Complication Prevention and Cost Savings in Total Joint Arthroplasty. The Effect of Orthopedic Procedure Migration within Hospital Referral Regions in the United States.

BACKGROUND: The shift to value based total joint arthroplasty (TJA) reimbursement strategies has led to an increased focus on quality and the avoidance of poor outcomes. As a result, there has been greater encouragement for patients to undergo joint replacements in high volume centers of excellence. In this study, we examined the potential complications avoided if TJA procedure volume was shifted from poor quality (high incidence) facilities to high quality (low incidence) facilities within Hospital Referral Regions (HRRs). METHODS: Using Medicare 100% claims data linked to the Dartmouth Atlas of Health Care, we examined the clinical and cost benefits of shifting TJA procedures from low performing hospital to high performing hospitals within HRRs. RESULTS: Across all HRRs, we identified 1,878 cases of deep infection and 3,393 annual readmissions in the Medicare population that could have potentially been avoided, resulting in a mean cost savings of $41 million and $62 million, respectively, solely due to shifting procedure location from lower third performing hospitals to the upper third performing hospitals. CONCLUSIONS: Our study demonstrates that the incidence of deep infection and all-cause readmission varies widely among and within HRRs. Further, the potential reallocation of joint procedures from low quality facilities to high quality Centers of Excellence within an HRR could result in over $103 million in annual savings related to mitigated deep infections and readmissions.

Trends in Lumpectomy and Oncoplastic Breast-Conserving Surgery in the US, 2011-2016.

BACKGROUND: Oncoplastic breast surgery aims to optimize efficacy of surgical resection and cosmesis to maximize patient satisfaction; however, despite the benefits, oncoplastic techniques have not been widely adopted in the US. This study examined trends in the incidence of lumpectomy (partial mastectomy) with or without oncoplastic techniques from 2011 to 2016. METHODS: This was a retrospective analysis of claims from the Optum Clinformatics database (January 2010-March 2017). Female patients with no history of breast surgery in the prior year were categorized into three independent cohorts: isolated lumpectomy (Lx), lumpectomy with tissue transfer (LxTT), or lumpectomy with mammaplasty and/or mastopexy (LxMM). Oncoplastic techniques (in cohorts two and three) were performed at either time of the initial lumpectomy or during 90-day follow-up. RESULTS: Overall, 19,253 patients met the inclusion criteria (91.1% Lx, 5.2% LxTT, and 3.7% LxMM). Significantly fewer patients with Lx had a family history of breast cancer compared with patients with oncoplastic techniques (26.4% vs. 33.7% and 37.9%, respectively; p < 0.001). The incidence of Lx declined significantly from 2011 (92.9%) to 2016 (88.1%), while LxTT and LxMM increased from 4.2 to 7.2% and 2.8 to 4.7%, respectively (both p < 0.001). The greatest utilization of oncoplastic techniques was observed in the Pacific census division (19.2%), while lowest utilization was in the East South Central division (3.2%; p < 0.001). CONCLUSIONS: While increased adoption of oncoplastic techniques was observed, the compound annual growth rate remained below 10% and varied significantly by region. Further adoption of oncoplastic techniques is necessary to improve cosmetic outcomes and patient satisfaction following breast-conserving surgery.

Skilled Nursing Facility Star Rating, Patient Outcomes, and Readmission Risk After Total Joint Arthroplasty.

