Estimating the Costs of End-of-Life Care in Patients With Advanced Cancer From the Perspective of an Insurance Organization: A Cross-Sectional Study in Iran.

OBJECTIVES: Cancers are significant medical conditions that contribute to the rising costs of healthcare systems and chronic diseases. This study aimed to estimate the average costs of medical services provided to patients with advanced cancers at the end of life (EOL). METHODS: We analyzed data from the Sata insurance claim database and the Health Information System of Baqiyatallah hospital in Iran. The study included all adult decedents who had advanced cancer without comorbidities, died between March 2020 and September 2020, and had a history of hospitalization in the hospital. We calculated the average total cost of healthcare services per patient during the EOL period, including both cancer-related and noncancer-related costs. RESULTS: A total of 220 patients met the inclusion criteria. The average duration of the EOL period for these patients was 178 days, with an average total cost of $8278 (SD $5698) for men and $9396 (SD $6593) for women. Cancer-related costs accounted for 64.42% of the total costs, including inpatient and outpatient services. Among these costs, hospitalization was the primary cost driver and had the greatest impact on EOL costs. This observation was supported by the multiple linear regression model, which suggested that hospitalization in the final days of life could potentially drive costs in these patients. Notably, no specialized palliative care was provided to the patients included in this study. CONCLUSIONS: The results demonstrate that there is a significant rise in costs of care in patients receiving routine cancer care rather than optimized EOL care.

Out-of-pocket costs for commercially insured patients with localized prostate cancer.

PURPOSE: Financial toxicity is an underappreciated component of cancer survivorship. Treatment-specific out-of-pocket costs for patients undergoing localized prostate cancer treatment have not, to date, been described and may influence patient's decision making. METHODS: We performed a retrospective cohort study among commercially-insured patients in the United States with incident prostate cancer from 2013 to 2018. We captured out-of-pocket and total costs in the year following diagnosis and compared these between patients receiving radical prostatectomy, radiotherapy, and no local treatment using propensity-score weighting adjusting for patient demographics and pre-diagnosis health utilization costs. RESULTS: Among 30,360 included men [median age 59 years, 83% Charlson score 0], 15,854 underwent surgery, 5,265 radiotherapy, and 9,241 no local therapy in the year following diagnosis. In the 6-months preceding diagnosis, median overall and out-of-pocket health care costs were $2022 (interquartile range $3778) and $466 (interquartile range $781), respectively. Following propensity-score weighting, out-of-pocket costs were significantly lower for patients who received no active treatment (adjusted cost $1746, 95% confidence interval [CI] $1704-1788), followed by those who underwent surgery ($2983, 95% CI $2832-3142, P < 0.001), and those who underwent radiation ($3139, 95% CI $2939-3353, P < 0.001) in the 6-months following diagnosis. Similar patterns were seen with out-of-pocket costs 6 to 12 months following index, with overall costs, and with costs attributable to inpatient, outpatient medical, and outpatient pharmacy services. CONCLUSIONS: Among commercially insured men with incident prostate cancer, active treatment with surgery or radiotherapy was associated with significantly higher out-of-pocket costs versus those who received no treatment, with little difference observed between treatment approaches.

Estimating the Theoretical Cost Implications of Funding New Drugs Considered Not to Be Cost-Effective.

This study aims to estimate the theoretical excess expenditure that would be incurred by the Irish state-payer, should drugs be reimbursed at their original asking ("list") price rather than at a price at which the drug is considered cost-effective. In Ireland, all new drugs are evaluated by the National Centre for Pharmacoeconomics. For this study, drugs that were submitted by pharmaceutical companies from 2012 to 2017 and considered not cost-effective at list price were reviewed. A total of 43 such drugs met our inclusion criteria, and their pharmacoeconomic evaluations were further assessed. The price at which the drug could be considered cost-effective (cost-effective price) at the upper cost-effectiveness threshold used in Ireland (€ 45 000/quality adjusted life-year) was estimated for 18 drugs with an available cost-effectiveness model. Then, for each drug, the list price and cost-effective price (both per unit) were both individually applied to 1 year of national real-world drug utilization data. This allowed the estimation of the expected expenditures under the assumptions of list price paid and cost-effective price paid. The resulting theoretical excess expenditure, the expenditure at list price minus the expenditure at the cost-effective price, was estimated to be €108.2 million. This estimate is theoretical because of the confidentiality of actual drug prices. The estimation is calculated using the list price and likely overestimates the actual excess expenditure, which would reduce to zero if cost-effective prices are agreed. Nevertheless, this estimate illustrates the importance of a process to assess the value of new drugs so that potential excess drug expenditure is identified.

