Modeling the Cost Savings of Continuous Pulse Oximetry and Capnography Monitoring of United States General Care Floor Patients Receiving Opioids Based on the PRODIGY Trial.

INTRODUCTION: Despite the high incidence of respiratory depression on the general care floor and evidence that continuous monitoring improves patient outcomes, the cost-benefit of continuous pulse oximetry and capnography monitoring of general care floor patients remains unknown. This study modeled the cost and length of stay savings, investment break-even point, and likelihood of cost savings for continuous pulse oximetry and capnography monitoring of general care floor patients at risk for respiratory depression. METHODS: A decision tree model was created to compare intermittent pulse oximetry versus continuous pulse oximetry and capnography monitoring. The model utilized costs and outcomes from the PRediction of Opioid-induced respiratory Depression In patients monitored by capnoGraphY (PRODIGY) trial, and was applied to a modeled cohort of 2447 patients receiving opioids per median-sized United States general care floor annually. RESULTS: Continuous pulse oximetry and capnography monitoring of high-risk patients is projected to reduce annual hospital cost by $535,531 and cumulative patient length of stay by 103 days. A 1.5% reduction in respiratory depression would achieve a break-even investment point and justify the investment cost. The probability of cost saving is ≥ 80% if respiratory depression is decreased by ≥ 17%. Expansion of continuous monitoring to high- and intermediate-risk patients, or to all patients, is projected to reach a break-even point when respiratory depression is reduced by 2.5% and 3.5%, respectively, with a ≥ 80% probability of cost savings when respiratory depression decreases by ≥ 27% and ≥ 31%, respectively. CONCLUSION: Compared to intermittent pulse oximetry, continuous pulse oximetry and capnography monitoring of general care floor patients receiving opioids has a high chance of being cost-effective. TRIAL REGISTRATION: www.clinicaltrials.gov , Registration ID: NCT02811302.

A Clinical and Budgetary Impact Analysis of Introducing Sugammadex for Routine Reversal of Neuromuscular Blockade in a Hypothetical Cohort in the US.

INTRODUCTION: Sugammadex rapidly reverses the effects of rocuronium- and vecuronium-induced neuromuscular blockade (NMB), offering a more complete and predictable NMB recovery than cholinesterase inhibitors. Despite clinical benefits, cost pressures on hospital budgets influence the choice of the NMB reversal method. This study evaluated clinical and healthcare system payer's budget impacts associated with sugammadex in the US for routine reversal of moderate or deep rocuronium- or vecuronium-induced NMB in adults undergoing surgery. METHODS: A 1-year decision analytic model was constructed reflecting a set of procedures using rocuronium or vecuronium that resulted in moderate or deep NMB at the end of surgery. Two scenarios were considered for a hypothetical cohort of 100,000 patients: without sugammadex versus with sugammadex. Comparators included neostigmine (+glycopyrrolate) and no neuromuscular blocking agents (NMBAs). Total costs (in 2019 US dollars) to a healthcare system [net of costs of reversal agents and overall cost offsets via reduction in postoperative pulmonary complications (PPC)] were compared. RESULTS: A total of 9971 surgical procedures utilized rocuronium or vecuronium, resulting in moderate (91.0% of cases) or deep (9.0%) blockade at the end of surgeries. In the with sugammadex scenario, sugammadex replaced neostigmine in 4156 of 9585 procedures versus the without sugammadex scenario that used only neostigmine for NMB reversal. Introducing sugammadex reduced PPC events by 12% (58 cases) among the modeled procedures, leading to a budget impact of -$3,079,703 (-$309 per modeled procedure, or a 10.9% reduction in total costs). The results did not vary qualitatively in one-way sensitivity analyses. CONCLUSIONS: The additional costs of sugammadex for the reversal of rocuronium- or vecuronium-induced NMB could be offset by improved outcomes (i.e., reduced PPC events), and potentially lead to overall healthcare budgetary savings versus reversal with neostigmine or spontaneous recovery. This study provides insights into savings that can be obtained beyond the anesthesia budget, reducing the broader clinical and budgetary burden on the hospital.

Opioid-induced respiratory depression increases hospital costs and length of stay in patients recovering on the general care floor.