BACKGROUND: This study examined the correlation between publicly reported indicators of skilled nursing facility (SNF) quality and clinical outcomes after primary total knee arthroplasty (TKA) and total hip arthroplasty (THA). METHODS: This retrospective analysis used Medicare claims from the Centers for Medicare and Medicaid Services 100% Standard Analytic File (2014-2015) that were linked to SNF quality star ratings from the Centers for Medicare and Medicaid Services Nursing Home Compare database. Overall SNF rating and subcomponents of the rating were evaluated for correlation to 30-day and 90-day risk of readmission. Ratings were based upon a 5-star rating system (1 representing the lowest quality). Cox proportional hazards regressions controlled for age, race, census division, hospital location, comorbidities, and SNF length of stay. RESULTS: A total of 9418 SNFs, 58,064 TKA patients, and 26,837 THA patients met criteria. As SNF overall star rating increased from 1 to 5, incidence of all-cause 30-day readmission decreased from 6.4% to 5.0% for TKA (relative reduction [RR] 22%; P < .001) and from 9.1% to 6.2% for THA (RR 32%; P < .001). As nurse staffing rating increased, incidence of all-cause readmission decreased from 6.8% to 4.7% for the TKA cohort (30.9% RR; P < .001), and from 7.7% to 6.0% for the THA cohort (22.1% RR; P = .003). Regression analysis demonstrated that a higher star rating was associated with decreased risk of readmission (both cohorts P < .05). CONCLUSIONS: For patients undergoing TKA or THA, the overall SNF star rating, nurse staffing ratios, and physical therapy intensity were significantly correlated with risk of readmission within 30 days of SNF admission.

The Payer and Patient Cost Burden of Open Breast Conserving Procedures Following Percutaneous Breast Biopsy.

OBJECTIVES: Percutaneous core-needle biopsy (PCNB) is the standard of care to biopsy and diagnose suspicious breast lesions. Dependent on histology, many patients require additional open procedures for definitive diagnosis and excision. This study estimated the payer and patient out-of-pocket (OOP) costs, and complication risk, among those requiring at least 1 open procedure following PCNB. METHODS: This retrospective study used the Truven Commercial database (2009-2014). Women who underwent PCNB, with continuous insurance, and no history of cancer, chemotherapy, radiation, or breast surgery in the prior year were included. Open procedures were defined as open biopsy or lumpectomy. Study follow-up ended at chemotherapy, radiation, mastectomy, or 90 days-whichever occurred first. RESULTS: In total, 143 771 patients (mean age 48) met selection criteria; 85.1% underwent isolated PCNB, 12.4% one open procedure, and 2.5% re-excision. Incidence of complications was significantly lower among those with PCNB alone (9.2%) vs 1 open procedure (15.6%) or re-excision (25.3%, P < .001). Mean incremental commercial payments were US $13 190 greater among patients with 1 open procedure vs PCNB alone (US $17 125 vs US $3935, P < .001), and US $4767 greater with re-excision (US $21 892) relative to 1 procedure. Mean patient OOP cost was US $858 greater for 1 open procedure vs PCNB alone (US $1527 vs US $669), and US $247 greater for re-excision vs 1 procedure. CONCLUSIONS: A meaningful proportion of patients underwent open procedure(s) following PCNB which was associated with increased complication risk and costs to both the payer and the patient. These results suggest a need for technologies to reduce the proportion of cases requiring open surgery and, in some cases, re-excision.

Clinical Outcomes and 90-Day Costs Following Hemiarthroplasty or Total Hip Arthroplasty for Hip Fracture.

BACKGROUND: In the era of bundled payments, many hospitals are responsible for costs from admission through 90 days postdischarge. Although bundled episodes for hip fracture will have a separate target price for the bundle, little is known about the 90-day resource use burden for this patient population. METHODS: Using Medicare 100% Standard Analytic Files (2010-2014), we identified patients undergoing hemiarthroplasty or total hip arthroplasty (THA). Patients were aged 65 and older with admitting diagnosis of closed hip fracture, no concurrent fractures of the lower limb, and no history of hip surgery in the prior 12 months baseline. Continuous Medicare-only enrollment was required. Complications, resource use, and mortality from admission through 90 days following discharge (follow-up) were summarized. RESULTS: Four cohorts met selection criteria for analysis: (1) hemiarthroplasty diagnosis-related group (DRG) 469 (N = 19,634), (2) hemiarthroplasty DRG 470 (N = 77,744), (3) THA DRG 469 (N = 1686), and (4) THA DRG 470 (N = 9314). All-cause mortality during the study period was 51.6%, 29.5%, 48.1%, and 24.9% with mean 90-day costs of $28,952, $19,243, $29,763, and $18,561, respectively. Most of the patients waited 1 day from admission to surgery (41%-51%). Incidence of an all-cause complication was approximately 70% in each DRG 469 cohort and 14%-16% in each DRG 470 cohort. CONCLUSION: This study confirms patients with hip fracture are a costly subpopulation. Tailored care pathways to minimize post-acute care resource use are warranted for these patients.