Association of Surprise-Billing Legislation with Prices Paid to In-Network and Out-of-Network Anesthesiologists in California, Florida, and New York: An Economic Analysis.

Importance: Several states have passed surprise-billing legislation to protect patients from unanticipated out-of-network medical bills, yet little is known about how state laws influence out-of-network prices and whether spillovers exist to in-network prices. Objective: To identify any changes in prices paid to out-of-network anesthesiologists at in-network facilities and to in-network anesthesiologists before and after states passed surprise-billing legislation. Design, Setting, and Participants: This retrospective economic analysis used difference-in-differences methods to compare price changes before and after the passage of legislation in California, Florida, and New York, which passed comprehensive surprise-billing legislation between January 1, 2014, and December 31, 2017, to 45 states that did not. Commercial claims data from the Health Care Cost Institute were used to identify prices paid to anesthesiologists in hospital outpatient departments and ambulatory surgery centers. The final analytic sample comprised 2 713 913 anesthesia claims across the 3 treated states and the 45 control states. Exposures: Temporal and state-level variation in exposure to surprise-billing legislation. Main Outcomes and Measures: The unit price (allowed amounts standardized per unit of service) paid to out-of-network anesthesiologists at in-network facilities and to in-network anesthesiologists. Results: This retrospective economic analysis of 2 713 913 anesthesia claims found that after surprise-billing laws were passed in 3 states, the unit price paid to out-of-network anesthesiologists at in-network facilities decreased significantly in 2 of them: California, -$12.71 (95% CI, -$25.70 to -$0.27; P = .05) and Florida, -$35.67 (95% CI, -$46.27 to -$25.07; P < .001). In New York, a decline in the overall out-of-network price was not statistically significant (-$7.91; 95% CI, -$17.48 to -$1.68; P = .10); however, by the fourth quarter of 2017, the decline was -$41.28 (95% CI, -$70.24 to -$12.33; P = .01). In-network prices decreased in California by -$10.68 (95% CI, -$12.70 to -$8.66; P < .001); in Florida, -$3.18 (95% CI, -$5.17 to -$1.19; P = .002); and in New York, -$8.05 (95% CI, -$11.46 to -$4.64; P < .001). Conclusions and Relevance: This retrospective study found that prices paid to in-network and out-of-network anesthesiologists in hospital outpatient departments and ambulatory surgery centers decreased after the introduction of surprise-billing legislation, providing early insights into how prices may change under the federal No Surprises Act and in states that have recently passed their own legislation.

Phase-Specific and Lifetime Costs of Multiple Myeloma Among Older Adults in the US.

