Beyond incidence: Costs of complications in trauma and what it means for those who pay.

INTRODUCTION: Trauma patients have greater rates of complications than general surgery patients; however, existing surgical pay-for-performance (P4P) guidelines have yet to be adapted for trauma care. To better understand whether current P4P measures are applicable to trauma, this study used nationally representative data to determine the mortality and attributable costs associated with the presence or absence of both Centers for Medicare and Medicaid Services-recognized complications (urinary tract infections, surgical site infections [SSIs], and pneumonia) and other major trauma-related complications. METHODS: Trauma admissions were extracted from the 2008 National Inpatient Sample using primary ICD-9-CM diagnosis codes (range, 800-905, 910-939, 950-958). Patients aged 18-65 years with a duration of hospital stay of >3 days and isolated complications were included. To account for differences in patient factors, coarsened-exact matching was used to create comparable cohorts of adult patients with and without complications. Multivariable regression was then performed within matched groups to determine differences in cost and mortality, controlling for hospital characteristics and wage index. RESULTS: Of 493,372 trauma patients, 78,156 met inclusion criteria, of whom 24.4% had an isolated complication. Consistent with surgical P4P guidelines, SSI, urinary tract infections, and pneumonia had the greatest incidence (8.0%, 5.2%, and 4.4%, respectively); however, mortality in matched patients with complications was greatest for sepsis (odds ratio [OR], 9.76; 95% CI, 3.84-24.80), myocardial infarction (MI; OR, 4.21; 95% CI, 1.70-10.44) and stroke (OR, 3.02; 95% CI, 1.40-6.52). Excess costs associated with a complication were similarly greatest for sepsis (relative cost, 1.84; 95% CI, 1.57-2.17), followed by acute respiratory distress syndrome (ARDS; relative cost, 1.84; 95% CI, 1.7-1.99) and MI (relative cost, 1.73; 95% CI, 1.51-1.99). CONCLUSION: Consideration of attributable costs and mortality suggest that additional complications have a substantial impact among trauma patients, beyond the conditions used in general surgery P4P guidelines. These aspects of trauma should be prioritized to capture the influence of complications in trauma that the incidence of frequent but less costly conditions overlooks.

Assessment of racial and sex disparities in open femoral fractures.

BACKGROUND: Open femoral fractures are common; however, many factors may affect treatment protocol. We aim to assess any racial/ethnic or sex disparities associated with the definitive fixation of open femoral fractures. METHODS: ICD-9 codes from the National Trauma Data Bank (2007 to 2010) for patients greater than or equal to 18 years with open femoral fractures who underwent operative management at level I or II trauma centers were identified and analyzed. RESULTS: Of the 9,406 cases, the majority were White (61%), men (73%), and aged between 25 and 44 years (41%). The odds of definitive fixation after hospital day 2 (odds ratio [OR] .96, 95% confidence interval [CI] .82 to 1.09, P = .53) or any complication (OR .96, 95% CI .79 to 1.15, P = .69) were not associated with race/ethnicity. Men were 17% less likely to have surgery after hospital day 2 (OR .83, 95% CI .78 to .96, P < .001), and 18% more likely to have a complication (OR 1.18, 95% CI 1.03 to 1.35, P = .02). CONCLUSIONS: There are no racial/ethnic disparities associated with the timing of definitive fixation. Men are more likely to undergo fixation earlier than women; however, they are more likely to have a complication. Fixation within the first 2 hospital days may decrease complications.

Optimal time for early laparoscopic cholecystectomy for acute cholecystitis.

