Emergency General Surgery Procedures and Cost of Care for Older Adults in the State of Maryland.

BACKGROUND: Older adults (OAs) ≥ 65 years of age, representing the fastest growing segment in the United States, are anticipated to require a greater percentage of emergency general surgery procedures (EGSPs) with an associated increase in health care costs. The aims of this study were to identify the frequency of EGSP and charges incurred by OA compared to their younger counterparts in the state of Maryland. METHODS: A retrospective review of the Maryland Health Services Cost Review Commission from 2009 to 2018 was undertaken. Patients undergoing urgent or emergent ESGP were divided into 2 groups (18-64 years and ≥65 years). Data collected included demographics, APR-severity of illness (SOI), APR-risk of mortality (ROM), the EGSP (partial colectomy [PC], small bowel resection [SBR], cholecystectomy, operative management of peptic ulcer disease, lysis of adhesions, appendectomy, and laparotomy), length of stay (LOS), and hospital charges. P-values (P < .05) were significant. RESULTS: Of the 181,283 patients included in the study, 55,401 (38.1%) were ≥65 years of age. Older adults presented with greater APR-SOI (major 37.7% vs 21.3%, extreme 5.2% vs 9.3%), greater APR-ROM (major 25.3% vs 8.7%, extreme 22.3% vs 5.3%), underwent PC (24.5% vs 10.9%) and SBR (12.8% vs 7.0%) more frequently, and incurred significantly higher median hospital charges for every EGSP, consistently between 2009 and 2018 due to increased LOS and complications when compared to those ≤65 years of age. CONCLUSION: These findings stress the need for validated frailty indices and quality improvement initiatives focused on the care of OAs in emergency general surgery to maximize outcomes and optimize cost.

A model-based cost-utility analysis of multi-professional simulation training in obstetric emergencies.

OBJECTIVE: To determine the cost-utility of a multi-professional simulation training programme for obstetric emergencies-Practical Obstetric Multi-Professional Training (PROMPT)-with a particular focus on its impact on permanent obstetric brachial plexus injuries (OBPIs). DESIGN: A model-based cost-utility analysis. SETTING: Maternity units in England. POPULATION: Simulated cohorts of individuals affected by permanent OBPIs. METHODS: A decision tree model was developed to estimate the cost-utility of adopting annual, PROMPT training (scenario 1a) or standalone shoulder dystocia training (scenario 1b) in all maternity units in England compared to current practice, where only a proportion of English units use the training programme (scenario 2). The time horizon was 30 years and the analysis was conducted from an English National Health Service (NHS) and Personal Social Services perspective. A probabilistic sensitivity analysis was performed to account for uncertainties in the model parameters. MAIN OUTCOME MEASURES: Outcomes for the entire simulated period included the following: total costs for PROMPT or shoulder dystocia training (including costs of OBPIs), number of OBPIs averted, number of affected adult/parental/dyadic quality adjusted life years (QALYs) gained and the incremental cost per QALY gained. RESULTS: Nationwide PROMPT or shoulder dystocia training conferred significant savings (in excess of £1 billion ($1.5 billion)) compared to current practice, resulting in cost-savings of at least £1 million ($1.5 million) per any type of QALY gained. The probabilistic sensitivity analysis demonstrated similar findings. CONCLUSION: In this model, national implementation of multi-professional simulation training for obstetric emergencies (or standalone shoulder dystocia training) in England appeared to both be cost-saving when evaluating their impact on permanent OBPIs.

Multimorbidity combinations, costs of hospital care and potentially preventable emergency admissions in England: A cohort study.

