Clinical characteristics and cost of hospital stay of octogenarians and nonagenarians in intensive care nephrology unit.

PURPOSE: As the population gets older, the elderly and very elderly patients are increasingly been treated in nephrology intensive care units (ICU). In this study we evaluated the characteristics and outcomes of the octogenarians (80-89 years old), nonagenarians (≥ 90 years old) and compared them with elderly (65-79 years old) patients treated in nephrology ICU. METHODS: Eighteen nonagenarians, 70 octogenarians and 88 elderly patients were included in the study. Indication for hospitalization, presence of comorbid diseases, and requirement for acute dialysis treatment were investigated. Need for mechanical ventilation, vasopressors, central venous catheterization, urinary catheterization, anticoagulation, and transfusion of blood products were evaluated. Mortality rate and hospital cost were calculated. Data about survival at 1 month after discharge was collected. RESULTS: Causes of hospitalization, need for dialysis treatment, mechanical ventilation, vasopressors, central venous catheterization, urinary catheterization, anticoagulation, and transfusion of blood products were not different between age groups. Diabetes mellitus and malignancy were more frequent in elderly, whereas dementia/Alzheimer's disease was more common in nonagenarians. Although, mortality in ICU was increased as the age increased, it was statistically insignificant. However, 1 month mortality rate after discharge from hospital was increased especially in nonagenarians. In nonagenarians infection, whereas in octogenarians need for dialysis treatment, were related with mortality. Length of intensive care stay and hospital cost did not differ between age groups. CONCLUSION: Length of nephrology intensive care stay, mortality rate and hospital cost did not differ for very elderly age groups, but mortality risk was higher for nonagenarians after discharge from hospital.

[Socio-economic aspects of neurogenic dysfunctions in urology].

AIM: to evaluate the medico-economic significance of neurogenic lower urinary tract dysfunction (NLUTD) in the Russian Federation, to calculate the economic burden of NLUTD in patients with targeted entities and to prepare suggestions for improving the methods of payment for the provision of medical care to patients with NLUTD in inpatient practice. MATERIALS AND METHODS: an analysis of the literature and an expert assessment of the prevalence of NLUTD in the Russian Federation were performed. Due to the various etiology of NLUTD, the following entities were considered: craniocerebral trauma, acute stroke, multiple sclerosis, spinal cord injury (hereinafter referred to as targeted entities), characterized by the highest rate of NLUTD and high social significance (damage to the working-age population): traumatic brain injury, acute stroke, multiple sclerosis, spinal cord injury. The calculations of the economic burden of NLUTD and its main complications (stage 5 of chronic kidney disease (CKD), urinary tract infection) in the Russian Federation (using mainly the normative method) were carried out, based on national statistics, regulatory legal acts and expert assessments of healthcare specialists. Proposals have been prepared for improving the reimbursement (tariffs of the KSG) for payment of NLUTD in the inpatient practice. RESULTS: according to the study, the number of patients with NLUTD due to the group of targeted entities is estimated at 910 000. The economic burden (excluding indirect and unaccounted costs) of the NLUTD is 33.3 billion rubles per year. The burden associated with secondary complications (stage 5 CKD, urogenital infection) due to ineffective diagnosis and treatment of NLUTD is 51.6 billion rubles. The total costs on the NLUTD is estimated at 84.9 billion rubles. Direct costs, calculated by the normative method based on the analysis of standards of medical care per patient are 36,546 rubles per year. Provision of medical care to patients with NLUTD in accordance with federal guarantees within the framework of the compulsory medical insurance is provided in accordance with the tariffs of KSG st30.005 (profile "urology"). The KSG tariff for 2019 (taking into account the established standards of financial costs for one case of hospitalization in the inpatient department and the established cost-intensity coefficients (CZ) established by the CG is 21,495.07 rubles, which is 58% of the minimum need, excluding the cost of treatment of complications, according to the normative method of calculation. The real estimate of the tariff for the payment of treatment of NLUTD in the constituent entities of the Russian Federation is 35-38% of the minimum need, excluding the cost of treatment of complications, according to the normative method of calculation. The real estimate of the costs for the treatment of NLUTD in regions is 35-38% of the minimum need, excluding the cost of treatment of complications, according to the normative method of calculation. To provide effective specialized urological care in the framework of compulsory medical insurance at the rates of the CSG for neuro-urological care (st30.005), expert calculations of the actual cost of NLUTD therapy were made. The proposed average cost of the CSG and the values of the cost intensity factors: CSG (min) st30.005.1 - 39,936 rubles, CZ - 1.65; CSG (max) st30.005.2 - 68,531 rubles, CZ - 2.75. The weighted average savings while expanding the availability of complex neuro-urological care for patients with NLUTD in accordance with the proposed payment rates is 9.4 billion rubles per year. CONCLUSIONS: Evaluation of the prevalence and burden of NLUTD showed the high medical and economic significance of NLUTD in the Russian Federation. The results of the study indicate a significant discrepancy between the requirements and the real costs within federal guarantees for the organization of medical care for patients with NLUTD. To provide effective specialized urological care in the compulsory medical insurance at the rates of CSG for neuro-urological care, it is necessary to increase funding, through the correction at the federal level of the cost-intensity coefficient from 1.65 to 2.75 for the CSG st30.005, which will ensure the increase in the cost for a case of treatment in inpatient department in form 39 936 to 68 531 rubles. The weighted average savings while expanding the availability of complex neuro-urological care for patients with NLUTD in accordance with the proposed payment rates is 9.4 billion rubles per year.