Use of a saline-coupled bipolar sealer open liver resection for hepatic malignancy: Medical resource use and costs.

AIM: To evaluate outcomes associated with use of a saline coupled bipolar sealer during open partial liver resection. METHODS: This retrospective analysis utilized the United States Premier™ insurance claims database (2010-2014). Patients were selected with codes for liver malignancy and partial hepatectomy or lobectomy. Cases were defined by use the saline-coupled bipolar sealer; controls had no use. A Propensity Score algorithm was used to match one case to five controls. A deviation-based cost modeling (DBCM) approach provided an estimate of cost-effectiveness. RESULTS: One hundred and forty-four cases and 720 controls were available for analysis. Patients in the case cohort received fewer transfusions vs controls (18.1% vs 29.4%, P = 0.007). In DBCM, more patients in the case cohort experienced "on-course" hospitalizations (53.5% vs 41.9%, P = 0.009). The cost calculation showed an average savings in total hospitalization costs of $1027 for cases vs controls. In multivariate analysis, cases had lower odds of receiving a transfusion (OR = 0.44, 95%CI: 0.27-0.71, P = 0.0008). CONCLUSION: Use of a saline-coupled bipolar sealer was associated with a greater proportion of patients with an "on course" hospitalization.

Patient Comorbidity Status and Incremental Total Hospitalization Costs in Elective Orthopedic Procedures.

This study examined the correlation between patient comorbidity status, hospitalization length of stay (LOS), and cost for total knee arthroplasty (TKA), total hip arthroplasty (THA), and 1- to 3-level lumbar spinal fusion procedures. Using the Premier Perspective Database, adults older than 18 years who underwent primary unilateral TKA, THA, or spinal fusion between January 1, 2008, and June 30, 2014, were identified. Generalized linear models controlling for age, sex, region, hospital size, academic status, payor, and procedure year predicted the incremental total hospitalization cost among the sickest patients (Charlson Comorbidity Index [CCI] ≥3) vs healthy controls (CCI=0). The study cohort included 536,582 TKAs, 275,953 THAs, and 177,493 spinal fusion procedures. The percentages of patients with a CCI of 3 or greater were 5.4%, 4.7%, and 4.3%, for TKA, THA, and spinal fusion procedures, respectively. Mean (SD) LOS was longer by 0.9 (1.5), 1.4 (2.3), and 2.3 (3.8) days for patients with a CCI of 3 or greater vs 0 for TKA, THA, and spinal fusion procedures, respectively. Unadjusted total hospitalization costs were $17,512 for TKA, $18,915 for THA, and $32,932 for spinal fusion procedures; generalized linear models showed an incremental total hospitalization cost for CCI scores of 3 or greater of $2211, $3041, and $3922 vs CCI equal to 0 for each procedure type, respectively. Although representing a relatively small proportion of all patients undergoing elective orthopedic procedures, highly comorbid patients were associated with a greater total hospitalization cost burden. With the average patient comorbidity burden growing nationally, this study warrants further examination of improved standards of care for comorbid patients undergoing elective orthopedic procedures. [Orthopedics. 2016; 39(4):237-246.].

Clinical Outcomes and Costs Within 90 Days of Primary or Revision Total Joint Arthroplasty.

BACKGROUND: This study evaluated the factors and costs associated with discharge destination and readmission, within 90 days of surgery, for primary or revision total knee arthroplasty (TKA) and total hip arthroplasty (THA). METHODS: This retrospective database analysis used health care claims from the Truven MarketScan Database (2009-2013). Patients were selected if aged ≥18 years, with continuous health plan enrollment from 3-month baseline through 3-month follow-up. Logistic regression and Cox proportional hazard models were used to analyze factors associated with discharge destination and risk of readmission. Total 90-day costs were calculated for different patient pathways of care, dependent on complications, discharge destination, and readmission status. RESULTS: A total of 323,803 primary TKA, 25,354 revision TKA, 159,390 primary THA, and 17,934 revision THA cases met selection criteria. All-cause complications occurred in 2.5%, 37.2%, 2.6%, and 35.0% of each cohort. Complications, transfusions, and length of stay ≥3 days were associated with greater odds of discharge to home with home health services or skilled nursing facility (SNF) vs home under self-care (P < .001 all cohorts), whereas discharge to home with home health services or SNF was associated with greater risk of readmission (P < .05 for all cohorts except one). The ratio of total 90-day costs for the highest- (revision, SNF, readmission) vs lowest-cost (primary, home under self-care, no readmission) care pathways ranged from 1.8 to 2.2. CONCLUSION: As Medicare payment policy for total joint arthroplasty shifts toward bundling, an awareness of factors associated with outlier costs will be requisite to remain profitable.