BACKGROUND: Patients with multimorbidities have the greatest healthcare needs and generate the highest expenditure in the health system. There is an increasing focus on identifying specific disease combinations for addressing poor outcomes. Existing research has identified a small number of prevalent "clusters" in the general population, but the limited number examined might oversimplify the problem and these may not be the ones associated with important outcomes. Combinations with the highest (potentially preventable) secondary care costs may reveal priority targets for intervention or prevention. We aimed to examine the potential of defining multimorbidity clusters for impacting secondary care costs. METHODS AND FINDINGS: We used national, Hospital Episode Statistics, data from all hospital admissions in England from 2017/2018 (cohort of over 8 million patients) and defined multimorbidity based on ICD-10 codes for 28 chronic conditions (we backfilled conditions from 2009/2010 to address potential undercoding). We identified the combinations of multimorbidity which contributed to the highest total current and previous 5-year costs of secondary care and costs of potentially preventable emergency hospital admissions in aggregate and per patient. We examined the distribution of costs across unique disease combinations to test the potential of the cluster approach for targeting interventions at high costs. We then estimated the overlap between the unique combinations to test potential of the cluster approach for targeting prevention of accumulated disease. We examined variability in the ranks and distributions across age (over/under 65) and deprivation (area level, deciles) subgroups and sensitivity to considering a smaller number of diseases. There were 8,440,133 unique patients in our sample, over 4 million (53.1%) were female, and over 3 million (37.7%) were aged over 65 years. No clear "high cost" combinations of multimorbidity emerged as possible targets for intervention. Over 2 million (31.6%) patients had 63,124 unique combinations of multimorbidity, each contributing a small fraction (maximum 3.2%) to current-year or 5-year secondary care costs. Highest total cost combinations tended to have fewer conditions (dyads/triads, most including hypertension) affecting a relatively large population. This contrasted with the combinations that generated the highest cost for individual patients, which were complex sets of many (6+) conditions affecting fewer persons. However, all combinations containing chronic kidney disease and hypertension, or diabetes and hypertension, made up a significant proportion of total secondary care costs, and all combinations containing chronic heart failure, chronic kidney disease, and hypertension had the highest proportion of preventable emergency admission costs, which might offer priority targets for prevention of disease accumulation. The results varied little between age and deprivation subgroups and sensitivity analyses. Key limitations include availability of data only from hospitals and reliance on hospital coding of health conditions. CONCLUSIONS: Our findings indicate that there are no clear multimorbidity combinations for a cluster-targeted intervention approach to reduce secondary care costs. The role of risk-stratification and focus on individual high-cost patients with interventions is particularly questionable for this aim. However, if aetiology is favourable for preventing further disease, the cluster approach might be useful for targeting disease prevention efforts with potential for cost-savings in secondary care.

Data-Driven Estimation of the Impact of Diversions Due to In-Flight Medical Emergencies on Flight Delay and Aircraft Operating Costs.

INTRODUCTION: In-flight medical emergencies (IFMEs) average 1 of every 604 flights and are expected to increase as the population ages and air travel increases. Flight diversions, or the rerouting of a flight to an alternate destination, occur in 2 to 13% of IFME cases, but may or may not be necessary as determined after the fact. Estimating the effect of IFME diversions compared to nonmedical diversions can be expected to improve our understanding of their impact and allow for more appropriate decision making during IFMEs.METHODS: The current study matched multiple disparate datasets, including medical data, flight plan and track data, passenger statistics, and financial data. Chi-squared analysis and independent samples t-tests compared diversion delays and costs metrics between flights diverted for medical vs. nonmedical reasons. Data were restricted to domestic flights between 1/1/2018 and 6/30/2019.RESULTS: Over 70% of diverted flights recover (continue on to their intended destination after diverting); however, flights diverted due to IFMEs recover more often and more quickly than do flights diverted for nonmedical reasons. IFME diversions introduce less delay overall and cost less in terms of direct operating costs and passenger value of time (averaging around 38,000) than do flights diverted for nonmedical reasons.DISCUSSION: Flights diverted due to IFMEs appear to have less impact overall than do flights diverted for nonmedical reasons. However, the lack of information related to costs for nonrecovered flights and the decision factors involved during nonmedical diversions hinders our ability to offer further insights.Lewis BA, Gawron VJ, Esmaeilzadeh E, Mayer RH, Moreno-Hines F, Nerwich N, Alves PM. Data-driven estimation of the impact of diversions due to in-flight medical emergencies on flight delay and aircraft operating costs. Aerosp Med Hum Perform. 2021; 92(2):99105.

Living with Ulcerative Colitis Study (LUCY) in England: a retrospective study evaluating healthcare resource utilisation and direct healthcare costs of postoperative care in ulcerative colitis.

