[National competitive bidding analysis of osteosynthesis materials in pediatric patients with femur fractures]. / Análisis de licitación pública nacional de materiales de osteosíntesis en los pacientes pediátricos con fracturas de fémur.

INTRODUCTION: health promotion policy requires the identification of barriers to the adoption of public policies. Paraguay's national healthcare system is inequitable, expensive, and inefficient. The Ministry of Public Health and Social Welfare (MSPyBS) is the entity responsible for covering the needs of a significant portion of the population. In January 2022, the MSPyBS financed the purchase of titanium elastic nails through a National Public Tender for Osteosynthesis Materials (LPN 02/22) to provide them for free in the pediatric service. Using research as a tool, we seek to analyze the impact of the implementation of LPN 02/22 at the Trauma Hospital, believing that this action would help streamline administrative and bureaucratic processes, making them more efficient with the assistance of the hospital's human resources. MATERIAL AND METHODS: a retrospective, analytical, and comparative study conducted at a high-complexity trauma center in Asunción, Paraguay. Patients aged 4 to 14 years with an indication for stabilization with elastic nails were included. Demographic data, the mechanism of injury, time elapsed from hospital arrival to surgical treatment, length of hospital stay, and the average hospital cost were analyzed based on the daily expense of pediatric patient hospitalization. RESULTS: 52 patients, divided into 25 cases in 2021 before implementation and 27 cases after implementation. The time elapsed from hospital arrival to definitive treatment was six days in the pre-implementation period, with an average stay from admission to discharge of 7.4 days. After implementation, the time from hospital arrival to definitive treatment was 4.3 days, and the average discharge time for the Post group was six days. The potential savings per patient amount to 332 dollars, offset by the institution's implant supply cost of 197 dollars, resulting in an approximate savings of 135 dollars per patient for the ministry. CONCLUSIONS: we view the implementation of free titanium elastic nails for pediatric femur fracture patients positively. We encourage the institution to continue with similar policies and strive to achieve even greater benefits for users.

INTRODUCCIÓN: la política de promoción de la salud requiere la identificación de los obstáculos para la adopción de políticas públicas. El sistema nacional de salud de Paraguay es inequitativo, caro e ineficiente. El Ministerio de Salud Pública y Bienestar Social (MSPyBS) es el ente que cubre las necesidades de gran parte de la población. El MSPyBS en Enero del 2022 financió, mediante la Licitación Pública Nacional de Materiales de Osteosíntesis (LPN 02/22), la compra de clavos elásticos de titanio para disponer de su uso gratuito en el Servicio de Pediatría; usando a la investigación como herramienta, buscamos analizar el impacto de la implementación de la LPN 02/22 en el Hospital de Trauma, creyendo que esta acción ayudaría a dinamizar los procesos administrativos y burocráticos, haciéndolos más eficientes con la ayuda de los recursos humanos del hospital. MATERIAL Y MÉTODOS: estudio retrospectivo, analítico y comparativo, realizado en un centro de trauma de alta complejidad de Asunción, Paraguay. Fueron incluidos los pacientes con edad comprendidas entre cuatro y 14 años, con indicación de estabilización con clavos elásticos. Se analizaron los datos demográficos, el mecanismo de trauma, el tiempo transcurrido desde la llegada al hospital hasta el tratamiento quirúrgico, así como el tiempo de estadía hospitalaria. Se evaluó el costo hospitalario promedio, basados en el gasto diario de la internación de un paciente pediátrico. RESULTADOS: cincuenta y dos pacientes, separados en 25 casos en el 2021 previo a la implementación y 27 casos posterior a la implementación. El tiempo transcurrido desde la llegada al hospital hasta el tratamiento definitivo fue de seis días para la etapa previa a la implementación; el promedio desde el ingreso hasta el alta fue de 7.4 días. Desde la implementación se tuvo un transcurso de 4.3 días desde la llegada al hospital hasta el tratamiento definitivo. El egreso del grupo Post tuvo un promedio de seis días. El ahorro probable en relación con cada paciente es de 332 dólares; a esto debemos contrarrestar el monto que paga la institución para la provisión del implante (197 dólares), por lo que el ahorro del ministerio sería de aproximadamente 135 dólares por cada paciente. CONCLUSIONES: vemos como positiva la implementación de la gratuidad de los clavos elásticos de titanio en los pacientes en edad pediátrica con fractura de fémur. Alentamos a la institución a seguir con políticas similares y tratar de lograr mayores beneficios para los usuarios.

Clinical and economic comparison of laparoscopic versus open hepatectomy for primary hepatolithiasis: a propensity score-matched cohort study.

