Estimating the cost of skin cancer detection by dermatology providers in a large health care system.

BACKGROUND: Data on the cost and efficiency of skin cancer detection through total body skin examination are scarce. OBJECTIVE: To determine the number needed to screen (NNS) and biopsy (NNB) and cost per skin cancer diagnosed in a large dermatology practice in patients undergoing total body skin examination. METHODS: This is a retrospective observational study. RESULTS: During 2011-2015, a total of 20,270 patients underwent 33,647 visits for total body skin examination; 9956 lesion biopsies were performed yielding 2763 skin cancers, including 155 melanomas. The NNS to detect 1 skin cancer was 12.2 (95% confidence interval [CI] 11.7-12.6) and 1 melanoma was 215 (95% CI 185-252). The NNB to detect 1 skin cancer was 3.0 (95% CI 2.9-3.1) and 1 melanoma was 27.8 (95% CI 23.3-33.3). In a multivariable model for NNS, age and personal history of melanoma were significant factors. Age switched from a protective factor to a risk factor at 51 years of age. The estimated cost per melanoma detected was $32,594 (95% CI $27,326-$37,475). LIMITATIONS: Data are from a single health care system and based on physician coding. CONCLUSION: Melanoma detection through total body skin examination is most efficient in patients ≥50 years of age and those with a personal history of melanoma. Our findings will be helpful in modeling the cost effectiveness of melanoma screening by dermatologists.

Intensive care unit drug costs in the context of total hospital drug expenditures with suggestions for targeted cost containment efforts.

PURPOSE: To assess costs of intensive care unit (ICU) related pharmacotherapy relative to hospital drug expenditures, and to identify potential targets for cost-effectiveness investigations. We offer the unique advantage of comparing ICU drug costs with previously published data a decade earlier to describe changes over time. MATERIALS AND METHODS: Financial transactions for all ICU patients during fiscal years (FY) 2009-2012 were retrieved from the hospital's data repository. ICU drug costs were evaluated for each FY. ICU departments' charges were also retrieved and calculated as percentages of total ICU charges. RESULTS: Albumin, prismasate (dialysate), voriconazole, factor VII and alteplase denoted the highest percentages of ICU drug costs. ICU drug costs contributed to an average of 31% (SD 1.0%) of the hospital's total drug costs. ICU drug costs per patient day increased by 5.8% yearly versus 7.8% yearly for non-ICU drugs. This rate was higher for ICU drugs costs at 12% a decade previous. Pharmacy charges contributed to 17.7% of the total ICU charges. CONCLUSIONS: Growth rates of costs per year have declined but still drug expenditures in the ICU are consistently a significant driver in this resource intensive environment with a high impact on hospital drug expenditures.

Cost-identification analysis of total laryngectomy: an itemized approach to hospital costs.

OBJECTIVES: To understand the contribution of intraoperative and postoperative hospital costs to total hospital costs, examine the costs associated with specific hospital services in the postoperative period, and recognize the impact of patient factors on hospital costs. STUDY DESIGN: Case series with chart review. SETTING: Large tertiary care teaching hospital system. SUBJECTS AND METHODS: Using the Pittsburgh Head and Neck Organ-Specific Database, 119 patients were identified as having total laryngectomy with bilateral selective neck dissection and primary closure from 1999 to 2009. Cost data were obtained for 112 patients. Costs include fixed and variable costs, adjusted to 2010 US dollars using the Consumer Price Index. RESULTS: Mean total hospital costs were $29,563 (range, $10,915 to $120,345). Operating room costs averaged 24% of total hospital costs, whereas room charges, respiratory therapy, laboratory, pharmacy, and radiology accounted for 38%, 14%, 8%, 7%, and 3%, respectively. Median length of stay was 9 days (range, 6-43), and median Charlson comorbidity index score was 8 (2-16). Patients with ≥1 day in the intensive care unit had significantly higher hospital costs ($46,831 vs $24,601, P < .01). The authors found no significant cost differences with stratification based on previous radiation therapy ($27,598 vs $29,915 with no prior radiation, P = .62) or hospital readmission within 30 days ($29,483 vs $29,609 without readmission, P = .97). CONCLUSION: This is one of few studies in surgery and the first in otolaryngology to analyze hospital costs for a relatively standardized procedure. Further work will include cost analysis from multiple centers with investigation of global cost drivers.

Patient-associated risk factors for acquisition of methicillin-resistant Staphylococcus aureus in a tertiary care hospital.