OBJECTIVE: Ulcerative colitis (UC) is a lifelong, relapsing-remitting disease. Patients non-responsive to pharmacological treatment may require a colectomy. We estimated pre-colectomy and post-colectomy healthcare resource utilisation (HCRU) and costs in England. DESIGN/METHOD: A retrospective, longitudinal cohort study indexing adult patients with UC undergoing colectomy (2009-2015), using linked Clinical Practice Research Datalink/Hospital Episode Statistics data, was conducted. HCRU, healthcare costs and pharmacological treatments were evaluated during 12 months prior to and including colectomy (baseline) and 24 months post-colectomy (follow-up; F-U), comparing baseline/F-U, emergency/elective colectomy and subtotal/full colectomy using descriptive statistics and paired/unpaired tests. RESULTS: 249 patients from 26 165 identified were analysed including 145 (58%) elective and 184 (74%) full colectomies. Number/cost of general practitioner consultations increased post-colectomy (p<0.001), and then decreased at 13-24 months (p<0.05). From baseline to F-U, the number of outpatient visits, number/cost of hospitalisations and total direct healthcare costs decreased (all p<0.01). Postoperative HCRU was similar between elective and emergency colectomies, except for the costs of colectomy-related hospitalisations and medication, which were lower in the elective group (p<0.05). Postoperative costs were higher for subtotal versus full colectomies (p<0.001). At 1-12 month F-U, 30%, 19% and 5% of patients received aminosalicylates, steroids and immunosuppressants, respectively. CONCLUSION: HCRU/costs increased for primary care in the first year post-colectomy but decreased for secondary care, and varied according to the colectomy type. Ongoing and potentially unnecessary pharmacological therapy was seen in up to 30% of patients. These findings can inform patients and decision-makers of potential benefits and burdens of colectomy in UC.

Emergency medical care of incarcerated patients: Opportunities for improvement and cost savings.

In the United States (US), the lifetime incidence of incarceration is 6.6%, exceeding that of any other nation. Compared to the general US population, incarcerated individuals are disproportionally affected by chronic health conditions, mental illness, and substance use disorders. Barriers to accessing medical care are common in correctional facilities. We sought to characterize the local incarcerated patient population and explore barriers to medical care in these patients. We conducted a retrospective, observational cohort study by reviewing the medical records of incarcerated patients presenting to the adult emergency department (ED) of a single academic, tertiary care facility with medical or psychiatric (med/psych) and trauma-related emergencies between January 2012 and December 2014. Data on demographics, medical complexity, trauma intentionality, and barriers to medical care were analyzed using descriptive statistics, unpaired student's t-test or one-way analysis of variance for continuous variables, and chi-square analysis or Fisher's exact test as appropriate. Trauma patients were younger with fewer medical comorbidities and were less likely to be admitted to the hospital than med/psych patients. 47.8% of injuries resulted from violence or were self-inflicted. Most trauma-related complaints were managed by the emergency medicine physician in the ED. While barriers to medical care were not correlated with hospital admission, 5.4% of med/psych and 2.9% of trauma patients reported barriers as a contributing factor to the ED encounter. Med/psych patients commonly reported a lack of access to medications, while trauma patients reported a delay in medical care. Trauma-related presentations were less medically complex than med/psych-related complaints. Medical management of most injuries required no hospital resources outside of the ED, indicating a potential role for outpatient management of trauma-related complaints. Additional opportunities for health care improvement and cost savings include the implementation of programs that target violence, prevent injuries, and promote the continuity of medical care while incarcerated.

Cash-based assistance and the nutrition status of pregnant and lactating women in the Somalia food crisis: A comparison of two transfer modalities.

