 and $144,257, respectively, P < 0.001). Cost-effectiveness analysis based on the national data demonstrated that pVAD achieved improved outcomes at lower cost. Data were also collected for similar patients who underwent protocol-guided pVAD therapy (using Impella 2.5) at PinnacleHealth, between 2009 and 2011 (n = 30). At this site, the survival rate increased to 60%, length of hospitalization was shortened to 6 days, and admission costs were lowered to $53,850 relative to the surgical alternatives strategy. CONCLUSIONS: For patients in CS requiring emergent hemodynamic support, pVAD therapy offers a less invasive alternative that can be deployed sooner, resulting in better outcomes, shorter LOS, lower costs and with no incremental cost, and a survival benefit when compared with traditional surgical hemodynamic support alternatives. PVAD therapy (and Impella 2.5 in particular) is emerging as a dominant strategy for this challenging patient population.

Rationale and design of the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) study.

BACKGROUND: Medication errors and adverse drug events are common after hospital discharge due to changes in medication regimens, suboptimal discharge instructions, and prolonged time to follow-up. Pharmacist-based interventions may be effective in promoting the safe and effective use of medications, especially among high-risk patients such as those with low health literacy. METHODS AND RESULTS: The Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) study is a randomized controlled trial conducted at 2 academic centers-Vanderbilt University Hospital and Brigham and Women's Hospital. Patients admitted with acute coronary syndrome or acute decompensated heart failure were randomly assigned to usual care or intervention. The intervention consisted of pharmacist-assisted medication reconciliation, inpatient pharmacist counseling, low-literacy adherence aids, and tailored telephone follow-up after discharge. The primary outcome is the occurrence of serious medication errors in the first 30 days after hospital discharge. Secondary outcomes are health care utilization, disease-specific quality of life, and cost-effectiveness. Enrollment was completed September 2009. A total of 862 patients were enrolled, and 430 patients were randomly assigned to receive the intervention. Analyses will determine whether the intervention was effective in reducing serious medication errors, particularly in patients with low health literacy. CONCLUSIONS: The PILL-CVD study was designed to reduce serious medication errors after hospitalization through a pharmacist-based intervention. The intervention, if effective, will inform health care facilities on the use of pharmacist-assisted medication reconciliation, inpatient counseling, low-literacy adherence aids, and patient follow-up after discharge. Clinical Trial Registration- clinicaltrials.gov. Identifier: NCT00632021.

Community health clinical education in Canada: part 2--developing competencies to address social justice, equity, and the social determinants of health.

Recently, several Canadian professional nursing associations have highlighted the expectations that community health nurses (CHNs) should address the social determinants of health and promote social justice and equity. These developments have important implications for (pre-licensure) CHN clinical education. This article reports the findings of a qualitative descriptive study that explored how baccalaureate nursing programs in Canada address the development of competencies related to social justice, equity, and the social determinants of health in their community health clinical courses. Focus group interviews were held with community health clinical course leaders in selected Canadian baccalaureate nursing programs. The findings foster understanding of key enablers and challenges when providing students with clinical opportunities to develop the CHN role related to social injustice, inequity, and the social determinants of health. The findings may also have implications for nursing programs internationally that are addressing these concepts in their community health clinical courses.

Patient safety: where is nursing education?

Patient safety is receiving unprecedented attention among clinicians, researchers, and managers in health care systems. In particular, the focus is on the magnitude of systems-based errors and the urgency to identify and prevent these errors. In this new era of patient safety, attending to errors, adverse events, and near misses warrants consideration of both active (individual) and latent (system) errors. However, it is the exclusive focus on individual errors, and not system errors, that is of concern regarding nursing education and patient safety. Educators are encouraged to engage in a culture shift whereby student error is considered from an education systems perspective. Educators and schools are challenged to look within and systematically review how program structures and processes may be contributing to student error and undermining patient safety. Under the rubric of patient safety, the authors also encourage educators to address discontinuities between the educational and practice sectors.

Case study: on the leading edge of new curricula concepts: systems and safety in nursing education.

The Nursing Division of the Saskatchewan Institute of Applied Science and Technology (SIAST) first included systems and patient safety as a priority in its institutional business and strategic plan in 2003. Three interrelated leading-edge, two-year projects (2004-2006) were launched: Best Practice, Mentorship and Patient Safety, with the intent that each project would enhance the others. This case study focuses on the work of the Patient Safety Project Team. The team developed a project framework and strategic plan, conducted a literature review and identified key concepts related to systems and patient safety. Strategies to integrate these concepts into the school's 15 nursing education programs are being implemented.

Factors influencing pregnant women's perceptions of risk.

PURPOSE: To explore factors women consider in determining their perceptions of pregnancy risk, and to compare and contrast factors considered by women with complicated and uncomplicated pregnancies. STUDY DESIGN AND METHODS: Descriptive qualitative study in which women described factors they considered in making personal risk assessments. Of the 205 women in the study, half (n = 103) had pregnancy complications, while the other half (n = 102) had no known complications. Written responses to three open-ended questions were used to determine factors women considered in assessing their risks. A qualitative content analysis approach was used to interpret the data. RESULTS: Four major themes emerged that influenced perception of risk for both groups: self image, history, healthcare, and "the unknown." Women with complications voiced greater risk perceptions and identified specific risks, while women with no complications mentioned potential risks that were diffuse and hypothetical.

How different can you be and still survive? Homogeneity and difference in clinical nursing education.

The article focuses on a component of a three-year institutional ethnography regarding the construction of cultural diversity in clinical education. Students in two Canadian schools of nursing described being a nursing student as bounded by unwritten and largely invisible expectations of homogeneity in the context of a predominant discourse of equality and cultural sensitivity. At the same time, they witnessed many incidents, both personally and those directed toward other individuals of the same culture, of clinical teachers problematizing difference and centering on difference as less than the expected norm. This complex and often contradictory experience of difference and homogeneity contributed to their construction of cultural diversity as a problem. The authors provide examples of how the perception of being different affected some students' learning in the clinical setting and their interactions with clinical teachers. They will illustrate that this occurred in the context of macro influences that shaped how both teachers and students experienced and perceived cultural diversity. The article concludes with a challenge to nurse educators to deconstruct their beliefs and assumptions about inclusivity in nursing education.