BACKGROUND: It is unclear whether laparoscopic hepatectomy (LH) for hepatolithiasis confers better clinical benefit and lower hospital costs than open hepatectomy (OH). This study aim to evaluate the clinical and economic value of LH versus OH. METHODS: Patients undergoing OH or LH for primary hepatolithiasis at Yijishan Hospital of Wannan Medical College between 2015 and 2022 were divided into OH group and LH group. Propensity score matching (PSM) was used to balance the baseline data. Deviation-based cost modelling and weighted average median cost (WAMC) were used to assess and compare the economic value. RESULTS: A total of 853 patients were identified. After exclusions, 403 patients with primary hepatolithiasis underwent anatomical hepatectomy (OH n=143; LH n=260). PSM resulted in 2 groups of 100 patients each. Although LH required a longer median operation duration compared with OH (285.0 versus 240.0 min, respectively, P<0.001), LH patients had fewer wound infections, fewer pre-discharge overall complications (26 versus 43%, respectively, P=0.009), and shorter median postoperative hospital stays (8.0 versus 12.0 days, respectively, P<0.001). No differences were found in blood loss, major complications, stone clearance, and mortality between the two matched groups. However, the median overall hospital cost of LH was significantly higher than that of OH (CNY¥52,196.1 versus 45,349.5, respectively, P=0.007). Although LH patients had shorter median postoperative hospital stays and fewer complications than OH patients, the WAMC was still higher for the LH group than for the OH group with an increase of CNY¥9,755.2 per patient undergoing LH. CONCLUSION: The overall clinical benefit of LH for hepatolithiasis is comparable or even superior to that of OH, but with an economic disadvantage. There is a need to effectively reduce the hospital costs of LH and the gap between costs and diagnosis-related group reimbursement to promote its adoption.

Hospital care direct costs due to ambulatory care sensitive conditions related to diabetes mellitus in the Mexican public healthcare system.

BACKGROUND: Hospitalizations for ambulatory care sensitive conditions (ACSC) incur substantial costs on the health system that could be partially avoided with adequate outpatient care. Complications of chronic diseases, such as diabetes mellitus (DM), are considered ACSC. Previous studies have shown that hospitalizations due to diabetes have a significant financial burden. In Mexico, DM is a major health concern and a leading cause of death, but there is limited evidence available. This study aimed to estimate the direct costs of hospitalizations by DM-related ACSC in the Mexican public health system. METHODS: We selected three hospitals from each of Mexico's main public institutions: the Mexican Social Security Institute (IMSS), the Ministry of Health (MoH), and the Institute of Social Security and Services for State Workers (ISSSTE). We employed a bottom-up microcosting approach from the healthcare provider perspective to estimate the total direct costs of hospitalizations for DM-related ACSC. Input data regarding length of stay (LoS), consultations, medications, colloid/crystalloid solutions, procedures, and laboratory/medical imaging studies were obtained from clinical records of a random sample of 532 hospitalizations out of a total of 1,803 DM-related ACSC (ICD-10 codes) discharges during 2016. RESULTS: The average cost per DM-related ACSC hospitalization varies among institutions, ranging from $1,427 in the MoH to $1,677 in the IMSS and $1,754 in the ISSSTE. The three institutions' largest expenses are LoS and procedures. Peripheral circulatory and renal complications were the major drivers of hospitalization costs for patients with DM-related ACSC. Direct costs due to hospitalizations for DM-related ACSC in these three institutions represent 1% of the gross domestic product (GDP) dedicated to health and social services and 2% of total hospital care expenses. CONCLUSIONS: The direct costs of hospitalizations for DM-related ACSC vary considerably across institutions. Disparities in such costs for the same ACSC among different institutions suggest potential disparities in care quality across primary and hospital settings (processes and resource utilization), which should be further investigated to ensure optimal supply utilization. Prioritizing preventive measures for peripheral circulatory and renal complications in DM patients could be highly beneficial.

Clinical outcomes and costs of retromuscular and intraperitoneal onlay mesh techniques in robotic incisional hernia repair.

BACKGROUND: This study aims to compare clinical outcomes and financial cost of intraperitoneal onlay mesh (IPOM) versus retromuscular (RM) repairs in robotic incisional hernia repairs (rIHR). METHODS: Patients who underwent either IPOM or RM elective rIHR from 2012 to 2022 were included. Demographics, operative details, postoperative outcomes, and hospital costs were directly compared. RESULTS: Sixty-nine IPOM and 55 RM were included. Age and body mass index (BMI) did not differ between both groups (IPOM vs RM: 59.3 ± 11.2 years vs. 57.5 ± 14 years, p = 0.423; BMI 34.1 ± 6.3 vs. BMI 33.2 ± 6.9, p = 0.435, respectively). Comorbidities and hernia characteristics were comparable. Extensive lysis of adhesions (> 30 min) was required more often in IPOM (18 vs. 6 in RM, p = 0.034). Defect closure was achieved in 100% of RM vs. 81.2% in IPOM (p < 0.001). Median (interquartile range) postoperative pain score was higher in RM than in IPOM [5(3-7) vs. 4(3-5), respectively, p = 0.006]. Median length of stay (0 day) and same-day discharge rate did not differ between groups (p = 0.598, p = 0.669, respectively). Six (8.7%) patients in the IPOM group versus one (1.8%) patient in the RM group were readmitted to hospital within 30 days postoperatively (p = 0.099). Perioperative complications were higher in IPOM (p = 0.011; 34.8% vs. 14.5% in RM) with higher Comprehensive Complication Index® morbidity scores [0(0-12.2) vs 0(0-0) in RM, p = 0.008)], Clavien-Dindo grade-II complications (8 vs 0 in RM, p = 0.009), and surgical site events (17 vs. 5 in RM, p = 0.024). Within a follow-up period of 57(± 28) months, recurrence rates were similar between both groups. Hospital costs did not differ between groups [IPOM: $9978 (7031-12,926) vs. RM: $8961(6701-11,222), p = 0.300]. Although postoperative complication costs were higher in IPOM ($2436 vs RM: $161, p = 0.020), total costs were comparable [IPOM: $12,415(8700-16,130) vs. RM: $9123(6789-11,457), p = 0.080]. CONCLUSION: Despite retromuscular repairs having lower postoperative complications than intraperitoneal onlay mesh repairs, both techniques offered encouraging results in robotic incisional hernia repair at a comparable total cost.