Costing Urologic Complications Following Pelvic Radiation Therapy.

OBJECTIVES: To describe patients presenting with urologic complications following pelvic radiation therapy and estimate the financial costs incurred in their treatment. PATIENTS AND METHODS: In the year ending June 2018, all urology admissions at Royal Newcastle Centre were reviewed for diagnostic codes pertaining to urethral or ureteric strictures, cystitis, and haematuria. Presentations were complications following radiotherapy if a diagnosis of radiation cystitis or stricture was recorded, and there was relevant prior radiotherapy. The Independent Hospital Pricing Authority's National Weighted Activity Unit (NWAU) 2018 calculators, admission data and the National Efficient Price were used to estimate costs of care. HNELHD HREC granted ethics approval (AU201808-10). RESULTS: Complications following radiotherapy accounted for 65 admissions in 53 discrete patients, accounting for 206 bed days and 3.7% of the 1748 total urology admissions in 1 year. The majority (86%) of admissions had at least 1 operation. Mean time since radiotherapy was 7 years (range 1-30). Mean number of operations related to complications following radiotherapy was 3 (range 0-11). Readmissions were more frequent (mean 1.9 admissions/year) than other urology inpatients (mean 1.3 admissions/year, P < .001). Mean NWAU18 value was 4.12 (range 2-8.3). Admission and procedure costs were AUD $1,346,700, secondary malignancies were $9,000 and emergency department costs were $45,864 for a combined total of $1,401,591. CONCLUSION: Patients requiring urological admission with complications following radiotherapy use more resources, stay for longer, have more operations and return more frequently than other urology patients. Conservative estimates of cost $25,900 per patient in the study year alone.

Characteristics, Burden, and Necessity of Inpatient Consults for Academic and Private Practice Urologists.

OBJECTIVE: To compare differences in the characteristics and outcomes of inpatient consults between academic and private practice urologists. MATERIALS AND METHODS: We performed a retrospective review of urology consults at a large tertiary-care hospital from June 1st, 2017 to June 30th, 2018. Patient demographics, timing of consult, location of consult, reasons for consult, requesting physicians, and procedures performed were analyzed and compared. RESULTS: A total of 613 consults were identified. The most common consults were for a Foley catheter/suprapubic tube (16%), urinary retention (15%), kidney/bladder stones (11%), and hematuria (11%). Seventy-seven percent of the consults were seen in the day time and 79% were seen on the weekdays. One hundred and ten (18%) consults resulted in an operative intervention during the same admission. The others required a Foley catheter placement or suprapubic exchange (17%), bedside procedure (9%), or interventional radiology procedure (4%). The remaining 319 consults (52%) required no intervention and were considered potentially unnecessary. There were no differences in the timing of the consults and the need for intervention between academic and private practice urologists (P = .20). Only 37% of patients followed up as an outpatient. These potentially unnecessary consults resulted an annual loss of 265.8 hours for the urologists and $44,376.09 in excess health care costs. CONCLUSION: Over half of inpatient urologic consultations required no urologic intervention and therefore represented potential overuse of urgent inpatient specialty care. This may contribute towards the growing epidemic of burnout in urology. Further work needs to be done to educate other hospital services and nurses to minimize these unnecessary consults.