BACKGROUND: Large-scale emergency assistance programmes in Somalia use a variety of transfer modalities including in-kind food provision, food vouchers, and cash transfers. Evidence is needed to better understand whether and how such modalities differ in reducing the risk of acute malnutrition in vulnerable groups, such as the 800,000 pregnant and lactating women affected by the 2017/18 food crisis. METHODS: Changes in diet and acute malnutrition status were assessed among pregnant and lactating women receiving similarly sized household transfers over a four-month period (total value of ~US$450 per household) delivered either as food vouchers or as mixed transfers consisting of in-kind food, vouchers, and cash. Baseline and endline comparisons were conducted for 514 women in Wajid, Somalia. Primary study outcomes were Minimum Dietary Diversity for Women, meal frequency, and mid-upper arm circumference (MUAC), with MUAC<21.0 cm classified as acute malnutrition. Adjusted analyses consisted of difference-in-difference analysis using linear and logistic regression models with inverse probability weighting based on propensity scores to account for the non-randomized design. FINDINGS: No significant difference in change in dietary quality was observed between food voucher and mixed transfer recipients; a significant difference in change in mean meal frequency was observed (0.3 meals/day, CI: 0.1-0.5, p = 0.001) and the mixed transfer group had significantly greater meal frequency at endline (p<0.001). Mean MUAC increased significantly among both voucher (0.9cm, CI: 0.6-1.3, p = 0.001) and mixed transfer recipients (1.3cm, CI: 1.1-1.5, p = 0.001) over the intervention period in adjusted analysis, however, the difference in magnitude of change between the two groups was not statistically significant (0.4cm, CI: -0.1-0.08, p = 0.086). CONCLUSIONS: Within the context of the 2017/18 Somalia food crisis, the modality of assistance provided to pregnant and lactating women (mixed transfers or food-vouchers) made no difference in preventing acute malnutrition and protecting nutritional status.

A needs assessment for a minor eye condition service within Leeds, Bradford and Airedale, UK.

BACKGROUND: There are a number of limitations to the present primary eye care system in the UK. Patients with minor eye conditions typically either have to present to their local hospital or GP, or face a charge when visiting eye care professionals (optometrists). Some areas of the UK have commissioned enhanced community services to alleviate this problem; however, many areas have not. The present study is a needs assessment of three areas (Leeds, Airedale and Bradford) without a Minor Eye Conditions Service (MECS), with the aim of determining whether such a service is clinically or economically viable. METHOD: A pro forma was developed for optometrists and practice staff to complete when a patient presented whose reason for attending was due to symptoms indicative of a problem that could not be optically corrected. This form captured the reason for visit, whether the patient was seen, the consultation funding, the outcome and where the patient would have presented to if the optometrists could not have seen them. Optometrists were invited to participate via Local Optical Committees. Results were submitted via a Google form or a Microsoft Excel document and were analysed in Microsoft Excel. RESULTS: Seventy-five percent of patients were managed in optometric practice. Nine and 16% of patients required subsequent referral to their General Practitioner or hospital ophthalmology department, respectively. Should they not have been seen, 34% of patients would have presented to accident and emergency departments and 59% to their general practitioner. 53% of patients paid privately for the optometrist appointment, 28% of patients received a free examination either through use of General Ophthalmic Service sight tests (9%) or optometrist good will (19%) and 19% of patients did not receive a consultation and were redirected to other providers (e.g. pharmacy, accident and emergency or General Practitioner). 88% of patients were satisfied with the level of service. Cost-analyses revealed a theoretical cost saving of £3198 to the NHS across our sample for the study period, indicating cost effectiveness. CONCLUSIONS: This assessment demonstrates that a minor eye condition service in the local areas would be economically and clinically viable and well received by patients.

Japanese surgical resource utilization in 2016.

PURPOSE: The purpose of this paper is to examine from the viewpoint of resource utilization the Japanese surgical payment system which was revised in April 2016. DESIGN/METHODOLOGY/APPROACH: The authors collected data from surgical records in the Teikyo University electronic medical record system from April 1 till September 30, 2016. The authors defined the decision-making unit as a surgeon with the highest academic rank in the surgery. Inputs were defined as the number of medical doctors who assisted surgery, and the time of operation from skin incision to closure. An output was defined as the surgical fee. The authors calculated each surgeon's efficiency score using output-oriented Charnes-Cooper-Rhodes model of data envelopment analysis. The authors compared the efficiency scores of each surgical specialty using the Kruskal-Wallis and the Steel method. FINDINGS: The authors analyzed 2,558 surgical procedures performed by 109 surgeons. The difference in efficiency scores was significant (p = 0.000). The efficiency score of neurosurgery was significantly greater than obstetrics and gynecology, general surgery, orthopedics, emergency surgery, urology, otolaryngology and plastic surgery (p<0.05). ORIGINALITY/VALUE: The authors demonstrated that the surgeons' efficiency was significantly different among their specialties. This suggests that the Japanese surgical reimbursement scales fail to reflect resource utilization despite the revision in 2016.