BACKGROUND: Determining risk factors for acquisition of methicillin-resistant Staphylococcus aureus (MRSA) in hospitals is important for defining infection-control measures that may lead to fewer hospital-acquired infections. OBJECTIVE: To determine patient-associated risk factors for acquisition of MRSA in a tertiary care hospital with the goal of identifying modifiable risk factors. METHODS: A retrospective matched case-control study was performed. Case patients who acquired MRSA during hospitalization and 2 matched control patients were selected among inpatients admitted to target units during the period from 2001 through 2008. The odds of exposure to potential risk factors were compared between case patients and control patients, using matched univariate conditional logistic regression. A single multivariate conditional logistic regression model identifying independent patient-specific risk factors was generated. RESULTS: A total of 451 case patients and 866 control patients were analyzed. Factors positively associated with MRSA acquisition were as follows: target unit stay before index culture; primary diagnosis of respiratory disease, digestive tract disease, injury or trauma, or other diagnosis compared with cardiocirculatory disease; peripheral vascular disease; mechanical ventilation with pneumonia; ventricular shunting or ventriculostomy; and ciprofloxacin use. Factors associated with decreased risk were receipt of a solid-organ transplant and use of penicillins, cephalosporins, rifamycins, daptomycin or linezolid, and proton pump inhibitors. CONCLUSION: Among the factors associated with increased risk, few are modifiable. Patients with at-risk conditions could be targeted for intensive surveillance to detect acquisition sooner. The association of MRSA acquisition with target unit exposure argues for rigorous application of hand hygiene, appropriate barriers, environmental control, and strict aseptic technique for all procedures performed on such patients. Our findings support focusing efforts to prevent MRSA transmission and restriction of ciprofloxacin use.

Improved outcomes with routine respiratory therapist evaluation of non-intensive-care-unit surgery patients.

BACKGROUND: Respiratory therapist (RT) driven protocols decrease ventilator days and resource utilization in the intensive care unit (ICU). Protocols have been studied in non-ICU settings, but their effect on mortality has been incompletely studied. METHODS: In our neurosurgery step-down, trauma/surgery step-down, and trauma/surgery general units we initiated an RT-driven evaluate-and-treat protocol that included a standardized, quantitative, RT-driven patient-assessment scale and protocolized interventions. Before and after initiation of the protocol we collected data on non-ICU patients at risk for pulmonary complications. RESULTS: The patient groups before (n = 2,230) and after (n = 2,805) protocol initiation were well matched in age, sex, Charlson score, and admitting service. Most of the patients, whether assessed by a physician or an RT, were deemed to have low risk of pulmonary complications and did not require any respiratory treatments. The number of respiratory treatments increased after protocol initiation, but the patients who received respiratory treatments after protocol initiation had shorter ICU stay and hospital stay, and lower total hospital costs than those who received respiratory treatments before protocol initiation. There was a nonsignificant trend toward lower mortality after protocol initiation. CONCLUSIONS: Our RT-evaluate-and-treat protocol for non-ICU surgery patients was associated with more patients receiving respiratory treatments but decreased ICU and hospital stay and lower total hospital costs. Routine RT-driven assessment of non-ICU patients may reduce pulmonary complications in high-risk patients.

Economic burden of not recognizing panic disorder in the emergency department.

The objective of this cohort study was to examine the diagnostic patterns and resource utilization of patients presenting to the Emergency Department with chest pain of unknown origin who may be experiencing a panic attack. Patients were excluded if they had coronary artery disease. In the 155 patients meeting study criteria, unspecified chest pain (78%) was the most common diagnostic code assigned. Total charges for the index hospitalization were $1,263,391 (median/visit = $7340). During the 1-year follow-up, 41% of patients had at least one repeat hospital visit and generated $1.6 million in charges. Patients on Medicare or Medicaid were more likely to have multiple hospital visits during the follow-up (odds ratio = 11.7). In conclusion, Emergency Department patients admitted with non-cardiac chest pain account for a significant amount of hospital resource use.

Outcomes and costs of abciximab versus eptifibatide for percutaneous coronary intervention.