Incidence and Costs Related to Lead Damage Occurring Within the First Year After a Cardiac Implantable Electronic Device Replacement Procedure.

BACKGROUND: Inadvertent damage to leads for transvenous pacemakers, implantable cardioverter-defibrillators, and cardiac resynchronization therapy defibrillators is an important complication associated with generator-replacement procedures. We sought to estimate the incidence and costs associated with transvenous lead damage following cardiac implantable electronic device replacement. METHODS AND RESULTS: Using the Truven Health Analytics MarketScan Commercial Research Database, we identified health care claims between 2009 and 2013 for lead damage following generator replacement. Patients were identified by claims with a procedure code for cardiac implantable electronic device replacement and then evaluated for 1 year. All follow-up visits for lead damage were identified, and incidence, risk factors, and hospitalization costs were determined. A total of 22 557 patients with pacemakers, 20 632 with implantable cardioverter-defibrillators, and 2063 with cardiac resynchronization therapy defibrillators met selection criteria. Incidence of lead damage was 0.46% for pacemaker replacement, 1.27% for implantable cardioverter-defibrillator replacement, and 1.94% for cardiac resynchronization therapy defibrillator replacement procedures (P<0.001). After adjusting for patient characteristics, patients with implantable cardioverter-defibrillators and cardiac resynchronization therapy defibrillators demonstrated risk of lead damage that was, respectively, double (hazard ratio 2.00, 95% CI 1.57-2.55) and >2.5 times (hazard ratio 2.58, 95% CI 1.73-3.83) that of patients with pacemakers. Lead revision or repair procedures were associated with increased inpatient hospitalization costs (mean $19 959 for pacemaker, $24 885 for implantable cardioverter-defibrillator, and $46 229 for cardiac resynchronization therapy defibrillator; P=0.048, Kruskal-Wallis test). CONCLUSIONS: These findings establish the first objective assessment of the incidence, risk factors, and economic burden of lead damage following cardiac implantable electronic device replacement in the United States. New care algorithms are warranted to avoid these events, which impose substantial burdens on patients, physicians, and payors.

Comparative Risk of Transfusion and Incremental Total Hospitalization Cost for Primary Unilateral, Bilateral, and Revision Total Knee Arthroplasty Procedures.

BACKGROUND: This study evaluated the comparative risk of autologous and allogenic blood transfusion, inhospital complications, and incremental total hospitalization costs for primary unilateral, simultaneous bilateral, and revision total knee arthroplasty (TKA) procedures. METHODS: Using the Premier Perspective database, we identified adults who underwent primary unilateral, simultaneous bilateral, or revision TKA procedures. Logistic regression, controlling for patient and hospital characteristics, was used to determine the risk of autologous or allogeneic blood transfusion. Controlling for the same factors, generalized linear models predicted incremental total hospitalization cost associated with transfusion. RESULTS: Between January 2008 and June 2014, 513,558 primary unilateral, 33,977 bilateral, and 32,494 revision TKA patients met selection criteria. The overall percentage receiving a transfusion was 14.1% for unilateral, 36.3% for bilateral, and 20.0% for revision procedures. Logistic regression showed patients aged >65 years, female gender, Northeastern location, large hospitals, and higher Charlson score to be significantly associated with higher transfusion risk. Although overall risk of transfusion decreased over the study period, patients with Charlson score ≥3 were at 2.27 (primary unilateral), 1.88 (bilateral), and 2.44 (revision) greater odds of transfusion compared with healthy controls (Charlson score = 0). Generalized linear models showed an incremental total hospitalization cost among those receiving a transfusion of $2477, $4235, and $8594, respectively, compared with those without transfusion. CONCLUSIONS: Transfusion risk remains a significant burden in select patient populations and procedures. The incremental cost of receiving a transfusion is significant, including not only direct costs but also staff time and increased hospital resource use.