Importance: Health care costs associated with diagnosis and care among older adults with multiple myeloma (MM) are substantial, with cost of care and the factors involved differing across various phases of the disease care continuum, yet little is known about cost of care attributable to MM from a Medicare perspective. Objective: To estimate incremental phase-specific and lifetime costs and cost drivers among older adults with MM enrolled in fee-for-service Medicare. Design, Setting, and Participants: A retrospective cohort study was conducted using population-based registry data from the 2007-2015 Surveillance, Epidemiology, and End Results database linked with 2006-2016 Medicare administrative claims data. Data analysis included 4533 patients with newly diagnosed MM and 4533 matched noncancer Medicare beneficiaries from a 5% sample of Medicare to assess incremental MM lifetime and phase-specific costs (prediagnosis, initial care, continuing care, and terminal care) and factors associated with phase-specific incremental MM costs. The study was conducted from June 1, 2019, to April 30, 2021. Main Outcomes and Measures: Incremental MM costs were calculated for the disease lifetime and the following 4 phases of care: prediagnosis, initial, continuing care, and terminal. Results: Of the 4533 patients with MM included in the study, 2374 were women (52.4%), 3418 (75.4%) were White, and mean (SD) age was 75.8 (6.8) years (2313 [51.0%] aged ≥75 years). The characteristics of the control group were similar; however, mean (SD) age was 74.2 (8.8) years (2839 [62.6%] aged ≤74 years). Mean adjusted incremental MM lifetime costs were $184 495 (95% CI, $183 099-$185 968). Mean per member per month phase-specific incremental MM costs were estimated to be $1244 (95% CI, $1216-$1272) for the prediagnosis phase, $11 181 (95% CI, $11 052-$11 309) for the initial phase, $5634 (95% CI, $5577-$5694) for the continuing care phase, and $6280 (95% CI, $6248-$6314) for the terminal phase. Although inpatient and outpatient costs were estimated as the major cost drivers for the prediagnosis (inpatient, 55.8%; outpatient, 40.2%), initial care (inpatient, 38.1%; outpatient, 35.5%), and terminal (inpatient, 33.0%; outpatient, 34.6%) care phases, prescription drugs (44.9%) were the largest cost drivers in the continuing care phase. Conclusions and Relevance: The findings of this study suggest that there is substantial burden to Medicare associated with diagnosis and care among older adults with MM, and the cost of care and cost drivers vary across different phases of the cancer care continuum. The study findings might aid policy discussions regarding MM care and coverage and help further the development of alternative payment models for MM, accounting for differential costs across various phases of the disease continuum and their drivers.

Cost Conversations About Anticoagulation Between Patients With Atrial Fibrillation and Their Clinicians: A Secondary Analysis of a Randomized Clinical Trial.

Importance: How patients with atrial fibrillation (AF) and their clinicians consider cost in forming care plans remains unknown. Objective: To identify factors that inform conversations regarding costs of anticoagulants for treatment of AF between patients and clinicians and outcomes associated with these conversations. Design, Setting, and Participants: This cohort study of recorded encounters and participant surveys at 5 US medical centers (including academic, community, and safety-net centers) from the SDM4AFib randomized trial compared standard AF care with and without use of a shared decision-making (SDM) tool. Included patients were considering anticoagulation treatment and were recruited by their clinicians between January 30, 2017, and June 27, 2019. Data were analyzed between August and November 2019. Main Outcomes and Measures: The incidence of and factors associated with cost conversations, and the association of cost conversations with patients' consideration of treatment cost burden and their choice of anticoagulation. Results: A total of 830 encounters (out of 922 enrolled participants) were recorded. Patients' mean (SD) age was 71.0 (10.4) years; 511 patients (61.6%) were men, 704 (86.0%) were White, 303 (40.9%) earned between $40 000 and $99 999 in annual income, and 657 (79.2%) were receiving anticoagulants. Clinicians' mean (SD) age was 44.8 (13.2) years; 75 clinicians (53.2%) were men, and 111 (76%) practiced as physicians, with approximately half (69 [48.9%]) specializing in either internal medicine or cardiology. Cost conversations occurred in 639 encounters (77.0%) and were more likely in the SDM arm (378 [90%] vs 261 [64%]; OR, 9.69; 95% CI, 5.77-16.29). In multivariable analysis, cost conversations were more likely to occur with female clinicians (66 [47%]; OR, 2.85; 95% CI, 1.21-6.71); consultants vs in-training clinicians (113 [75%]; OR, 4.0; 95% CI, 1.4-11.1); clinicians practicing family medicine (24 [16%]; OR, 12.12; 95% CI, 2.75-53.38]), internal medicine (35 [23%]; OR, 3.82; 95% CI, 1.25-11.70), or other clinicians (21 [14%]; OR, 4.90; 95% CI, 1.32-18.16) when compared with cardiologists; and for patients with an annual household income between $40 000 and $99 999 (249 [82.2%]; OR, 1.86; 95% CI, 1.05-3.29) compared with income below $40 000 or above $99 999. More patients who had cost conversations reported cost as a factor in their decision (244 [89.1%] vs 327 [69.0%]; OR 3.66; 95% CI, 2.43-5.50), but cost conversations were not associated with the choice of anticoagulation agent. Conclusions and Relevance: Cost conversations were common, particularly for middle-income patients and with female and consultant-level primary care clinicians, as well as in encounters using an SDM tool; they were associated with patients' consideration of treatment cost burden but not final treatment choice. With increasing costs of care passed on to patients, these findings can inform efforts to promote cost conversations in practice. Trial Registration: ClinicalTrials.gov Identifier: NCT02905032.