Cost analysis of removing pediatric ureteral stents with and without a retrieval string.

BACKGROUND: Indwelling ureteral stents are commonly placed in urologic surgeries where optimal urinary drainage is necessary. In the pediatric population, removing a stent without retrieval string (SWOS) requires a secondary operation and additional anesthetic exposure. Although these burdens can be mitigated through the placement of a stent with retrieval string (SWS), fears of complications may prevent widespread adoption of this practice by pediatric urologists. OBJECTIVE: The authors sought to assess the differential cost of removing SWS and SWOS. It was hypothesized that costs associated with removing SWS are significantly lower than those associated with removing SWOS, without increasing complications. STUDY DESIGN: A retrospective chart review was performed on pediatric patients undergoing common urologic surgeries with concurrent stent placement at a single tertiary referral center. Charges and healthcare costs surrounding the removal of ureteral stents were evaluated using the institution-specific ratio of cost to charges, by estimating lost wages, and by exploring differences in poststent healthcare-related events that incur additional cost. RESULTS: A total of 109 patients with a median age of 5 years (range: 6 months-20 years) were reviewed. A total of 29 patients had SWS, and 80 had SWOS. The theoretical cost of SWS removal in clinic was $400.48 compared with $2290.86 ± $119.30 for operative removal of SWOS, with mean difference of $1890.38 (P < 0.01). The mean stent duration of SWOS was 34.0 ± 13.2 days vs. 10.1 ± 4.9 days for SWS (P < 0.01). Subgroup analysis of the ureteral reconstruction group showed no difference in any complications (35% vs 27%, respectively), early dislodgment (7% vs 7%, respectively) or costly healthcare utilization (23% vs 20%, respectively) among patients with SWOS compared with those with SWS. In SWS group with early dislodgment, neither required a secondary procedure. DISCUSSION: With rising healthcare expenditures, physicians must be able to provide cost-effective treatment while not compromising safety or outcomes. Unlike prior analyses of cost related to the type of the stent used, the present study specifically reviewed costs of removing SWS versus SWOS and evaluated rates of costly complications. The study findings provide a preliminary basis for advocating the more economical use of SWS when indicated. Lack of power and heterogeneity of the groups need to be addressed in future analyses with larger, matched cohorts. CONCLUSION: Removal of SWS is more cost-effective than that of SWOS while maintaining similar safety outcomes and should be considered in certain pediatric urology cases to decrease healthcare cost. SWS should be preferred for uncomplicated ureteroscopy, but benefits are less certain in ureteral reconstruction; further studies are needed.

Longitudinal Comparison of Patient-Level Outcomes and Costs Across Prostate Cancer Treatments With Urinary Problems.

Prostate cancer (PCa) is the leading cancer in men in the United States. This study evaluated direct costs of treating urinary problems after PCa treatments and determined predictors of long-term costs for urinary problems. Data from the Cancer of Prostate Strategic Urologic Research Endeavor registry was analyzed for this study. Annual treatment costs for urinary problems for up to 14 years were compared among different primary PCa treatments, which included radical prostatectomy, external beam radiation therapy, brachytherapy, and watchful waiting. A multivariate generalized estimating equation (GEE) model with bootstrapping was estimated to identify the predictors associated with treatment costs for urinary problems. A total of 3,062 eligible patients were identified with a mean age of 65 years at diagnosis. Mean annual treatment cost for urinary problems across all patients with PCa was $118/patient. Those greater than 74 years old had the highest cost ($238/patient). Mean annual cost for urinary problems among only those with urinary problems was $432. Multivariate regression showed patients undergoing radical prostatectomy had significantly lower (-63%, p = .01) costs for urinary problems than those treated with watchful waiting. This study helps to understand the importance of treating urinary problems associated with different PCa treatments and highlights their medical care costs. The pattern of treatment costs for urinary problems across all PCa treatments suggests that clinicians need to offer treatment for urinary problems to all PCa patients over longer time periods, even to those choosing watchful waiting.