Factors Associated With Prolonged Mental Health Admissions at US Children's Hospitals.

BACKGROUND AND OBJECTIVES: Mental health (MH) hospitalizations at medical hospitals are associated with longer length of stay (LOS) compared with non-MH hospitalizations, but patient factors and costs associated with prolonged MH hospitalizations are unknown. The objective of this paper is to assess patient clinical and demographic factors associated with prolonged MH hospitalizations and describe variation in MH LOS across US children's hospitals. METHODS: We studied children aged 5 to 20 years hospitalized with a primary MH diagnosis during 2021 and 2022 across 46 children's hospitals using the Pediatric Health Information System database. Generalized estimating equations, clustered on hospital, tested associations between patient characteristics with prolonged MH hospitalization, defined as those in the 95th percentile or above (>14 days). RESULTS: Among 42 654 primary MH hospitalizations, most were aged 14 to 18 (62.4%), female (68.5%), and non-Hispanic white (53.8%). The most common primary MH diagnoses were suicide/self-injury (37.4%), depressive disorders (16.6%), and eating disorders (10.9%). The median (interquartile range) LOS was 2 days (1-5), but 2169 (5.1%) experienced a hospitalization >14 days. In adjusted analyses, race and ethnicity, category of MH diagnosis, and increasing medical and MH complexity were associated with prolonged hospitalization. CONCLUSIONS: Our results emphasize several diagnoses and clinical descriptors for targeted interventions, such as behavioral and inpatient MH resources and discharge planning. Expanded investment in both community and inpatient MH supports have the potential to improve health equity and reduce prolonged MH hospitalizations.

Association of social determinants of health-related diagnosis codes with postoperative outcomes.

BACKGROUND: The association of an individual's social determinants of health-related problems with surgical outcomes has not been well-characterized. The objective of this study was to determine whether documentation of social determinants of a health-related diagnosis code (Z code) is associated with postoperative outcomes. METHODS: This retrospective cohort study included surgical cases from a single institution's national surgical quality improvement program (NSQIP) clinical registry from October 2015 to December 2021. The primary predictor of interest was documentation of a Z code for social determinants of health-related problems. The primary outcome was 30-day postoperative morbidity. Secondary outcomes included postoperative length of stay, disposition, and 30-day postoperative mortality, reoperation, and readmission. Multivariable regression models were fit to evaluate the association between the documentation of a Z code and outcomes. RESULTS: Of 10,739 surgical cases, 348 patients (3.2%) had a documented social determinants of health-related Z code. In multivariable analysis, documentation of a Z code was associated with increased odds of morbidity (20.7% vs. 9.9%; adjusted odds ratio [aOR], 1.88; 95% confidence interval [CI], 1.39-2.53), length of stay (median, 3 vs. 1 day; incidence rate ratio, 1.49; 95% CI, 1.33-1.67), odds of disposition to a location other than home (11.3% vs. 3.9%; aOR, 2.86; 95% CI, 1.89-4.33), and odds of readmission (15.3% vs. 6.1%; aOR, 1.99; 95% CI, 1.45-2.73). CONCLUSIONS: Social determinants of health-related problems evaluated using Z codes were associated with worse postoperative outcomes. Improved documentation of social determinants of health-related problems among surgical patients may facilitate improved risk stratification, perioperative planning, and clinical outcomes.

A Cost Analysis of Surgical Approach in Total Hip Arthroplasty.

BACKGROUND: With pressures to decrease the financial burden of total hip arthroplasty (THA), it is imperative to understand the cost drivers of this procedure. This study evaluated operative and total encounter costs for two surgical approaches to THA-posterior (P) and direct anterior (DA). MATERIALS AND METHODS: A total of 233 THAs (134 P and 99 DA) performed by two fellowship-trained arthroplasty surgeons from 2017 to 2022 were reviewed. Demographics, comorbidities, mobility status, operative time, length of stay, implants used, discharge location, and complications until final follow-up were recorded. Total encounter cost was collected and itemized. Multivariable regression analyses evaluated predictors of cost. RESULTS: There were differences in age (67 years for DA and 63 years for P; P=.03), body mass index (28.0 kg/m2 for DA and 33.8 kg/m2 for P; P<.01), Elixhauser Comorbidity Index score (4.6 for DA and 5.6 for P; P=.04), and operative time (2.1 hours for DA and 1.9 hours for P; P<.01) between the two cohorts. The DA cohort trended toward shorter length of stay, with the highest percentage of patients discharged home (86.9%; P=.02). The P cohort had the lowest encounter ($9601 for DA and $9100 for P; P=.20) and intraoperative (including implant used) ($7268 for DA and $6792 for P; P<.01) costs. The DA cohort had a significantly higher cost of radiology during the encounter ($244; P<.01). Regression analysis demonstrated that length of stay and DA approach were both predictors of increased encounter cost. CONCLUSION: The DA cohort had improved measures of health; however, this approach was associated with a higher operative cost and was predictive of increased encounter cost despite a shorter length of stay. [Orthopedics. 2024;47(3):e151-e156.].