Association of Costs and Days at Home With Transfer Hospital in Home.

Importance: New Centers for Medicare & Medicaid Services waivers created a payment mechanism for hospital at home services. Although it is well established that direct admission to hospital at home from the community as a substitute for hospital care provides superior outcomes and lower cost, the effectiveness of transfer hospital at home-that is, completing hospitalization at home-is unclear. Objective: To evaluate the outcomes of the transfer component of a Veterans Affairs (VA) Hospital in Home program (T-HIH), taking advantage of natural geographical limitations in a program's service area. Design, Setting, and Participants: In this quality improvement study, T-HIH was offered to veterans residing in Philadelphia, Pennsylvania, and their outcomes were compared with those of propensity-matched veterans residing in adjacent Camden, New Jersey, who were admitted to the VA hospital from 2012 to 2018. Data analysis was performed from October 2019 to May 2020. Intervention: Enrollment in the T-HIH program. Main Outcomes and Measures: The main outcomes were hospital length of stay, 30-day and 90-day readmissions, VA direct costs, combined VA and Medicare costs, mortality, 90-day nursing home use, and days at home after hospital discharge. An intent-to-treat analysis of cost and utilization was performed. Results: A total of 405 veterans (mean [SD] age, 66.7 [0.83] years; 399 men [98.5%]) with medically complex conditions, primarily congestive heart failure and chronic obstructive pulmonary disease exacerbations (mean [SD] hierarchical condition categories score, 3.54 [0.16]), were enrolled. Ten participants could not be matched, so analyses were performed for 395 veterans (all of whom were men), 98 in the T-HIH group and 297 in the control group. For patients in the T-HIH group compared with the control group, length of stay was 20% lower (6.1 vs 7.7 days; difference, 1.6 days; 95% CI, -3.77 to 0.61 days), VA costs were 20% lower (-$5910; 95% CI, -$13 049 to $1229), combined VA and Medicare costs were 22% lower (-$7002; 95% CI, -$14 314 to $309), readmission rates were similar (23.7% vs 23.0%), the numbers of nursing home days were significantly fewer (0.92 vs 7.45 days; difference, -6.5 days; 95% CI, -12.1 to -0.96 days; P = .02), and the number of days at home was 18% higher (81.4 vs 68.8 days; difference, 12.6 days; 95% CI, 3.12 to 22.08 days; P = .01). Conclusions and Relevance: In this study, T-HIH was significantly associated with increased days at home and less nursing home use but was not associated with increased health care system costs.

Improving clinical documentation of evaluation and management care and patient acuity improves reimbursement as well as quality metrics.

OBJECTIVE: Accurate documentation of patient care and acuity is essential to determine appropriate reimbursement as well as accuracy of key publicly reported quality metrics. We sought to investigate the impact of standardized note templates by inpatient advanced practice providers (APPs) on evaluation and management (E/M) charge capture, including outside of the global surgical package (GSP), and quality metrics including case mix index (CMI) and mortality index (MI). We hypothesized this clinical documentation initiative as well as improved coding of E/M services would result in increased reimbursement and quality metrics. METHODS: A documentation and coding initiative on the heart and vascular service line was initiated in 2016 with focus on improving inpatient E/M capture by APPs outside the GSP. Comprehensive training sessions and standardized documentation templates were created and implemented in the electronic medical record. Subsequent hospital care E/M (current procedural terminology codes 99231, 99232, 99233) from the years 2015 to 2017 were audited and analyzed for charge capture rates, collections, work relative value units (wRVUs), and billing complexity. Data were compared over time by standardizing CMS values and reimbursement rates. In addition, overall CMI and MI were calculated each year. RESULTS: One year following the documentation initiative, E/M charges on the vascular surgery service line increased by 78.5% with a corresponding increase in APP charges from 0.4% of billable E/M services to 70.4% when compared with pre-initiative data. The charge capture of E/M services among all inpatients rose from 21.4% to 37.9%. Additionally, reimbursement from CMS increased by 65% as total work relative value units generated from E/M services rose by 78.4% (797 to 1422). The MI decreased over the study period by 25.4%. Additionally, there was a corresponding 5.6% increase in the cohort CMI. Distribution of E/M encounter charges did not vary significantly. Meanwhile, the prevalence of 14 clinical comorbidities in our cohort as well as length of stay (P = .88) remained non-statistically different throughout the study period. CONCLUSIONS: Accurate clinical documentation of E/M care and ultimately inpatient acuity is critical in determining quality metrics that serve as important measures of overall hospital quality for CMS value-based payments and rankings. A system-based documentation initiative and expanded role of inpatient APPs on vascular surgery teams significantly improved charge capture and reimbursement outside the GSP as well as CMI and MI in a consistently complex patient population.