Concentration of Costs Among High Utilizers of Health Care Services Over the First 10 Years After Spinal Cord Injury Rehabilitation: A Population-based Study.

OBJECTIVE: The purpose of this study was to (1) categorize individuals into high, medium, and low utilizers of health care services over a 10-year period after the onset of spinal cord injury (SCI) and (2) identify the pattern of causes of hospitalizations and the characteristics associated with high utilization. DESIGN: Retrospective analysis of self-report assessment linked to administrative data. SETTING: Data were collected from participants living in and utilizing hospitals in the state of South Carolina. PARTICIPANTS: Adult participants with traumatic SCI were identified through a state SCI Surveillance System Registry, a population-based system capturing all incident cases treated in nonfederal facilities. Among 963 participants who completed self-report assessments, we matched those with a minimum of 10 years of administrative records for a final sample of 303 participants (N=303). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Costs related to health care utilization for emergency department visits and hospitalizations, as measured operationally by hospital charges at full and established rates; causes of hospitalizations RESULTS: Over two-thirds of the total $49.4 million in charges for hospitalization over the 10-year timeframe (69%) occurred among 16.5% of the cohort (high utilizers), whereas those in the low utilizer group comprised 53% of the cohort with only 3.5% of the charges. The primary diagnoses were septicemia (50%), other urinary tract disorder (48%), mechanical complication of device, implant, or graft (48%), and chronic ulcer of skin (40%). Primary diagnoses were frequently accompanied by secondary diagnoses, indicating the co-occurrence of multiple secondary health conditions. High utilizers were more likely to be male, minority, have a severe SCI, have reported frequent pressure ulcers and have income of less than $35,000 per year. CONCLUSIONS: The high cost of chronic health care utilization over a 10-year timeframe was concentrated in a relatively small portion of the SCI population who have survived more than a decade after SCI onset.

Disease and Economic Burden of Hospitalizations Attributable to Diabetes Mellitus and Its Complications: A Nationwide Study in Brazil.

Diabetes is associated with a significant burden globally. The costs of diabetes-related hospitalizations are unknown in most developing countries. The aim of this study was to estimate the total number and economic burden of hospitalizations attributable to diabetes mellitus (DM) and its complications in adults from the perspective of the Brazilian Public Health System in 2014. Data sources included the National Health Survey (NHS) and National database of Hospitalizations (SIH). We considered diabetes, its microvascular (retinopathy, nephropathy, and neuropathy) and macrovascular complications (coronary heart disease, cerebrovascular disease, and peripheral arterial disease), respiratory and urinary tract infections, as well as selected cancers. Assuming that DM patients are hospitalized for these conditions more frequently that non-DM individuals, we estimated the etiological fraction of each condition related to DM, using the attributable risk methodology. We present number, average cost per case, and overall costs of hospitalizations attributable to DM in Brazil in 2014, stratified by condition, state of the country, gender and age group. In 2014, a total of 313,273 hospitalizations due to diabetes in adults were reported in Brazil (4.6% of total adult hospitalization), totaling (international dollar) Int$264.9 million. The average cost of an adult hospitalization due to diabetes was Int$845, 19% higher than hospitalization without DM. Hospitalizations due to cardiovascular diseases related to diabetes accounted for the higher proportion of costs (47.9%), followed by microvascular complications (25.4%) and DM per se (18.1%). Understanding the costs of diabetes and its major complications is crucial to raise awareness and to support the decision-making process on policy implementation, also allowing the assessment of prevention and control strategies.

Profile and costs of secondary conditions resulting in emergency department presentations and readmission to hospital following traumatic spinal cord injury.