Association between socioeconomic status and hospitalisation requirement in older patients attended at the emergency department: A retrospective cohort study.

INTRODUCTION AND OBJECTIVE: A low socioeconomic status (SES) has been associated with poor health results. The present study aimed to investigate if SES of older patients attending the emergency department is associated with the use of healthcare resources and outcomes. PATIENTS AND METHODS: Observational, retrospective study including consecutive patients 65 years or older admitted to the emergency department. Variables at baseline, index episode, and follow-up were recorded. SES was measured using an indirect theoretical index and patients were categorised into two groups according to whether they lived in a neighbourhood with a low or high SES. Primary outcomes included hospitalisation after the emergency department visit and prolonged hospitalisation (>7 days) at index episode. Secondary outcomes included emergency department re-consultant and hospital admission in the following 3 months after the index episode, and all-cause mortality after long-term follow-up. Logistic regression and cumulative hazards regression models were used to investigate associations between SES and outcomes. RESULTS: The cohort included 553 patients (80 years [73-85], 50.5% female, 55.9% with low SES). After the emergency department visit, 234 patients (42.3%) required hospital admission. A low SES was inversely associated with hospitalisation with an adjusted odds ratio=0.654 (95% CI 0.441-0.970). Among hospitalised patients, a low SES was associated with prolonged hospitalisation (adjusted odds ratio=2.739; 95% CI 1.470-5.104). Follow-up outcomes, including all-cause mortality, were not associated with SES. CONCLUSIONS: Older patients living in more deprived urban areas were hospitalised less often after emergency department care, but hospital stays were longer. Understanding the effect of social determinants in healthcare use is mandatory to tailor resources to patient needs.

The intersection of pediatric anesthesiology and social determinants of health.

PURPOSE OF REVIEW: There is increasing evidence of racial and ethnic disparities in pediatric perioperative care, which indicates a need to identify factors driving disparities. Social determinants of health (SDOH) play a fundamental role in pediatric health and are recognized as key underlying mechanisms of healthcare inequities. This article summarizes recent research exploring the influence of SDOH on pediatric perioperative outcomes. RECENT FINDINGS: Despite the scarcity of research exploring SDOH and pediatric perioperative outcomes, recent work demonstrates an association between SDOH and multiple outcomes across the perioperative care continuum. Measures of social disadvantage were associated with preoperative symptom severity, longer hospital stays, and higher rates of postoperative complications and mortality. In some studies, these adverse effects of social disadvantage persisted even when controlling for medical comorbidities and clinical severity. SUMMARY: The existing literature offers compelling evidence of the impact of SDOH on perioperative outcomes in children and reveals a critical area in pediatric anesthesia that necessitates further exploration and action. To improve outcomes and address care inequities, future efforts should prioritize the integration of SDOH assessment into pediatric perioperative research and practice.

The impact of different co-morbidities on clinical outcomes and resource utilization in critically ill burn and surgical patients: A population-based analysis of social determinants of health.

BACKGROUND: This study aims to establish the significance of social determinants of health and prevalent co-morbidities on multiple indicators for quality of care in patients admitted to the Burn and Surgical Intensive Care Unit (ICU). METHODS: We performed a retrospective analysis of population group data for patients admitted at the Burn and Surgical ICU from January 1, 2016, to November 18, 2019. The primary outcomes were length of hospital stay (LOS), mortality, 30-day readmission, and hospital charges. Pearson's chi-square test for categorical variables and t-test for continuous variables were used to compare population health groups. RESULTS: We analyzed a total of 487 burn and 510 surgical patients. When comparing ICU patients, we observed significantly higher mean hospital charges and length of stay (LOS) in BICU v. SICU patients with a history of mental health ($93,259.40 v. $50,503.36, p = 0.013 and 16.28 v. 9.16 days, p = 0.0085), end-stage-renal-disease (ESRD) ($653,871.05 v. $75,746.35, p = 0.0047 and 96.15 v. 17.53 days, p = 0.0104), sepsis ($267,979.60 v. $99,154.41, p = <0.001 and 39.1 v. 18.42 days, p = 0.0043), and venous thromboembolism (VTE) ($757,740.50 v. $117,816.40, p = <0.001 and 93.11 v. 20.21 days, p = 0.002). Also, higher mortality was observed in burn patients with ESRD, ST-Elevation Myocardial Infarction (STEMI), sepsis, VTE, and diabetes mellitus. 30-day-readmissions were greater among burn patients with a history of mental health, drug dependence, heart failure, and diabetes mellitus. CONCLUSIONS: Our study provides new insights into the variability of outcomes between burn patients treated in different critical care settings, underlining the influence of comorbidities on these outcomes. By comparing burn patients in the BICU with those in the SICU, we aim to highlight how differences in patient backgrounds, including the quality of care received, contribute to these outcomes. This comparison underscores the need for tailored healthcare strategies that consider the unique challenges faced by each patient group, aiming to mitigate disparities in health outcomes and healthcare spending. Further research to develop relevant and timely interventions that can improve these outcomes.