Current Interventional Radiology-Related Benchmarked Clinical Quality Measures Are Less Likely to be "Capped" Than Diagnostic Radiology Clinical Quality Measures.

In the merit-based incentive payment system (MIPS), quality measures are considered topped out if national median performance rates are ≥95%. Quality measures worth 10 points can be capped at 7 points if topped out for ≥2 years. This report compares the availability of diagnostic radiology (DR)-related and interventional radiology (IR)-related measures worth 10 points. A total of 196 MIPS clinical quality measures were reviewed on the Center for Medicare and Medicaid Services MIPS website. There are significantly more IR-related measures worth 10 points than DR measures (2/9 DR measures vs 9/12 IR measures; P = .03), demonstrating that clinical IR services can help mixed IR/DR groups maximize their Center for Medicare and Medicaid Services payment adjustment.

Using Contingent Valuation Method to Estimate Adults' Willingness to Pay for a Future Coronavirus 2019 Vaccination.

OBJECTIVES: Vaccines are recognized as the most effective strategy for long-term prevention of coronavirus disease 2019 (COVID-19) because they can reduce morbidity and mortality. The purpose of the present study was to evaluate willingness to pay (WTP) for a future COVID-19 vaccination among young adults in Southern Vietnam. METHODS: A cross-sectional, descriptive, and analytic study was undertaken with data collected from a community-based survey in southern Vietnam for 2 weeks in May 2020. The contingent valuation method was used to estimate WTP for COVID-19 vaccine. The average amount that respondents were willing to pay for the vaccine was US$ 85.9 2 ± 69.01. RESULTS: We also found the differences in WTP according to sex, living area, monthly income, and the level of self-rated risk of COVID-19. CONCLUSION: Our findings possibly contribute to the implementation of a pricing policy when the COVID-19 vaccine is introduced in Vietnam.

Real-world healthcare costs of localized and regionally advanced cutaneous melanoma in the Netherlands.

The aim of this study was to provide insight into real-world healthcare costs of patients initially diagnosed with localized or regionally advanced melanoma in three Dutch hospitals between 2003 and 2011. Patients were stratified according to their stage at diagnosis and recurrence status. Costs were calculated by applying unit costs to individual patient resource use and reported for the full disease course, the initial treatment episode, and treatment episodes for disease recurrence (stratified by type of recurrence). We included 198 patients with localized melanoma and 98 patients with regionally advanced melanoma. Total costs were much higher for patients with disease recurrence than for patients without disease recurrence: €20 007 versus €3032 for patients with localized melanoma and €19 519 versus €5951 for patients with regionally advanced melanoma. This was owing to the costs of disease recurrence because the costs of the initial treatment were comparable between patients with and without disease recurrence. Costs of disease recurrence were dependent on the type of recurrence: €4414, €4604, €8129 and €10 393 for a local recurrence, intralymphatic metastases, regional lymph node metastases and distant metastases, respectively. In conclusion, healthcare costs of patients with localized and regionally advanced melanoma were rather low for the initial treatment. Costs became, however, more substantial in case of disease recurrence. In the context of a rapidly changing treatment paradigm, it remains crucial to monitor treatment outcomes as well as healthcare expenditures.