IMPORTANCE: There is growing evidence in support of performing early laparoscopic cholecystectomy (LC) for acute cholecystitis. However, the definition of early LC varies from 0 through 10 days depending on the research protocol. The optimum time to perform early LC is still unclear. OBJECTIVES: To determine whether outcomes after early LC for acute cholecystitis vary depending on time from presentation to surgery and to determine the optimum time to perform LC for acute cholecystitis. DESIGN, SETTING, AND PARTICIPANTS: We performed a retrospective review of prospectively collected data from the Nationwide Inpatient Sample (NIS) for 2005 through 2009. The population-based sample included 95,523 adults (18 years and older) who underwent LC within 10 days of presentation for acute cholecystitis. INTERVENTIONS: Patients were categorized and analyzed in 2 ways based on length of time from presentation to surgery. First, patients were categorized into 3 groups: 0 through 1 day, 2 through 5 days, and 6 through 10 days. Second, we compared outcomes for each incremental preoperative day (days 0-5). MAIN OUTCOMES AND MEASURES: Outcomes of interest were mortality, length of stay, complications, and cost. Propensity score matching and generalized linear modeling were used. The hypothesis being tested was formulated after data collection was complete. RESULTS: A total of 95,523 patients were selected. After matching the 3 groups based on propensity scores, patients who underwent surgery during days 2 through 5 and days 6 through 10 had increasingly worse outcomes when compared with those undergoing surgery on days 0 through 1. The odds of mortality were 1.26 (95% CI, 1.00-1.58) and 1.93 (95% CI, 1.38-2.68), and the odds of postoperative infections were 0.88 (95% CI, 0.69-1.12) and 1.53 (95% CI, 1.05-2.23) for days 2 through 5 and days 6 through 10, respectively. Adjusted mean hospital cost increased from $8974 (days 0-1) to $17,745 (days 6-10). Analysis by each incremental day revealed the optimal time of surgery to be within the first 48 hours of presentation. CONCLUSIONS AND RELEVANCE: Laparoscopic cholecystectomy performed within 2 days of presentation of acute cholecystitis yielded the best outcomes and lowest costs. Although causality could not be established, delaying LC was associated with more complications, higher mortality, and higher costs.

African-American Men with Low-Risk Prostate Cancer: Modern Treatment and Outcome Trends.

OBJECTIVE: To investigate the clinical characteristics and treatment patterns for African-American (AA) men with low-risk prostate cancer (PCa) using a national, population-based dataset. METHODS: We conducted a retrospective review of the Surveillance Epidemiology and End Results database 2004-2008. AA men aged ≥40 years with low-risk PCa were identified. For comparison, white men were selected using the same selection criteria. We reviewed all recorded treatment modalities. Definitive treatment (DT) was defined as undergoing radiotherapy or prostatectomy. RESULTS: Overall, 7246 AA men and 47,154 white men met the criteria. Most of the patients had PSA level between 4.1 and 6.9 ng/mL (56.2 %) and received DT (76 %). Black men were younger (mean age: 62(±8) vs. 65(±10) years), less likely to receive DT (adjusted odds ratio (AOR), 0.71 [0.67-0.76]), and of those receiving DT, less likely to undergo prostatectomy (AOR, 0.58 [0.54-0.62]). Patients receiving DT had lower crude cancer-specific and overall mortality (0.17 vs. 0.41 % and 2.9 vs. 7.8 %, p value < 0.001, respectively, among blacks). The difference in overall mortality was largest among ≥ 75 years (5.6 vs. 18.2 %). Across age groups, blacks had higher all-cause mortality (AOR, 1.45 [1.13-1.87] and 1.56[1.31-1.86] for <65 and ≥ 65 years, respectively). CONCLUSION: Our study of a large modern cohort of men with low-risk PCa demonstrates significant lower receipt of DT, lower receipt of prostatectomy among those receiving DT, and lower survival for black men compared to their white counterparts. Older men were less likely to receive DT. Patients who received DT had better survival. The survival difference was most striking among the elderly.

Incremental Cost of Emergency Versus Elective Surgery.

OBJECTIVE: To determine hospital costs and the adjusted risk of death associated with emergent versus elective surgery. BACKGROUND: Emergency surgery has a higher cost and worse outcomes compared with elective surgery. However, no national estimates of the excess burden of emergency surgery exist. METHODS: Nationwide Inpatient Sample (NIS) data from 2001 to 2010 were analyzed. Patients aged 18 years or older who underwent abdominal aortic aneurysm repair, coronary artery bypass graft, or colon resection for neoplasm were included. Using generalized linear models with propensity scores, cost differences for emergent versus elective admission were calculated for each procedure. Multivariable logistic regression was performed to investigate the adjusted odds of mortality comparing elective and emergent cases. Discharge-level weights were applied to analyses. RESULTS: A total of 621,925 patients, representing a weighted population of 3,057,443, were included. The adjusted mean cost difference for emergent versus elective care was $8741.22 (30% increase) for abdominal aortic aneurysm repair, $5309.78 (17% increase) for coronary artery bypass graft, and $7813.53 (53% increase) for colon resection. If 10% of the weighted estimates of emergency procedures had been performed electively, the cost benefit would have been nearly $1 billion, at $996,169,160 (95% confidence interval [CI], $985,505,565-$1,006,834,104). Elective surgery patients had significantly lower adjusted odds of mortality for all procedures. CONCLUSIONS: Even a modest reduction in the proportion of emergent procedures for 3 conditions is estimated to save nearly $1 billion over 10 years. Preventing emergency surgery through improved care coordination and screening offers a tremendous opportunity to save lives and decrease costs.