Same day discharge colon surgery: is it financially worth it?

AIM: Same day discharge (SDD) for colorectal surgery shows increasing promise in the era of enhanced recovery after surgery protocols and minimally invasive surgery. It has become increasingly relevant due to the constraints posed by the COVID-19 pandemic. The aim of this study was to compare SDD and postoperative day 1 (POD1) discharge to understand the clinical outcomes and financial impact on factors such as cost, charge, revenue, contribution margin and readmission. METHOD: A retrospective review of colectomies was performed at a single institution over a 2-year period (n = 143). Two populations were identified: SDD (n = 51) and POD1 (n = 92). Patients were selected by International Statistical Classification of Diseases and Related Health Problems-10 (ICD-10) and Diagnosis Related Grouper (DRG) codes. RESULTS: There was a statistically significant difference favouring SDD in total hospital cost (p < 0.0001), average direct costs (p < 0.0001) and average charges (p < 0.0016). SDD average hospital costs were $8699 (values in USD throughout) compared with $11 652 for POD 1 (p < 0.0001), and average SDD hospital charges were $85 506 compared with $97 008 for POD1 (p < 0.0016). The net revenue for SDD was $22 319 while for POD1 it was $26 173 (p = 0.14). Upon comparison of contribution margins (SDD $13 620 vs. POD1 $14 522), the difference was not statistically significant (p = 0.73). There were no identified statistically significant differences in operating room time, robotic console time, readmission rates or surgical complications. CONCLUSIONS: Amidst the pandemic-related constraints, we found that SDD was associated with lower hospital costs and comparable contribution margins compared with POD1. Additionally, the study was unable to identify any significant difference between operating time, readmissions, and surgical complications when performing SDD.

Development of a modified frailty index for adult spinal deformities independent of functional changes following surgical correction: a true baseline risk assessment tool.

PURPOSE: To develop a simplified, modified frailty index for adult spinal deformity (ASD) patients dependent on objective clinical factors. METHODS: ASD patients with baseline (BL) and 2-year (2Y) follow-up were included. Factors with the largest R2 value derived from multivariate forward stepwise regression were including in the modified ASD-FI (clin-ASD-FI). Factors included in the clin-ASD-FI were regressed against mortality, extended length of hospital stay (LOS, > 8 days), revisions, major complications and weights for the clin-ASD-FI were calculated via Beta/Sullivan. Total clin-ASD-FI score was created with a score from 0 to 1. Linear regression correlated clin-ASD-FI with ASD-FI scores and published cutoffs for the ASD-FI were used to create the new frailty cutoffs: not frail (NF: < 0.11), frail (F: 0.11-0.21) and severely frail (SF: > 0.21). Binary logistic regression assessed odds of complication or reop for frail patients. RESULTS: Five hundred thirty-one ASD patients (59.5 yrs, 79.5% F) were included. The final model had a R2 of 0.681, and significant factors were: < 18.5 or > 30 BMI (weight: 0.0625 out of 1), cardiac disease (0.125), disability employment status (0.3125), diabetes mellitus (0.0625), hypertension (0.0625), osteoporosis (0.125), blood clot (0.1875), and bowel incontinence (0.0625). These factors calculated the score from 0 to 1, with a mean cohort score of 0.13 ± 0.14. Breakdown by clin-ASD-FI score: 51.8% NF, 28.1% F, 20.2% SF. Increasing frailty severity was associated with longer LOS (NF: 7.0, F: 8.3, SF: 9.2 days; P < 0.001). Frailty independently predicted occurrence of any complication (OR: 9.357 [2.20-39.76], P = 0.002) and reop (OR: 2.79 [0.662-11.72], P = 0.162). CONCLUSIONS: Utilizing an existing ASD frailty index, we proposed a modified version eliminating the patient-reported components. This index is a true assessment of physiologic status, and represents a superior risk factor assessment compared to other tools for both primary and revision spinal deformity surgery as a result of its immutability with surgery, lack of subjectivity, and ease of use.

The association of timing of coronary artery bypass grafting for non-ST-elevation myocardial infarction and clinical outcomes in the contemporary United States.

BACKGROUND: In contrast to the timing of coronary angiography and percutaneous coronary intervention, the optimal timing of coronary artery bypass grafting (CABG) in non-ST-elevation myocardial infarction (NSTEMI) has not been determined. Therefore, we compared in-hospital outcomes according to different time intervals to CABG surgery in a contemporary NSTEMI population in the USA. METHODS: We identified all NSTEMI hospitalizations from 2016 to 2020 where revascularization was performed with CABG. We excluded NSTEMI with high-risk features using prespecified criteria. CABG was stratified into ≤24 h, 24-72 h, 72-120 h, and >120 h from admission. Outcomes of interest included in-hospital mortality, perioperative complications, length of stay (LOS), and hospital cost. RESULTS: A total of 147 170 NSTEMI hospitalizations where CABG was performed were assessed. A greater percentage of females, Blacks, and Hispanics experienced delays to CABG surgery. No difference in in-hospital mortality was observed, but CABG at 72-120 h and at >120 h was associated with higher odds of non-home discharge and acute kidney injury compared with CABG at ≤24 h from admission. In addition to these differences, CABG at >120 h was associated with higher odds of gastrointestinal hemorrhage and need for blood transfusion. All 3 groups with CABG delayed >24 h had longer LOS and hospital-associated costs compared with hospitalizations where CABG was performed at ≤24 h. CONCLUSION: CABG delays in patients with NSTEMI are more frequently experienced by women and minority populations and are associated with an increased burden of complications and healthcare cost.

