Cost-effectiveness of routine type and screens in select urological surgeries.

PURPOSE: To evaluate the cost-effectiveness of obtaining a preoperative type and screen (T/S) for common urologic procedures. METHODS: A decision tree model was constructed to track surgical patients undergoing two preoperative blood ordering strategies as follows: obtaining a preoperative T/S versus not doing so. The model was applied to the National (Nationwide) Inpatient Sample (NIS) data, from January 1, 2006 to September 30, 2015. Cost estimates for the model were created from combined patient-level data with published costs of a T/S, type and crossmatch (T/C), a unit of pRBC, and one unit of emergency-release transfusion (ERT). The primary outcome was the incremental cost per ERT prevented, expressed as an incremental cost-effectiveness ratio (ICER) between the two preoperative blood ordering strategies. A cost-effectiveness analysis determined the ICER of obtaining preoperative T/S to prevent an emergency-release transfusion (ERT), with a willingness-to-pay threshold of $1,500.00. RESULTS: A total of 4,113,144 surgical admissions from 2006 to 2015 were reviewed. The overall transfusion rate was 10.54% (95% CI, 10.17-10.91) for all procedures. The ICER of preoperative T/S was $1500.00 per ERT prevented. One-way sensitivity analysis demonstrated that the risk of transfusion should exceed 4.12% to justify preoperative T/S. CONCLUSION: Routine preoperative T/S for radical prostatectomy (rate = 3.88%) and penile implants (rate = .91%) does not represent a cost-effective practice for these surgeries. It is important for urologists to review their institution T/S policy to reduce inefficiencies within the preoperative setting.

Cost-Effectiveness of Routine Type and Screens in Select Endonasal Skull Base Surgeries.

Objective The study aimed to evaluate the cost-effectiveness of obtaining preoperative type and screens (T/S) for common endonasal skull base procedures, and determine patient and hospital factors associated with receiving blood transfusions. Study Design Retrospective database analysis of the 2006 to 2015 National (nationwide) Inpatient Sample and cost-effectiveness analysis. Main Outcome Measures Multivariate regression analysis was used to identify factors associated with transfusions. A cost-effectiveness analysis was then performed to determine the incremental cost-effectiveness ratio (ICER) of obtaining preoperative T/S to prevent an emergency-release transfusion (ERT), with a willingness-to-pay threshold of $1,500. Results A total of 93,105 cases were identified with an overall transfusion rate of 1.89%. On multivariate modeling, statistically significant factors associated with transfusion included nonelective admission (odds ratio [OR]: 2.32; 95% confidence interval [CI]: 1.78-3.02), anemia (OR: 4.42; 95% CI: 3.35-5.83), coagulopathy (OR: 4.72; 95% CI: 2.94-7.57), diabetes (OR: 1.45; 95% CI: 1.14-1.84), liver disease (OR: 2.37; 95% CI: 1.27-4.43), pulmonary circulation disorders (OR: 3.28; 95% CI: 1.71-6.29), and metastatic cancer (OR: 5.85; 95% CI: 2.63-13.0; p < 0.01 for all). The ICER of preoperative T/S was $3,576 per ERT prevented. One-way sensitivity analysis demonstrated that the risk of transfusion should exceed 4.12% to justify preoperative T/S. Conclusion Routine preoperative T/S does not represent a cost-effective practice for these surgeries using nationally representative data. A selective T/S policy for high-risk patients may reduce costs.

The Impact of Month on Joint Arthroplasty In-Hospital Outcomes: The December Effect.

Background: The purpose of this study was to assess the impact of month of the year on postsurgical outcomes after primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) and to specifically analyze for a December effect. Material and methods: The National Inpatient Sample was used to identify all patients older than 40 years undergoing primary TKA and THA between 2006 and 2015. Patients were stratified based on the month of the year of surgery. In-hospital complication, disposition, and economic outcomes were comparatively analyzed. Results: There were statistically significant differences in outcomes based on month of the year. When comparing December to the other months, both TKA and THA patients had significantly lower rates of any complication, postoperative anemia, and genitourinary complications, while there were significantly higher rates of home than rehab discharge and shorter average length of stay in December. THA patients additionally had significantly lower rates of cardiac and respiratory complications during December. Conclusion: Postoperative outcomes are significantly associated with the month in which arthroplasty is performed. This study provides evidence of a positive "December effect" of improved in-hospital complications and economic outcomes for surgeries performed in December. Future research should direct attention to the impact that social factors may have on outcomes after elective surgical procedures and how these factors may be translated to other months.