National cost of trauma care by payer status.

BACKGROUND: Several studies have described the burden of trauma care, but few have explored the economic burden of trauma inpatient costs from a payer's perspective or highlighted the differences in the average costs per person by payer status. The present study provides a conservative inpatient national trauma cost estimate and describes the variation in average inpatient trauma cost by payer status. METHODS: A retrospective analysis of patients who had received trauma care at hospitals in the Nationwide Inpatient Sample from 2005-2010 was conducted. Our sample patients were selected using the appropriate "International Classification of Diseases, Ninth Revision, Clinical Modification" codes to identify admissions due to traumatic injury. The data were weighted to provide national population estimates, and all cost and charges were converted to 2010 US dollar equivalents. Generalized linear models were used to describe the costs by payer status, adjusting for patient characteristics, such as age, gender, and race, and hospital characteristics, such as location, teaching status, and patient case mix. RESULTS: A total of 2,542,551 patients were eligible for the present study, with the payer status as follows: 672,960 patients (26.47%) with private insurance, 1,244,817 (48.96%) with Medicare, 262,256 (10.31%) with Medicaid, 195,056 (7.67%) with self-pay, 18,506 (0.73%) with no charge, and 150,956 (5.94%) with other types of insurance. The estimated yearly trauma inpatient cost burden was highest for Medicare at $17,551,393,082 (46.79%), followed by private insurance ($10,772,025,421 [28.72%]), Medicaid ($3,711,686,012 [9.89%], self-pay ($2,831,438,460 [7.55%]), and other payer types ($2,370,187,494 [6.32%]. The estimated yearly trauma inpatient cost burden was $274,598,190 (0.73%) for patients who were not charged for their inpatient trauma treatment. Our adjusted national inpatient trauma yearly costs were estimated at $37,511,328,659 US dollars. Privately insured patients had a significantly higher mean cost per person than did the Medicare, Medicaid, self-pay, or no charge patients. CONCLUSIONS: The results of the present study have demonstrated that the distribution of trauma burden across payers is significantly different from that of the overall healthcare system and suggest that although the burden of trauma is high, the burden of self-pay or nonreimbursed inpatient services is actually lower than that of overall medical care.

Regional variations in cost of trauma care in the United States: who is paying more?

BACKGROUND: The study of regional variations in costs of care has been used to identify areas of savings for several diseases and conditions. This study investigates similar potential regional differences in the cost of adult trauma care using an all-payer, nationally representative sample. METHODS: Trauma patients aged 18 to 64 years in the 2006-2008 Nationwide Inpatient Sample were identified using International Classification of Diseases, 9th Revision, Clinical Modification codes. Those with isolated diagnoses for five index conditions (ICs): blunt splenic injury, liver injury, tibia fracture, moderate traumatic brain injury, and pneumothorax/hemothorax were selected. Cost was estimated from charges using a cost-to-charge ratio. Generalized linear modeling was used to compare the mean cost for treating these ICs between US regions (Northeast, South, Midwest, and West), adjusting for hospital factors (size, teaching status, and location), patient demographics, injury severity, length of stay, Charlson comorbidity index, local wage index, and payer. Relative mean cost (RC) was calculated using Northeast as the reference, and sampling weights were applied to obtain regional estimates. Differences in adjusted mortality between regions were also assessed. RESULTS: Adjusted relative costs were estimated for 62,678 patients (South: 28,536; West: 12,975; Midwest: 11,450; and Northeast: 9,717). Mean costs for liver injury were 22%higher in the Midwest compared with the Northeast (RC: 1.22; 95%confidence interval [CI]: 1.10-1.35). Similarly higher costs were seen with other regions and ICs (RC for blunt splenic injury in the South: 1.18; 95% CI: 1.07-1.31; RC for pneumothorax/hemothorax in the West: 1.31; 95% CI: 1.22-1.41). No differences in adjusted mortality by region were noted overall. CONCLUSION: Even after controlling for factors known to influence medical care cost, as well as controlling for geographic differences in pricing, significant regional differences exist in the cost of trauma care. Exploring these variations may assist in identifying potential areas for cost savings.