Comparisons between White and Black Patients Hospitalized with Postliver Transplant Complications/Failure.

OBJECTIVES: The impact of race on patients presenting to North American hospitals with postliver transplant complications/failure (PLTCF) has not been studied fully. We compared in-hospital mortality and resource utilization outcomes between White and Black patients hospitalized with PLTCF. METHODS: This was a retrospective cohort study that evaluated the years 2016 and 2017 from the National Inpatient Sample. Regression analysis was used to determine in-hospital mortality and resource utilization. RESULTS: There were 10,805 hospitalizations for adults with liver transplants who presented with PLTCF. White and Black patients with PLTCF made up 7925 (73.3%) hospitalizations from this population. Among this group, 6480 were White (81.7%) and 1445 were Black (18.2%). Blacks were younger than Whites (mean age ± standard error of the mean: 46.8 ± 1.1 vs 53.6 ± 0.39 years, P < 0.01). Blacks were more likely to be female (53.9% vs 37.4%, P < 0.01). Charlson Comorbidity Index scores were not significantly different (scores ≥3: 46.7% vs 44.2%, P = 0.83). Blacks had significantly higher odds for in-hospital mortality (adjusted odds ratio 2.9, confidence interval [CI] 1.4-6.1; P < 0.01). Hospital charges were higher for Blacks compared with Whites (adjusted mean difference $48,432; 95% CI $2708-$94,157, P = 0.03). Blacks had significantly longer lengths of hospital stays (adjusted mean difference 3.1 days, 95% CI 1.1-5.1, P < 0.01). CONCLUSIONS: Compared with White patients hospitalized for PLTCF, Black patients had higher in-hospital mortality and resource use. Investigation into causes leading to this health disparity is needed to improve in-hospital outcomes.

Differences in Treatment Patterns and Outcomes of Acute Myocardial Infarction for Low- and High-Income Patients in 6 Countries.

Importance: Differences in the organization and financing of health systems may produce more or less equitable outcomes for advantaged vs disadvantaged populations. We compared treatments and outcomes of older high- and low-income patients across 6 countries. Objective: To determine whether treatment patterns and outcomes for patients presenting with acute myocardial infarction differ for low- vs high-income individuals across 6 countries. Design, Setting, and Participants: Serial cross-sectional cohort study of all adults aged 66 years or older hospitalized with acute myocardial infarction from 2013 through 2018 in the US, Canada, England, the Netherlands, Taiwan, and Israel using population-representative administrative data. Exposures: Being in the top and bottom quintile of income within and across countries. Main Outcomes and Measures: Thirty-day and 1-year mortality; secondary outcomes included rates of cardiac catheterization and revascularization, length of stay, and readmission rates. Results: We studied 289 376 patients hospitalized with ST-segment elevation myocardial infarction (STEMI) and 843 046 hospitalized with non-STEMI (NSTEMI). Adjusted 30-day mortality generally was 1 to 3 percentage points lower for high-income patients. For instance, 30-day mortality among patients admitted with STEMI in the Netherlands was 10.2% for those with high income vs 13.1% for those with low income (difference, -2.8 percentage points [95% CI, -4.1 to -1.5]). One-year mortality differences for STEMI were even larger than 30-day mortality, with the highest difference in Israel (16.2% vs 25.3%; difference, -9.1 percentage points [95% CI, -16.7 to -1.6]). In all countries, rates of cardiac catheterization and percutaneous coronary intervention were higher among high- vs low-income populations, with absolute differences ranging from 1 to 6 percentage points (eg, 73.6% vs 67.4%; difference, 6.1 percentage points [95% CI, 1.2 to 11.0] for percutaneous intervention in England for STEMI). Rates of coronary artery bypass graft surgery for patients with STEMI in low- vs high-income strata were similar but for NSTEMI were generally 1 to 2 percentage points higher among high-income patients (eg, 12.5% vs 11.0% in the US; difference, 1.5 percentage points [95% CI, 1.3 to 1.8 ]). Thirty-day readmission rates generally also were 1 to 3 percentage points lower and hospital length of stay generally was 0.2 to 0.5 days shorter for high-income patients. Conclusions and Relevance: High-income individuals had substantially better survival and were more likely to receive lifesaving revascularization and had shorter hospital lengths of stay and fewer readmissions across almost all countries. Our results suggest that income-based disparities were present even in countries with universal health insurance and robust social safety net systems.

Racial/ethnic disparities in costs, length of stay, and severity of severe maternal morbidity.