Social Determinants of Health Correlating with Mechanical Ventilation of COVID-19 Patients: A Multi-Center Observational Study.

IMPORTANCE: Several studies have relayed the disproportionate impact of COVID-19 on marginalized communities; however, few have specifically examined the association between social determinants of health and mechanical ventilation (MV). OBJECTIVE: To determine which demographics impact MV rates among COVID-19 patients. DESIGN: This observational study included COVID-19 patient data from eight hospitals' electronic medical records (EMR) between February 25, 2020, to December 31, 2020. Associations between demographic data and MV rates were evaluated using uni- and multivariate analyses. SETTING: Multicenter (eight hospitals), largest health system in Southeast Michigan. PARTICIPANTS: Inpatients with a positive RT-PCR for SARS-CoV-2 on nasopharyngeal swab. Exclusion criteria were missing demographic data or non-permanent Michigan residents. EXPOSURE: Patients were divided into two groups: MV and non-MV. MAIN OUTCOME AND MEASURES: The primary outcome was MV rate per demographic. A multivariate model then predicted the odds of MV per demographic descriptor. Hypotheses were formulated prior to data collection. RESULTS: Among 11,304 COVID-19 inpatients investigated, 1621 (14.34%) were MV, and 49.96% were male with a mean age of 63.37 years (17.79). Significant social determinants for MV included Black race (40.19% MV vs 31.31% non-MV, p<0.01), poverty (14.60% vs. 13.21%, p<0.01), and disability (12.65% vs 9.14%; p<0.01). Black race (AOR 1.61 (CI 1.41-1.83; p<0.01)), median income (AOR 0.99 (CI 0.99-0.99; p<0.01)), disability (AOR 1.55 (CI 1.26, 1.90; p<0.01)), and non-English-speaking status (AOR 1.26 (CI 1.05, 1.53)) had significantly higher odds of MV. CONCLUSIONS AND RELEVANCE: Black race, low socioeconomic status, disability, and non-English-speaking status were significant risk factors for MV from COVID-19. An urgent need remains for a pandemic response program that strategizes care for marginalized communities.

The Impact of Disparities in Social Determinants of Health on Hospitalization Rates for Patients with COVID-19 in Michigan (USA).

IMPORTANCE: The COVID-19 pandemic continues to impact the health-care system in the United States and has brought further light on health disparities within it. However, only a few studies have examined hospitalization risk with regard to social determinants of health. OBJECTIVE: We aimed to identify how health disparities affect hospitalization rates among patients with COVID-19. DESIGN: This observational study included all individuals diagnosed with COVID-19 from February 25, 2020 to December 31, 2020. Uni- and multivariate analyses were utilized to evaluate associations between demographic data and inpatient versus outpatient status for patients with COVID-19. SETTING: Multicenter (8 hospitals), largest size health system in Southeast Michigan, a region highly impacted by the pandemic. PARTICIPANTS: All outpatients and inpatients with a positive RT-PCR for SARS-CoV-2 on nasopharyngeal swab were included. Exclusion criteria included missing demographic data or status as a non-permanent Michigan resident. EXPOSURE: Patients who met inclusion and exclusion criteria were divided in 2 groups: outpatients and inpatients. MAIN OUTCOME AND MEASURES: We described the comparative demographics and known disparities associated with hospitalization status. RESULTS: Of 30,292 individuals who tested positive for SARS-CoV-2, 34.01% were admitted to the hospital. White or Caucasian race was most prevalent (57.49%), and 23.35% were African-American. The most common ethnicity was non-Hispanic or Latino (70.48%). English was the primary language for the majority of patients (91.60%). Private insurance holders made up 71.11% of the sample. Within the hospitalized patients, lower socioeconomic status, African-American race and Hispanic and Latino ethnicity, non-English speaking status, and Medicare and Medicaid were more likely to be admitted to the hospital. CONCLUSIONS AND RELEVANCE: Several health disparities were associated with greater rates of hospitalization due to COVID-19. Addressing these inequalities from an individual to system level may improve health-care outcomes for those with health disparities and COVID-19.