BACKGROUND: Patients undergoing percutaneous coronary intervention (PCI) with stent placement are often prescribed glycoprotein IIb/IIIa inhibitors. However, drug selection is often based on clinicians' preference and cost because few studies have directly compared abciximab and eptifibatide. OBJECTIVE: To compare clinical outcomes and total hospital costs of abciximab and eptifibatide in patients undergoing stent placement during PCI in a real-world setting. METHODS: A retrospective cohort analysis was conducted of 960 patients administered abciximab or eptifibatide for intracoronary stent placement between 1999 and 2001 at a tertiary care hospital. The primary outcome was bleeding, defined as major, moderate, or minor according to published criteria. Secondary outcomes included in-hospital death, myocardial infarction, revascularization, and the triple composite endpoint of those outcomes, thrombocytopenia, length-of-stay, and total hospital costs. Pearson's chi(2) analysis, Fisher's exact test, and ANOVA were used for statistical analysis. RESULTS: The frequency of bleeding complications based on severity was similar between abciximab and eptifibatide: major (2.4% vs 2.8%), moderate (12.4% vs 10.5%), and minor (4.0% vs 3.9%), respectively (p = 0.86). Secondary clinical outcomes were also similar between groups (p > 0.05). Total costs for hospitalization were significantly greater for abciximab compared with eptifibatide ($16,383 +/- 6799 vs $14,115 +/- 6285; p < 0.001). Drug acquisition costs were also significantly greater for abciximab compared with eptifibatide ($508 +/- 159 vs $465 +/- 263; p = 0.003). CONCLUSIONS: In patients undergoing stent placement during PCI, abciximab and eptifibatide are comparable in terms of safety and effectiveness despite significant differences in hospitalization and acquisition costs.

Short-term complications and resource utilization in matched subjects after on-pump or off-pump primary isolated coronary artery bypass.

BACKGROUND: Studies suggest that patients who undergo off-pump coronary artery bypass grafting (OPCABG) have fewer short-term complications and use fewer inpatient resources than do patients who undergo standard coronary artery bypass grafting (CABG) with extracorporeal circulation. However, dissimilarity between groups in risk factors for complications has hindered interpretation of results. OBJECTIVES: To compare the prevalence of selected complications (atrial fibrillation, stroke, reoperation, and bleeding) and inpatient resource utilization (length of stay, discharge disposition, total charges) between subjects undergoing primary isolated CABG or OPCABG who were matched with respect to key risk factors. METHODS: Retrospective, causal-comparative survey conducted in 1 center for 18 months. Patients who underwent primary isolated CABG or OPCABG were matched for sex, age (within 2 years), left ventricular ejection fraction (within 0.05), and graft-patient ratio (exact match) and compared for prevalence of new-onset atrial fibrillation, stroke, reoperation within 24 hours, and bleeding. Statistical analysis included Wilcoxon and t tests for paired comparisons. RESULTS: The sample (107 matched pairs) was 63% male, with a mean age of 66 (SD 9.5) years, a mean left ventricular ejection fraction of 0.51 (SD 0.13), and a mean graft-patient ratio of 3.41 (SD 0.74). The 2 groups did not differ significantly in New York Heart Association class (P = .43), Acute Physiology and Chronic Health Evaluation III score (P = .22), postoperative beta-blocker use (P = .73), or comorbid conditions. None of the complications examined differed significantly between pairs. CONCLUSION: Patients with comparable risk profiles have similar prevalences of selected complications after CABG and OPCABG.

Resource utilization related to atrial fibrillation after coronary artery bypass grafting.

BACKGROUND: Studies of resource utilization by patients with new-onset atrialfibrillation after coronary artery bypass grafting have addressed only length of stay and bed charges. OBJECTIVE: To compare resource utilization between patients with new-onset atrial fibrillation and patients without atrialfibrillation after isolated coronary artery bypass grafting. METHODS: Retrospective review of clinical and administrative electronic databases for 720 subjects who underwent isolated coronary artery bypass grafting with cardiopulmonary bypass in 25 months at one medical center The prevalence of atrial fibrillation was determined, and resource utilization in various hospital cost centers was compared between subjects with and without atrialfibrillation. RESULTS: The prevalence of new-onset atrial fibrillation was 33.1%. Compared with subjects without atrialfibrillation, subjects with atrialfibrillation had a longer stay (5.8 +/- 2.4 vs. 4.4+/-1.2 days, P<.001), more days receiving mechanical ventilation (P =.002) and oxygen therapy (P<.001), and higher rates of readmission to the intensive care unit (4.6% vs. 0.2%, P<.001). Subjects with atrial fibrillation also had more laboratory tests (P<.001) and more days receiving cardiac drugs, heparin, diuretics, and electrolytes. Subjects with atrialfibrillation had higher total postoperative charges ($57261 +/- $17101 vs. $50905 +/- $10062, P = .001), a mean difference of $6356. The mean differences were greatest for bed charges ($1642), laboratory charges ($1215), pharmacy ($989), and respiratory care ($582). CONCLUSION: The economic impact of atrialfibrillation after coronary artery bypass grafting has been underestimated.