BACKGROUND: In contrast to other high-resource countries, the United States has experienced increases in the rates of severe maternal morbidity. In addition, the United States has pronounced racial and ethnic disparities in severe maternal morbidity, especially for non-Hispanic Black people, who have twice the rate as non-Hispanic White people. OBJECTIVE: This study aimed to examine whether the racial and ethnic disparities in severe maternal morbidity extended beyond the rates of these complications to include disparities in maternal costs and lengths of stay, which could indicate differences in the case severity. STUDY DESIGN: This study used California's linkage of birth certificates to inpatient maternal and infant discharge data for 2009 to 2011. Of the 1.5 million linked records, 250,000 were excluded because of incomplete data, for a final sample of 1,262,862. Cost-to-charge ratios were used to estimate costs from charges (including readmissions) after adjusting for inflation to December 2017. Mean diagnosis-related group-specific reimbursement was used to estimate physician payments. We used the Centers for Disease Control and Prevention definition of severe maternal morbidity, including readmissions up to 42 days after delivery. Adjusted Poisson regression models estimated the differential risk of severe maternal morbidity for each racial or ethnic group, compared with the non-Hispanic White group. Generalized linear models estimated the associations of race and ethnicity with costs and length of stay. RESULTS: Asian or Pacific Islander, Non-Hispanic Black, Hispanic, and other race or ethnicity patients all had higher rates of severe maternal morbidity than non-Hispanic White patients. The largest disparity was between non-Hispanic White and non-Hispanic Black patients, with unadjusted overall rates of severe maternal morbidity of 1.34% and 2.62%, respectively (adjusted risk ratio, 1.61; P<.001). Among patients with severe maternal morbidity, the adjusted regression estimates showed that non-Hispanic Black patients had 23% (P<.001) higher costs (marginal effect of $5023) and 24% (P<.001) longer hospital stays (marginal effect of 1.4 days) than non-Hispanic White patients. These effects changed when cases, such as cases where a blood transfusion was the only indication of severe maternal morbidity, were excluded, with 29% higher costs (P<.001) and 15% longer length of stay (P<.001). For other racial and ethnic groups, the increases in costs and length of stay were smaller than those observed for non-Hispanic Black patients, and many were not significantly different from non-Hispanic White patients. Hispanic patients had higher rates of severe maternal morbidity than non-Hispanic White patients; however, Hispanic patients had significantly lower costs and length of stay than non-Hispanic White patients. CONCLUSION: There were racial and ethnic differences in the costs and length of stay among patients with severe maternal morbidity across the groupings that we examined. The differences were especially large for non-Hispanic Black patients compared with non-Hispanic White patients. Non-Hispanic Black patients experienced twice the rate of severe maternal morbidity; in addition, the higher relative costs and longer lengths of stay for non-Hispanic Black patients with severe maternal morbidity support greater case severity in that population. These findings suggest that efforts to address racial and ethnic inequities in maternal health need to consider differences in case severity in addition to the differences in the rates of severe maternal morbidity and that these differences in case severity merit additional investigation.

Associação entre peso ao nascer, idade gestacional e diagnósticos secundários na permanência hospitalar de recém-nascidos prematuros / Asociación entre peso al nacimiento, edad gestacional y diagnóstico secundario en estancia hospitalaria de recién nacido prematuro / Association between birth weight, gestational age and secondary diagnoses in the hospital stay of premature newborns

RESUMO Objetivo: verificar a associação entre peso ao nascer, idade gestacional e diagnósticos médicos secundários no tempo de permanência hospitalar de recém-nascidos prematuros. Métodos: estudo transversal, com 1.329 prontuários de recém-nascidos no período de julho de 2012 a setembro de 2015, em dois hospitais de Belo Horizonte, que utilizam o sistema Diagnosis Related Groups Brasil. Para determinar um ponto de corte para o peso ao nascer e a idade gestacional no nascimento que melhor determinasse o tempo de internação, foi utilizada a curva Receive Operator Characteristic. Posteriormente, utilizou-se o teste de análise de variância e teste de Duncan para a comparação entre a média de tempo de permanência hospitalar. Resultados: a prematuridade sem problemas maiores (DRG 792) foi a categoria mais prevalente (43,12%). O maior tempo médio de internação foi de 34,9 dias, identificado entre os recém-nascidos prematuros ou com síndrome da angústia respiratória (DRG 790). A combinação de menor peso ao nascer e menor IG ao nascimento apresentou o maior risco de permanência hospitalar, aumentada quando comparados aos demais perfis formados para esse DRG. Conclusão: os achados poderão direcionar a assistência em relação à mobilização de recursos físicos, humanos e de bens de consumo, além da análise crítica de condições que influenciam os desfechos clínicos. A possibilidade da otimização do uso desses recursos hospitalares aliada à melhoria da qualidade dos atendimentos e da segurança dos pacientes está associada à minimização do tempo de permanência hospitalar e da carga de morbidade e mortalidade neonatal.