Healthcare Disparities Correlated with In-Hospital Mortality in COVID-19 Patients.

INTRODUCTION: Increasing age, male gender, African American race, and medical comorbidities have been reported as risk factors for COVID-19 mortality. We aimed to identify health-care disparities associated with increased mortality in COVID-19 patients. METHODS: We performed an observational study of all hospitalized patients with SARS-CoV2 infection from within the largest multicenter healthcare system in Southeast Michigan, from February to December, 2020. RESULTS: From 11,304 hospitalized patients, 1295 died, representing an in-hospital mortality rate of 11.5%. The mean age of hospitalized patients was 63.77 years-old, with 49.96% being males. Older age (AOR = 1.05, p < 0.0001), male gender (AOR = 1.43, p < 0.0001), divorced status (AOR = 1.25, p = 0.0256), disabled status (AOR = 1.42, p = 0.0091), and homemakers (AOR = 1.96, p = 0.0216) were significantly associated with in-hospital mortality. CONCLUSION: Older age, male gender, divorced and disabled status and homemakers were significantly associated with in-hospital mortality if they developed COVID-19. Further research should aim to identify the underlying factors driving these disparities in COVID-19 in-hospital mortality.

Trends, survival outcomes, and predictors of nonadherence to mastectomy guidelines for nonmetastatic inflammatory breast cancer.

BACKGROUND: The Current National Comprehensive Cancer Network guidelines recommend modified radical mastectomy (MRM) as the surgical treatment of choice for nonmetastatic inflammatory breast cancer (IBC). Limited studies have looked into the outcomes of breast conserving surgery (BCS) vs. MRM for IBC. METHODS: National Cancer Database (NCDB) data from 2004 to 2014 were retrospectively analyzed. Patients' demographics, tumor characteristics, and overall survival (OS) trends were compared for BCS and MRM cases of nonmetastatic IBC. Univariate and multivariate analyses were performed. RESULTS: A total of 413 (3.89%) BCS and 10,197 (96.11%) MRM cases were identified. Median follow-up was 58.45 months. Compared to MRM, BCS patients were more likely to be older, be African American, have Medicare/Medicaid or be uninsured, live in lower education ZIP codes, and live in a metropolitan area (all p < 0.05). BCS rates significantly decreased from 5.84% in 2004 to 3.19% in 2014 (p < 0.001). BCS patients also were more likely to have less than 50% of the breast involved (51.57% vs. 43.88%; p = 0.0081) and were less likely to receive trimodal therapy (50.85% vs. 74.62%; p = <0.0001). The OS was significantly higher in the mastectomy group over 9 years at 62.02% vs. 54.47% in the BCS group. Additionally, in the adjusted multivariate model, BCS cases were associated with 23% higher hazards of overall mortality (p = 0.0091). CONCLUSION: BCS was performed in a limited number of cases, which decreased over the study period. The analysis identified both demographic predictors of receiving BCS and significantly lower OS for IBC patients undergoing a BCS.

Industry-Sponsored Research Payments in Neurosurgery-Analysis of the Open Payments Database From 2014 to 2018.

BACKGROUND: The Open Payments Database (OPD) started in 2013 to combat financial conflicts of interest between physicians and medical industry. OBJECTIVE: To evaluate the first 5 yr of the OPD regarding industry-sponsored research funding (ISRF) in neurosurgery. METHODS: The Open Payments Research Payments dataset was examined from 2014 to 2018 for payments where the clinical primary investigator identified their specialty as neurosurgery. RESULTS: Between 2014 and 2018, a $106.77 million in ISRF was made to 731 neurosurgeons. Fewer than 11% of neurosurgeons received ISRF yearly. The average received $140 000 in total but the median received $30,000. This was because the highest paid neurosurgeon received $3.56 million. A greater proportion ISRF was made to neurosurgeons affiliated with teaching institutions when compared to other specialties (26.74% vs 20.89%, P = .0021). The proportion of the total value of ISRF distributed to neurosurgery declined from 0.43% of payments to all specialties in 2014 to 0.37% in 2018 (P < .001), but no steady decline was observed from year to year. CONCLUSION: ISRF to neurosurgeons comprises a small percentage of research payments made to medical research by industry sponsors. Although a greater percentage of payments are made to neurosurgeons in teaching institutions compared to other specialties, the majority is given to neurosurgeons not affiliated with a teaching institution. A significant percentage of ISRF is given to a small percentage of neurosurgeons. There may be opportunities for more neurosurgeons to engage in industry-sponsored research to advance our field as long as full and complete disclosures can always be made.