An Evaluation of Emergency Hand Coverage in Tennessee After Implementation of the Affordable Care Act.

Although the upper extremity is the most commonly injured part of the body, many studies have indicated that there is a lack of emergency hand coverage in the United States. In 2010, our laboratory evaluated on-call hand coverage in Tennessee (TN) and found that only 7% of hospitals had a hand surgeon on call for emergency cases at all times. In 2014, the Affordable Care Act (ACA) was implemented with the goal of increasing overall access to care and decreasing health care costs. Hand surgeons were surveyed on their attitudes toward the ACA, and the majority of surgeons surveyed disagreed or strongly disagree that the ACA would improve access to emergent hand surgery. This study aimed to determine if there has been an increase in emergency hand coverage in TN since the implementation of the ACA. A survey was administered to all hospitals in TN with both an emergency department and operating room to determine the percentage of TN hospitals offering elective hand surgery and on-call emergency hand coverage. With 94% of TN hospitals responding to the emergency department survey, we determined that there has been a 138% significant increase in the percentage of hospitals reporting 24/7 emergency hand coverage by a hand specialist since our last study in 2010. There has also been a significant increase in elective hand coverage in TN, although much smaller at 13% since 2010. This study suggests that there has been an overall increase in access to hand care in TN since the implementation of the ACA, most profoundly seen in the increase in hand specialists available for emergent cases.

Association of Psoriasis with Psychiatric Hospitalization in United States Children and Adults.

BACKGROUND: Psoriasis is associated with psychosocial distress. Little is known about the relationship between psoriasis and mental health (MH) emergencies. OBJECTIVE: To examine the associations of psoriasis and MH hospitalizations in the USA. METHODS: Data from the 2002-2012 National Inpatient Sample were analyzed, including an approximately 20% sample of all US hospitalizations (n = 87,053,155 children and adults). RESULTS: Hospitalization for MH disorders occurred more commonly in those with psoriasis compared to those without psoriasis (4.04 vs. 2.21%). In multivariable logistic regression models, psoriasis was associated with higher odds of admission for any MH disorder overall (adjusted odds ratio [95% confidence interval]: 2.32 [2.24-2.41]), as well as 9 of the 15 MH-specific disorders examined. Associated MH disorders included: anxiety, schizophrenia, personality disorder, depression, substance use disorders, history of MH disorder, alcohol-related disorders, adjustment disorders, and cognitive disorders. Children with versus those without psoriasis were also more likely to have a primary hospitalization for any MH disorder (2.82 [2.24-3.56]). Psoriasis inpatients were also more likely to have a primary hospitalization for any MH disorder compared to those with alopecia areata (1.99 [1.45-2.74]) or hidradenitis suppurativa (3.97 [3.49-4.52]). Psoriasis patients hospitalized with any MH disorder had higher mean [95% confidence interval] cost of inpatient care (USD 11,004 [10,846-11,241] vs. 9,547 [8,730-10,364]; p < 0.0001) compared to those without psoriasis, with USD 1,610,860 excess costs annually, with the majority of the costs coming from depression and mood disorders. CONCLUSIONS: Children and adults with psoriasis had increased hospitalization for multiple MH disorders, which were associated with a considerable financial burden.

Elective or emergency heart transplantation: Cost comparison in a single center.