Medical costs of Japanese lung cancer patients during end-of-life care.

OBJECTIVE: The medical costs associated with cancer treatment have increased rapidly in Japan; however, little data exist on actual costs, especially for end-of-life care. Therefore, this study aimed to examine the medical costs of lung cancer patients during the last 3 months before death and to compare the costs with those of initial anticancer treatment. METHODS: We retrospectively evaluated all patients who died from lung cancer at the Japanese Red Cross Medical Center between 1 January 2008 and 31 August 2019. Patients were classified into three cohorts (2008-2011, 2012-2015 and 2016-2019) according to the year of death; the medical costs were evaluated for each cohort. Costs were then divided into outpatient and inpatient costs and calculated per month. RESULTS: Seventy-nine small cell lung cancer and 213 non-small cell lung cancer patients were included. For small cell lung cancer and non-small cell lung cancer patients, most end-of-life medical costs were inpatient costs across all cohorts. The median monthly medical costs for the last 3 months among both small cell lung cancer and non-small cell lung cancer patients did not differ significantly among the cohorts, but the mean monthly costs for non-small cell lung cancer tended to increase. The monthly medical costs for the last 3 months were significantly higher than those for the first year in SCLC (P = 0.013) and non-small cell lung cancer (P < 0.001) patients and those for the first 3 months in non-small cell lung cancer patients (P = 0.005). CONCLUSIONS: The medical costs during the end-of-life period for lung cancer were high and surpassed those for initial treatment.

Medical costs of lung cancer care in Japan during the first one or two years after initial diagnosis.

OBJECTIVES: Japan's healthcare expenditures, especially on oncology, are rapidly growing; however, there are scant data on actual costs and cost-effectiveness in the real world. The aim was to assess the medical costs and outcomes of patients with advanced lung cancer. METHODS: We retrospectively investigated all patients who were diagnosed with advanced lung cancer at the Japanese Red Cross Medical Center between 1 January 2008 and 31 December 2018. Patients were classified into three cohorts according to the year of diagnosis-Cohort 1: 2008-2010, Cohort 2: 2011-2014 and Cohort 3: 2015-2018-and assessed for medical costs and outcome. Medical costs were divided into outpatient and inpatient costs and were calculated on a monthly basis. RESULTS: Ninety-five patients with small cell lung cancer (SCLC) and 330 with nonsmall cell lung cancer (NSCLC) were included. There was a trend toward increased costs during the first two years after diagnosis in NSCLC patients, without changes in monthly costs, reflecting improved survival. Compared to Cohort 1, Cohort 3 patients with NSCLC had longer survival (median: 24 versus 12 months, P < 0.001), with a median incremental cost of Japanese Yen 6 million during the initial two years. The proportion of outpatient costs increased over time, especially for NSCLC patients (P < 0.001). No changes in costs or survival were observed in SCLC patients. CONCLUSIONS: In NSCLC patients, medical costs increased with prolonged survival during the last decade. The costs on a monthly basis did not change. The proportion of outpatient costs increased.

The Politics of Health Care.

What can we expect from the Biden administration?

What Is the Quality of Surgical Care for Patients with Hip Fractures at Critical Access Hospitals?