Narrative review of the literature on adherence to disease-modifying therapies among patients with multiple sclerosis.

While no curative treatment exists for multiple sclerosis (MS), several disease-modifying therapies (DMTs) have been developed to reduce relapse rates, slow disability progression, and modify the overall disease course. However, because of the chronic nature of the disease, long-term therapy adherence can be challenging for some patients with MS. Low adherence to DMTs has been shown to be associated with higher rates of disease relapses and progression as well as with an increase in medical resource utilization. As new MS treatments are developed, a comprehensive understanding of current adherence rates and the impact of adherence on clinical and economic outcomes is of particular interest. Our objective was to conduct a review of the published literature to evaluate rates of adherence to DMTs in MS and the impact of adherence on both clinical and economic outcomes from the patient and payer perspectives. Systematic literature searches were conducted using MEDLINE, EMBASE, and the Cochrane Central Register for Controlled Trials. Studies were limited to those completed on human subjects, written in the English language, and published between May 1, 2001, and May 1, 2011. Additional inclusion criteria required that studies involve a population of patients with MS, utilize the administration of DMTs, and report a measurement of adherence. Studies reporting persistence measures (e.g., treatment discontinuation rates) or rates of switching between DMTs (with no other measure of adherence reported) were excluded if they did not also assess adherence. Among the 24 studies meeting inclusion criteria, adherence to DMTs ranged from 41% to 88%. Weighted mean adherence rates were higher for intramuscular (IM) interferon beta-1a (IFNß-1a) administered once a week (69.4%), and subcutaneous (SC) IFNß-1b administered every other day (63.8%) than for SC IFNß-1a administered 3 times a week (58.4%) and glatiramer acetate administered daily (56.8%). There was a numerically greater risk of MS relapse or disease progression among patients nonadherent to therapy versus adherent patients, with findings statistically significant in 2 of 4 studies. Additionally, 2 studies showed statistically significant reductions in inpatient or emergency room utilization and total MS-related medical costs among patients adherent to therapy compared with nonadherent patients. Higher patient out-of-pocket copayments and coinsurance were significantly associated with lower adherence to DMTs, while the use of interventional or disease therapy management programs were associated with improved adherence. Lack of medication adherence remains a problem among patients with MS. Improvements in adherence have the potential to improve patient and payer burden in terms of improved clinical outcomes and lower nonpharmacy medical resource utilization.  

The economic burden of advanced liver disease among patients with hepatitis C virus: a large state Medicaid perspective.

BACKGROUND: Chronic hepatitis C virus (HCV) may progress to advanced liver disease (ALD), including decompensated cirrhosis and/or hepatocellular carcinoma (HCC). ALD can lead to significant clinical and economic consequences, including liver transplantation. This study evaluated the health care costs associated with ALD among HCV infected patients in a Medicaid population. METHODS: Using Florida Medicaid claims data, cases were patients with at least 1 diagnosis of HCV or prescription therapy for HCV (ribavirin plus interferon, peginterferon, or interferon alfacon-1) prior to an incident ALD-related diagnosis ("index event") between 1999 and 2007. ALD-related conditions included decompensated cirrhosis, HCC, or liver transplant. A cohort of HCV patients without ALD (comparison group subjects) were matched 1-to-1 based on age, sex, and race. Baseline and follow-up were the 12 months prior to and following index, respectively; with both periods allowing for a maximum one month gap in eligibility. For both case and comparison patient cohorts, per-patient-per-eligible month (PPPM) costs were calculated as total Medicaid paid amount for each patient over their observed number of eligible months in follow-up, divided by the patient's total number of eligible months. A generalized linear model (GLM) was constructed controlling for age, race, Charlson score, alcoholic cirrhosis, and hepatitis B to explore all-cause PPPM costs between study groups. The final study group included 1,193 cases and matched comparison patients (mean age: 49 years; 45% female; 54% white, 23% black, 23% other). RESULTS: The majority of ALD-related diagnoses were for decompensated cirrhosis (92%), followed by HCC (6%) and liver transplant (2%). Cases had greater comorbidity (mean Charlson score: 3.1 vs. 2.3, P < 0.001). All-cause inpatient use up to 1-year following incident ALD diagnosis was significantly greater among cases with ALD (74% vs. 27%, P < 0.001). In the GLM, cases had 2.39 times greater total adjusted mean all-cause PPPM costs compared to the comparison group ($4,956 vs. $1,735 respectively; P < 0.001). Among cases, mean total unadjusted ALD-related costs were $1,356 PPPM, which were largely driven by inpatient costs ($1,272). CONCLUSIONS: Our results suggest that among patients diagnosed with HCV, the incremental costs of developing ALD are substantial, with inpatient stays as the main driver of these increased costs.