INTRODUCTION: People with traumatic spinal cord injury (SCI) face complex challenges in their care, recovery and life. Secondary conditions can develop to involve many body systems and can impact health, function, quality of life, and community participation. These secondary conditions can be costly, and many are preventable. The aim of this study was to describe the type and direct costs of secondary conditions requiring readmission to hospital, or visit to an emergency department (ED), within the first two years following traumatic spinal cord injury (SCI). METHODS: A retrospective cohort study using population-level linked data from hospital ED and admission datasets was undertaken in Victoria, Australia. The incidence and direct treatment costs of readmission to hospital and ED visit within 2-years post-injury for secondary conditions related to SCI were measured for the 356 persons with traumatic SCI with a date of injury from 2008 to 2011. RESULTS: Of the 356 cases, 141 (40%) experienced 366 (median 2, range 1-11) readmissions to hospital for secondary conditions. 95 (27%) visited an ED at least once, within two years of injury for a secondary condition. The cost of hospital readmissions was AUD$5,553,004 and AUD$87,790 for ED visits. The mean±SD cost was AUD$15,172±$20,957 per readmission and AUD$670±$198 per ED visit. Urological conditions (e.g. urinary tract infection) were most common, followed by pressure areas/ulcers for readmissions, and fractures in the ED. CONCLUSIONS: Hospitalisation for complications within two years of traumatic SCI was common and costly in Victoria, Australia. Improved bladder and pressure area management could result in substantial morbidity and cost savings following SCI.

[Development of the 2014 G-DRG system. Departure from coding of secondary diagnoses?]. / Entwicklung des G-DRG-Systems 2014. Abkehr von der Kodierung der Nebendiagnosen?

The objective of the German DRG (diagnosis-related groups) system is to adequately reimburse hospital costs using flat rate payments. The goal is to thereby achieve the most adequate representation of hospital costs in flat rate payments. The DRG for 2014 is based on the actual number of cases treated and the costs determined from 2012. For 2014, the current changes of the DRG system for the specialty urology concerning the coding and recording of secondary diagnoses are presented and discussed.

Community household income and resource utilization for common inpatient pediatric conditions.

BACKGROUND AND OBJECTIVE: Child health is influenced by biomedical and socioeconomic factors. Few studies have explored the relationship between community-level income and inpatient resource utilization for children. Our objective was to analyze inpatient costs for children hospitalized with common conditions in relation to zip code-based median annual household income (HHI). METHODS: Retrospective national cohort from 32 freestanding children's hospitals for asthma, diabetes, bronchiolitis and respiratory syncytial virus, pneumonia, and kidney and urinary tract infections. Standardized cost of care for individual hospitalizations and across hospitalizations for the same patient and condition were modeled by using mixed-effects methods, adjusting for severity of illness, age, gender, and race. Main exposure was median annual HHI. Posthoc tests compared adjusted standardized costs for patients from the lowest and highest income groups. RESULTS: From 116,636 hospitalizations, 4 of 5 conditions had differences at the hospitalization and at the patient level, with lowest-income groups having higher costs. The individual hospitalization level cost differences ranged from $187 (4.1%) to $404 (6.4%). Patient-level cost differences ranged from $310 to $1087 or 6.5% to 15% higher for the lowest-income patients. Higher costs were typically not for laboratory, imaging, or pharmacy costs. In total, patients from lowest income zip codes had $8.4 million more in hospitalization-level costs and $13.6 million more in patient-level costs. CONCLUSIONS: Lower community-level HHI is associated with higher inpatient costs of care for 4 of 5 common pediatric conditions. These findings highlight the need to consider socioeconomic status in health care system design, delivery, and reimbursement calculations.

Quality assessment of economic analyses in pediatric urology.