BACKGROUND: Opioid-induced respiratory depression is common on the general care floor. However, the clinical and economic burden of respiratory depression is not well-described. The PRediction of Opioid-induced respiratory Depression In patients monitored by capnoGraphY (PRODIGY) trial created a prediction tool to identify patients at risk of respiratory depression. The purpose of this retrospective sub-analysis was to examine healthcare utilization and hospital cost associated with respiratory depression. METHODS: One thousand three hundred thirty-five patients (N = 769 United States patients) enrolled in the PRODIGY trial received parenteral opioids and underwent continuous capnography and pulse oximetry monitoring. Cost data was retrospectively collected for 420 United States patients. Differences in healthcare utilization and costs between patients with and without ≥1 respiratory depression episode were determined. The impact of respiratory depression on hospital cost per patient was evaluated using a propensity weighted generalized linear model. RESULTS: Patients with ≥1 respiratory depression episode had a longer length of stay (6.4 ± 7.8 days vs 5.0 ± 4.3 days, p = 0.009) and higher hospital cost ($21,892 ± $11,540 vs $18,206 ± $10,864, p = 0.002) compared to patients without respiratory depression. Patients at high risk for respiratory depression, determined using the PRODIGY risk prediction tool, who had ≥1 respiratory depression episode had higher hospital costs compared to high risk patients without respiratory depression ($21,948 ± $9128 vs $18,474 ± $9767, p = 0.0495). Propensity weighted analysis identified 17% higher costs for patients with ≥1 respiratory depression episode (p = 0.007). Length of stay significantly increased total cost, with cost increasing exponentially for patients with ≥1 respiratory depression episode as length of stay increased. CONCLUSIONS: Respiratory depression on the general care floor is associated with a significantly longer length of stay and increased hospital costs. Early identification of patients at risk for respiratory depression, along with early proactive intervention, may reduce the incidence of respiratory depression and its associated clinical and economic burden. TRIAL REGISTRATION: ClinicalTrials.gov , NCT02811302 .

Early Surgery Confers 1-Year Mortality Benefit in Hip-Fracture Patients.

BACKGROUND: To evaluate the relationship between surgical timing and 1-year mortality in patients requiring hip fracture repair. METHODS: We analyzed all 720 patients (>65 years) who had hip fracture surgery between March 2005 and February 2015, identifying patients by ICD-9 diagnosis and procedure codes using electronic data query. Mortality data were obtained from the institutional database, state and Social Security Death Indices. The relationship between surgical timing (defined as the interval from admission to the start of surgery) and 1-year mortality was assessed using a multivariable logistic regression, adjusting for baseline clinical status and surgical factors. RESULTS: Among the 720 patients, 159 patients (22%) died within 1 year. The median time from admission to surgery was 30 hours. A linear relationship between the surgical timing and 1-year mortality was demonstrated. Delaying surgery was significantly associated with increased 1-year mortality, odds ratio 1.05 (95% CI: 1.02-1.08) per 10-hour delay (P = 0.001). CONCLUSIONS: A linear relationship was observed between surgical timing and 1-year mortality. Each 10-hour delay from admission to surgery was associated with an estimated 5% higher odds of 1-year mortality. Therefore, we suggest that hip fractures should be treated urgently similar to other time-sensitive pathology such as stroke and myocardial ischemia. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Lack of value of scheduling processes to move cases from a heavily used main campus to other facilities within a health care system.

BACKGROUND: Economically, the most important anesthesia group and operating room (OR) management decision is the choice made months before surgery of the allocated OR time (duration of the workday) for each service. Consider a health system with surgeons who practice at multiple hospitals and ambulatory surgery centers. The main campus' ORs are busy, with nearly 8 h of cases, including turnovers, per anesthetizing location per workday. The other (regional) facilities have substantial underutilized time. A surgeon wants to do one 3-hour case at the main campus and have an afternoon start. The anesthesia group's OR director could use the health systems' common OR information system to examine the surgeons' schedules at all facilities. In this study, we quantify the percentage of OR hours that can practically be off-loaded from a main campus with long duration workdays. METHODS: One year of cases were evaluated from a health system with a busy main campus, multiple (11) regional facilities with low workload per OR per day, and a common OR information system. RESULTS: The OR time was summed among surgeons meeting the following criteria: no first case start at the main campus that day; performing <4 hour of elective cases at the main campus that day; and doing at least 1 case at any of the regional facilities within the preceding or following week. The OR time potentially moveable was <0.8% (95% CI, 0.7% to 0.8%) of the total OR time used by all surgeons operating at the main campus, considerably less than the managerially important threshold of "≥ 5.0%" (P < 0.0001). The principal reason for the result was that few (10%) OR hours at the main campus were used by surgeons performing <4 hour of cases that day. To understand why so little OR time could be moved, we performed secondary analysis of different data from 21 facilities nationwide. Larger hours of cases per OR per workday (e.g., 7.8 hour at the main facility) were commonly associated with larger percentages of workdays for which single surgeons filled an OR for the day (r = 0.87 ± 0.05). CONCLUSIONS: For many health systems, investing in the software and personnel to coordinate case scheduling among facilities is unlikely to be of benefit, either operationally or financially.