BACKGROUND AND AIMS: Heart transplantation (HT) is the treatment of choice for selected cases of advanced heart failure. There is an increasing rate of emergency HT in our country. The aim of this study was to determine the cost of HT in our hospital according to emergent vs. elective transplantation status. METHODS: The costs of all consecutive HTs performed in our center between January 2010 and May 2015 were analyzed. The cost of elective and emergent HT was compared. RESULTS: HT mean cost at our institution was €62 203 ± 47 976. Elective HT mean cost was €47 540 ± 25 140, whereas emergent HT cost was €102 733 ± 68 050 (emergency status 1, as regional priority, was €66 077 ± 28 067 and emergency status 0, as the highest national priority, was €136 056 ± 77 080; P < 0.001). Increased emergent HT cost was mainly related to a longer admission (32 ± 24 days vs. 69 ± 53 days; P = 0.006; accounting for a cost of €14 517 ± 12 475 vs. €37 846 ± 31 702; P < 0.001) and increased drug-related expenses (€6622 ± 7465 vs. €15,171 ± 15,758; P < 0.02). Elective HT survival rate was 96%, compared to 68% for emergent HT; P = 0.002. CONCLUSIONS: Elective HT showed a high survival rate with a relatively low and less variable cost, leading to a favorable economic balance in today's public health reimbursement system. In contrast, emergent HT showed a higher cost and a lower survival rate. New treatment strategies should be identified for heart failure patients at risk of requiring emergency HT.

Emergency Laparoscopic Cholecystectomy: Is Dedicated Hot Gall Bladder List Cost Effective?

BACKGROUND: Acute presentation of gall stone disease is a common emergency. Resource limitation often results in unnecessary long waiting times and repeat hospital admissions. The aim of this study was to investigate if funding a dedicated hot gall bladder list is justified. METHODS: Patients with acute gall stone related complications between 1st January 2016 and 31st December 2017 were studied. Outcome measures included the number of acute admissions, length of hospital stay (LOS), approximate cost per patient. The length of stay was identified as a critical outcome measure. RESULTS: Fourteen hundred and ninety-five (11%) out of 14189 acute surgical admissions were related to gall stone complications. These included acute cholecystitis 576 (39%), biliary colic 485 (32%), pancreatitis 405 (27%) and jaundice 34 (2%). Twelve hundred and twenty-two patients accounted for 1461 admissions. 182 (15%) patients had recurrent admissions (35%) and on average stayed 11.2 days in the hospital compared to 5.8 days for that of single presentation. The cost of emergency LC (£2053) was less than half of elective LC following single emergency admission (£5661) and less than one third of Elective LC following recurrent admissions (£7453). A trust can save £1,891,784 per year by achieving 80% target. The savings can be used to fund a dedicated hot gall bladder list, releasing hospital beds and additional benefit of reducing the workforce days lost to sickness in general. CONCLUSIONS: Emergency LC is cost effective and savings made for such a service is sufficient to fund a dedicated hot gall bladder list..

Emergency department visits in older patients: a population-based survey.

BACKGROUND: Given the higher incidence of emergency conditions in older inhabitants, the global increase in aged population will pose a challenge for emergency services. In this study we examined the burden caused to emergency health care by the aged population. METHODS: Consecutive patients aged 80 years or over visiting a high-volume, collaborative emergency department (ED) between 2015 and 2016 were included. The key factors under analysis were the incidence of emergency conditions and costs associated with emergency care. RESULTS: A total of 6944 patients (median age 85 years, range 80-104 years; 67% female) aged ≥80 years representing 1.5% of the local population, made 17,769 ED visits during the two-year observation period accounting for 15% of all ED visits. Forty-two percent (n = 2884) of patients had a single ED visit, whereas 8.2% (n = 570) made ≥5 ED visits/year for a total of 1400 visits (7.9%). Thirty-two percent of those aged ≥80 years required ED services each year. The number of ED visits increased with age (p < 0.001); and was 768/1000 person-years among octogenarians and 1007/1000 among nonagenarians, in comparison to 233/1000 among those aged < 80 years. One in five of the study population were discharged with non-specific diagnoses. Typical diagnoses included pneumonia (4.8%), malaise and fatigue (4.5%) and heart failure (4.3%). Non-specific diagnoses were frequent, and examination of patients with non-specific diagnoses incurred costs similar to or higher than those of other patients. The mean cost per ED visit in older patients was 422 €. CONCLUSIONS: We demonstrated a high incidence of emergency department visits in older patients. While our aim was not to solve how the growing demand should be met, it seems unlikely that increasing ED resources is feasible. Instead, the focus should be on chronic care of the aged and prevention of potentially avoidable ED visits.