OBJECTIVE: To describe and evaluate economic analyses or economic evaluations in pediatric urologic literature, including study types such as cost-effectiveness analysis, which are increasingly common in the medical literature. METHODS: We performed a systematic literature review of the MEDLINE, EMBASE, and Cochrane databases (1990-2011) to identify economic analyses of pediatric urologic topics. Studies were evaluated using published quality metrics. We examined the analysis type, data sources, perspective, methodology, sensitivity analyses, and the reporting of methods, results, limitations, and conclusions. RESULTS: We identified 2945 nonduplicated studies, 60 of which met inclusion criteria. Economic analyses of pediatric urologic topics increased in number during the study period, from 1 study (2%) in 1990 to 7 (12%) in 2010 (P <.0001 for trend). The most common types of analyses were cost-effectiveness and cost-minimization (22 each, 37%), typically performed from the payer perspective (26 [43%]). Although 44 (73%) correctly identified the analysis type, only 21 (35%) correctly identified the study perspective. Optimal data sources were used in 7 studies (11%). Appropriate inflationary discounting was used in 17 of 53 (32%). Sensitivity analyses were not reported in 31 of 53 (58%). The descriptions of study methods were adequate in 43 studies (72%), assumptions were adequately reported in 42 (70%), and 37 (62%) adequately discussed limitations. CONCLUSION: Although economic analyses are increasing in the pediatric urologic literature, there is a need for standardization in methods and reporting. Future investigations should attempt to follow standardized reporting guidelines and should pay particular attention to reporting of methods and results, including a comprehensive discussion of limitations.

Hot topics in urological health economics. A mini review.

Urological diseases are becoming a major public health problem. In fact, they increasingly weigh on the economy of a country due to the high direct costs and the consequent significant loss of productivity. Prostate cancer represents 11% of the costs for the treatment of all cancers in the United States with $8 billion and a cost per-patient from diagnosis to death of $81,658. Instead bladder cancer has the higher costs per-patient in terms of medical care, from diagnosis until death (U.S. $ 96,553). In Italy, in a reference hospital, the average costs of non muscle-invasive forms treated with endoscopic resection (TURB) and infiltrating forms treated with radical cystectomy are approximately Euro 2242.20 and Euro 6860 respectively, but they increase due to the follow-up and the ancillary treatments. In the field of functional disease, in the U.S. the average annual expenditure per capita for incontinence, including inpatient and outpatient services is $1382. While for patients who had undergone surgery the average total spending rose to $3620. For overactive bladder the total cost in the United States is estimated at 12.02 billion U.S. dollars, with $9.17 billion allocated to the community costs and $ 2.85 billion for institutional costs. However, further pharmacoeconomic studies are required to better understand the net economic impact of any alternative strategies to those actually present. Stone disease is a highly prevalent and costly condition for which United States total health care expenditures, in the year 2000, were estimated to be almost $ 2.1 billion. Treatment of nephrolithiasis depends on stone size and location, but typically involves a surgical procedure such as extracorporeal shock wave lithotripsy (ESWL), ureteroscopic laser lithotripsy, percutaneous nephrostolithotomy (PCNL) or open stone surgery with an average expenditure per procedure of $2295, $1425, $3624, $2916 respectively.

[Amendments to the German diagnosis-related groups (G-DRG) system for urology in 2012]. / Veränderungen des G-DRG-Systems für die Urologie im Jahre 2012.

The remuneration system of German diagnosis-related groups (G-DRG) is updated every year in a clearly defined process. This article presents all changes relevant for urologists in 2012.

[Complexity level simulation in the German diagnosis-related groups system: the financial effect of coding of comorbidity diagnostics in urology]. / Schweregradsimulation im G-DRG-System : Die finanziellen Auswirkungen der Nebendiagnosenkodierung in der Urologie.

BACKGROUND: Precise and complete coding of diagnoses and procedures is of value for optimizing revenues within the German diagnosis-related groups (G-DRG) system. The implementation of effective structures for coding is cost-intensive. The aim of this study was to prove whether higher costs can be refunded by complete acquisition of comorbidities and complications. METHODS: Calculations were based on DRG data of the Department of Urology, University Hospital of Münster, Germany, covering all patients treated in 2009. The data were regrouped and subjected to a process of simulation (increase and decrease of patient clinical complexity levels, PCCL) with the help of recently developed software. RESULTS: In urology a strong dependency of quantity and quality of coding of secondary diagnoses on PCCL and subsequent profits was found. Departmental budgetary procedures can be optimized when coding is effective. The new simulation tool can be a valuable aid to improve profits available for distribution. Nevertheless, calculation of time use and financial needs by this procedure are subject to specific departmental terms and conditions. CONCLUSIONS: Completeness of coding of (secondary) diagnoses must be the ultimate administrative goal of patient case documentation in urology.