Pediatric acquired subglottic stenosis: Associated costs and comorbidities of 7,981 hospitalizations.

OBJECTIVES: Numerous risk factors have been characterized for acquired subglottic stenosis (ASGS) in the pediatric population. This analysis explores the comorbidities of hospitalized ASGS patients in the United States and associated costs and length of stay (LOS). METHODS: A retrospective analysis of the Kids' Inpatient Database (KID) from 2009 to 2012 for inpatients ≤ 20 years of age who were diagnosed with ASGS. International Classification of Diseases, Clinical Modification, Version 9 diagnosis codes were used to extract diagnoses of interest from 14, 045, 425 weighted discharges across 4179 hospitals in the United States. An algorithm was created to identify the most common co-diagnoses and subsequently evaluated for total charges and LOS. RESULTS: ASGS was found in 7981 (0.06%) of total discharges. The mean LOS in discharges with ASGS is 13.11 days while the mean total charge in discharges with ASGS is $114,625; these values are significantly greater in discharges with ASGS than discharges without ASGS. Patients with ASGS have greater odds of being co-diagnosed with gastroesophageal reflux, Trisomy 21, other upper airway anomalies and asthma, while they have lower odds of being diagnosed with prematurity and dehydration. Aside from Trisomy 21 and asthma, hospitalizations of ASGS patients with the aforementioned comorbidities incurred a greater LOS and mean total charge. CONCLUSION: Our analysis identifies numerous comorbidities in children with ASGS that are associated with increased resource utilization amongst US hospitalizations. The practicing otolaryngologist should continue to advocate interdisciplinary care and be aware of the need for future controlled studies that investigate the management of such comorbidities.

Use of Prescription Assistance Programs After the Affordable Health Care Act.

BACKGROUND: Insurance coverage in the United States seems to be in a state of unrest. The 2010 passage of the Patient Protection and Affordable Health Care Act (ACA) extended health insurance coverage to roughly 32 million people. An increase in the number of people with health insurance benefits raised the question of whether prescription assistance programs (PAPs) would still be used after ACA implementation. OBJECTIVE: To evaluate the use of PAPs following the implementation of the ACA insurance mandate. METHODS: Health insurance was not required by the ACA until January 2014, so we retrospectively examined the use of drug company-sponsored PAPs before and after the ACA implementation. Since each PAP had its own qualifying criteria, any person who used a PAP through the assistance of NeedyMeds and its PAPTracker between the years of 2011 and 2016 were included for analysis. Data were pulled by NeedyMeds from the PAPTracker software, which produces completed PAP applications from drug manufacturer forms for PAPs. The number of PAP orders, number of unique patient orders, and annual patient prescription savings were assessed. RESULTS: Between 2011 and 2013, there was an average of 4.2 annual PAP orders per patient; however, annual PAP orders decreased to 3.1 per patient between 2014 and 2016 (P < 0.001). PAP orders declined by an average of 3.0% per month between 2014 and 2016 (P < 0.001), and average prescription savings per order increased from $870.40 before the ACA to $1,086.40 after ACA implementation (P = 0.0024). Patients saved an average of over $3,000 on prescriptions annually with the use of PAPs after the ACA mandate. CONCLUSIONS: Although health care reform is inevitable, our study showed that PAPs remain important to help cover prescription drug costs for eligible patients, even with invariable changes to health insurance, including a health insurance requirement. While the ACA may have been an important step forward in extending health insurance coverage to millions, PAPs are still used to help U.S. patients obtain their medications at no cost or very low cost. These programs will most likely remain relevant until other approaches are taken to help alleviate the effects of increasing drug prices in the United States. DISCLOSURES: No outside funding supported this research. The authors have no relevant financial or nonfinancial relationships to disclose. Study concept and design were contributed by Khan, Lerchenfeldt, and Karabon. Khan collected the data, and all authors participated in data analysis. The manuscript was primarily written by Lerchenfeldt, along with Khan and Karabon, and revised by Lerchenfeldt, along with Karabon and Khan.