Incidence of venous thromboembolism among chemotherapy-treated patients with lung cancer and its association with mortality: a retrospective database study.

Cancer patients, especially those with lung cancer and undergoing chemotherapy, have an elevated risk for venous thromboembolism (VTE). This study assessed incidence, timing, and risk factors for VTE (specifically receipt of chemotherapy), along with the association between VTE and survival among lung cancer patients receiving chemotherapy. Using Florida Medicaid administrative claims data (2000-2008), patients with any diagnosis of primary lung cancer were selected. Patients with recent prior VTE and those enrolled in Medicare or an HMO were excluded. Crude rates of VTE per 100 person years were estimated, and Cox proportional hazards models were developed to assess risk factors for VTE in the lung cancer population, and the association between VTE and survival among patients undergoing chemotherapy. Of 15,749 lung cancer patients, 7,052 (2,242 receiving chemotherapy and 4,810 not receiving chemotherapy) met cohort selection criteria. The incidence of VTE was 10.8 per 100 person-years (PYs) in the chemotherapy cohort and 6.8 per 100 PYs in the non-chemotherapy cohort. Among patients on chemotherapy developing VTE, median time to occurrence was 109 days, with 61 and 82 % of patients experiencing an event within six and 12 months, respectively. In multivariate analyses, the adjusted risk of VTE was 30 % higher among patients undergoing chemotherapy. Comorbidity and the presence of a central venous catheter also were significantly associated with a greater risk of developing VTE. Moreover, patients in the chemotherapy cohort who developed VTE had a significantly faster time-to-death (adjusted hazard ratio [HR] = 1.97; 95 % CI 1.69-2.29).VTE was common among lung cancer patients, especially among patients receiving chemotherapy, with the majority of VTE events occurring within 6 months of initiation of chemotherapy. The presence of a VTE event was significantly associated with an increased risk of mortality.

A review of the costs and cost effectiveness of interventions in chronic kidney disease: implications for policy.

Given rising healthcare costs and a growing population of patients with chronic kidney disease (CKD), there is an urgent need to identify health interventions that provide good value for money. For this review, the English-language literature was searched for studies of interventions in CKD reporting an original incremental cost-utility (cost per QALY) or cost-effectiveness (cost per life-year) ratio. Published cost studies that did not report cost-effectiveness or cost-utility ratios were also reviewed. League tables were then created for both cost-utility and cost-effectiveness ratios to assess interventions in patients with stage 1-4 CKD, waitlist and transplant patients and those with end-stage renal disease (ESRD). In addition, the percentage of cost-saving or dominant interventions (those that save money and improve health) was compared across these three disease categories. A total of 84 studies were included, contributing 72 cost-utility ratios, 20 cost-effectiveness ratios and 42 other cost measures. Many of the interventions were dominant over the comparator, indicating better health outcomes and lower costs. For the three disease categories, the greatest number of dominant or cost-saving interventions was reported for stage 1-4 CKD patients, followed by waitlist and transplant recipients and those with ESRD (91%, 87% and 55% of studies reporting a dominant or cost-saving intervention, respectively). There is evidence of opportunities to lower costs in the treatment of patients with CKD, while either improving or maintaining the quality of care. In order to realize these cost savings, efforts will be required to promote and effectively implement changes in treatment practices.