BACKGROUND: Critical access hospitals (CAHs) play an important role in providing access to care for many patients in rural communities. Prior studies have shown that these facilities are able to provide timely and quality care for patients who undergo various elective and emergency general surgical procedures. However, little is known about the quality and reimbursement of surgical care for patients undergoing surgery for hip fractures at CAHs compared with non-CAH facilities. QUESTIONS/PURPOSES: Are there any differences in 90-day complications, readmissions, mortality, and Medicare payments between patients undergoing surgery for hip fractures at CAHs and those undergoing surgery at non-CAHs? METHODS: The 2005 to 2014 Medicare 100% Standard Analytical Files were queried using ICD-9 procedure codes to identify Medicare-eligible beneficiaries undergoing open reduction and internal fixation (79.15, 79.35, and 78.55), hemiarthroplasty (81.52), and THA (81.51) for isolated closed hip fractures. This database was selected because the claims capture inpatient diagnoses, procedures, charged amounts and paid claims, as well as hospital-level information of the care, of Medicare patients across the nation. Patients with concurrent fixation of an upper extremity, lower extremity, and/or polytrauma were excluded from the study to ensure an isolated cohort of hip fractures was captured. The study cohort was divided into two groups based on where the surgery took place: CAHs and non-CAHs. A 1:1 propensity score match, adjusting for baseline demographics (age, gender, Census Bureau-designated region, and Elixhauser comorbidity index), clinical characteristics (fixation type and time to surgery), and hospital characteristics (whether the hospital was located in a rural ZIP code, the average annual procedure volume of the operating facility, hospital bed size, hospital ownership and teaching status), was used to control for the presence of baseline differences in patients presenting at CAHs and those presenting at non-CAHs. A total of 1,467,482 patients with hip fractures were included, 29,058 of whom underwent surgery in a CAH. After propensity score matching, each cohort (CAH and non-CAH) contained 29,058 patients. Multivariate logistic regression analyses were used to assess for differences in 90-day complications, readmissions, and mortality between the two matched cohorts. As funding policies of CAHs are regulated by Medicare, an evaluation of costs-of-care (by using Medicare payments as a proxy) was conducted. Generalized linear regression modeling was used to assess the 90-day Medicare payments among patients undergoing surgery in a CAH, while controlling for differences in baseline demographics and clinical characteristics. RESULTS: Patients undergoing surgery for hip fractures were less likely to experience many serious complications at a critical access hospital (CAH) than at a non-CAH. In particular, after controlling for patient demographics, hospital-level factors and procedural characteristics, patients treated at a CAH were less likely to experience: myocardial infarction (3% (916 of 29,058) versus 4% (1126 of 29,058); OR 0.80 [95% CI 0.74 to 0.88]; p < 0.001), sepsis (3% (765 of 29,058) versus 4% (1084 of 29,058); OR 0.69 [95% CI 0.63 to 0.78]; p < 0.001), acute renal failure (6% (1605 of 29,058) versus 8% (2353 of 29,058); OR 0.65 [95% CI 0.61 to 0.69]; p < 0.001), and Clostridium difficile infections (1% (367 of 29,058) versus 2% (473 of 29,058); OR 0.77 [95% CI 0.67 to 0.88]; p < 0.001) than undergoing surgery in a non-CAH. CAHs also had lower rates of all-cause 90-day readmissions (18% (5133 of 29,058) versus 20% (5931 of 29,058); OR 0.83 [95% CI 0.79 to 0.86]; p < 0.001) and 90-day mortality (4% (1273 of 29,058) versus 5% (1437 of 29,058); OR 0.88 [95% CI 0.82 to 0.95]; p = 0.001) than non-CAHs. Further, CAHs also had risk-adjusted lower 90-day Medicare payments than non-CAHs (USD 800, standard error 89; p < 0.001). CONCLUSION: Patients who received hip fracture surgical care at CAHs had a lower risk of major medical and surgical complications than those who had surgery at non-CAHs, even though Medicare reimbursements were lower as well. Although there may be some degree of patient selection at CAHs, these facilities appear to provide high-value care to rural communities. These findings provide evidence for policymakers evaluating the impact of the CAH program and allocating funding resources, as well as for community members seeking emergent care at local CAH facilities. LEVEL OF EVIDENCE: Level III, therapeutic study.

High-need high-cost patients: A Concept Analysis.

High-need high-cost (HNHC) patients are variously defined in the literature as the small subset of the population who account for the majority of US health care costs. Lack of consensus on the defining attributes of HNHC patients has challenged the effectiveness of interventions aimed to improve disease management and reduce costs. Guided by the Walker and Avant method of concept analysis, a literature review of 2 databases (PubMed and CINAHL) was conducted. Three main subgroups of HNHC patients were identified: adults with multiple chronic conditions and functional disability, the frail elderly, and patients under 65 years old with a disability or behavioral health condition. HNHC patients are categorized by a feedback loop of acute-on-chronic health conditions, preventable health service utilization, and fragmented care. Antecedents that predispose becoming a HNHC patient include challenges accessing timely care, low socioeconomic status, unmet support, and social factors such as isolation and inadequate.