Prostate Cancer Screening in Early Medicaid Expansion States.

PURPOSE: The PPACA (Patient Protection and Affordable Care Act) of 2010 included a provision to expand Medicaid by 2014. Six states and jurisdictions elected to expand Medicaid early before 2012. This provided a natural experiment to test the association between expanded insurance coverage and preventive service utilization, including prostate cancer screening. MATERIALS AND METHODS: Using the 2012 and 2014 BRFSS (Behavioral Risk Factor Surveillance System) surveys we identified men 40 to 64 years old who reported prostate specific antigen testing in the preceding 12 months. Sociodemographic and access to care variables were extracted. Income was stratified by the relationship to Medicaid eligibility and the federal poverty level (less than 138%, 138% to 400% and greater than 400%). The weighted prevalence of prostate specific antigen was estimated. Multivariable logistic regression models were used to evaluate factors associated with prostate specific antigen screening. Interaction analysis for Medicaid expansion was performed. RESULTS: Among 158,103 respondents individuals in nonexpansion states had the highest incidence of prostate specific antigen screening. Nationally screening decreased between 2011 and 2013 (OR 0.87, 95% CI 0.83-0.91). In only early expansion states there was a 3% absolute increase in screening among men in the less than 138% federal poverty level, which was associated with expansion status (pinteraction = 0.04). Increased screening in early expansion states was also seen in men who were 55 to 59 years old, nonHispanic African American, Hispanic, previously married, not high school graduates and current smokers. CONCLUSIONS: Between 2011 and 2013 there were national declines in prostate cancer screening. However, there was significant narrowing of the gap in prostate specific antigen screening between higher and low income men in Medicaid early expansion states. This may reflect improved access to preventive services among populations with historic barriers to care.

Generalizability of the Prostate Cancer Intervention Versus Observation Trial (PIVOT) Results to Contemporary North American Men with Prostate Cancer.

The Prostate Cancer Intervention Versus Observation Trial (PIVOT) concluded that radical prostatectomy (RP) offered no survival benefit compared with observation in men with clinically localized prostate cancer (PCa). We identified patients within the National Cancer Database (NCDB) for the period 2004-2012 who met the inclusion criteria of PIVOT (ie, histologically confirmed PCa, clinical stage T1-2NxM0, prostate-specific antigen <50 ng/ml, age <75 yr, estimated life expectancy >10 yr, and undergoing RP or observation as initial treatment within 12 mo of diagnosis) to confirm the generalizability of the PIVOT results to the US population. Life expectancy was calculated using the US Social Security Administration life tables and was adjusted for comorbidities at diagnosis. Compared with PIVOT, men in the NCDB were younger (mean age 60.3 vs 67.0 yr) and healthier (Charlson-Deyo comorbidity index of 0: 93% vs 56%; both p < 0.001). Furthermore, 42% of men randomized to receive RP in PIVOT harbored D'Amico low-risk PCa, whereas 32% of men undergoing RP in the NCDB had low-risk disease. Our findings were confirmed in a sensitivity analysis including men regardless of life expectancy but satisfying all other inclusion criteria of PIVOT. Given that the NCDB represents nearly 70% of all incident cancers diagnosed in the United States, our data provide further evidence that PIVOT results may not be generalizable to contemporary clinical practice. PATIENT SUMMARY: We observed that men diagnosed with clinically localized prostate cancer within the National Cancer Database (2004-2012) were younger, healthier, and more likely to have radical prostatectomy for higher risk disease than men in the Prostate Cancer Intervention Versus Observation Trial (PIVOT), raising questions about the applicability of PIVOT conclusions to the contemporary US population.