RESUMEN Objetivo: verificar la asociación entre el peso al nacer, la edad gestacional y los diagnósticos médicos secundarios en la duración de la estancia hospitalaria de los recién nacidos prematuros. Métodos: estudio transversal, con 1.329 registros de recién nacidos de julio de 2012 a septiembre de 2015, en dos hospitales de Belo Horizonte, que utilizan el sistema Diagnosis Related Groups Brasil. Para determinar un punto de corte para el peso al nacer y la edad gestacional al nacer que mejor determina la duración de la estadía, se utilizó la curva Receive Operator Characteristic. Posteriormente, se utilizó la prueba de análisis de varianza y la prueba de Duncan para comparar la duración media de la estancia hospitalaria. Resultados: la prematuridad sin mayores problemas (DRG 792) fue la categoría más prevalente (43,12%). La estancia media más larga fue de 34,9 días, identificada entre los recién nacidos prematuros o aquellos con síndrome de dificultad respiratoria (DRG 790). La combinación de menor peso al nacer y menor IG al nacer presentó el mayor riesgo de estancia hospitalaria, que se incrementó en comparación con los otros perfiles formados para este DRG. Conclusión: los hallazgos pueden orientar la atención en relación con la movilización de recursos físicos, humanos y de bienes de consumo, además del análisis crítico de las condiciones que influyen en los resultados clínicos. La posibilidad de optimizar el uso de estos recursos hospitalarios, aliada a mejorar la calidad de la atención y la seguridad del paciente, está asociada a minimizar la duración de la estancia hospitalaria y la carga de morbilidad y mortalidad neonatal.

ABSTRACT Objective: to verify the association between birth weight, gestational age, and secondary medical diagnoses in the length of hospital stay of premature newborns. Methods: cross-sectional study, with 1,329 medical records of newborns from July 2012 to September 2015, in two hospitals in Belo Horizonte, which use the Diagnosis Related Groups Brasil system. To determine a cutoff point for birth weight and gestational age at birth that best determined the length of hospital stay, the Receive Operator Characteristic curve was used. Subsequently, the analysis of variance test and Duncan's test were used to compare the mean length of hospital stay. Results: prematurity without major problems (DRG792) was the most prevalent category (43.12%). The longest mean length of hospital stay was 34.9 days, identified among preterm infants or infants with respiratory distress syndrome (DRG 790). The combination of lower birth weight and lower GA at birth presented the highest risk of hospital stay, increased when compared to the other profiles formed for this DRG. Conclusion: the findings may direct assistance in relation to the mobilization of physical, human and consumer goods resources, in addition to the critical analysis of conditions that influence clinical outcomes. The possibility of optimizing the use of these hospital resources, allied to improving the quality of care and patient safety, is associated with minimizing the length of hospital stay and the burden of neonatal morbidity and mortality.

Evaluation of Length of Stay, Care Volume, In-Hospital Mortality, and Emergency Readmission Rate Associated With Use of Diagnosis-Related Groups for Internal Resource Allocation in Public Hospitals in Hong Kong.

Importance: Hong Kong's internal resource allocation system for public inpatient care changed from a global budget system to one based on diagnosis-related groups (DRGs) in 2009 and returned to a global budget system in 2012. Changes in patient and hospital outcomes associated with moving from a DRG-based system to a global budget system for inpatient care have rarely been evaluated. Objective: To examine associations between the introduction and discontinuation of DRGs and changes in length of stay, volume of care, in-hospital mortality rates, and emergency readmission rates in the inpatient population in acute care hospitals overall, stratified by age group, and across 5 medical conditions. Design, Setting, and Participants: This cross-sectional study included data from patients aged 45 years or older who were hospitalized in public acute care settings in Hong Kong before the introduction (April 2006 to March 2009), during implementation (April 2009 to March 2012), and after discontinuation (April 2012 to November 2014) of the DRG scheme. Data analysis was conducted from January to June 2021. Exposures: Public hospitals transitioned from a global budget payment system to a DRG-based system in April 2009 and returned to a global budget system in April 2014. Main Outcomes and Measures: The main outcome was the association of use of DRGs with patient-level length of stay, in-hospital mortality rate, 1-month emergency readmission rate, and population-level number of admissions per month. An interrupted time series design was used to estimate changes in the level and slope of outcome variables after introduction and discontinuation of DRGs, accounting for pretrends. Results: This study included 7 604 390 patient episodes. Overall, the mean (SD) age of patients was 68.97 (13.20) years, and 52.17% were male. The introduction of DRGs was associated with a 1.77% (95% CI, 1.23%-2.32%) decrease in the mean length of stay, a 2.90% (95% CI, 2.52%-3.28%) increase in the number of patients admitted, a 4.12% (95% CI, 1.89%-6.35%) reduction in in-hospital mortality, and a 2.37% (95% CI, 1.28%-3.46%) decrease in emergency readmissions. Discontinuation of the DRG scheme was associated with a 0.93% (95% CI, 0.42%-1.44%) increase in the mean length of stay and a 1.82% (95% CI, 1.47%-2.17%) reduction in the number of patients treated after adjusting for covariates; no statistically significant change was observed in in-hospital mortality (-0.14%; 95% CI, -2.29% to 2.01%) or emergency readmission rate (-0.29%; 95% CI, -1.30% to 0.71%). Conclusions and Relevance: In this cross-sectional study, the introduction of DRGs was associated with shorter lengths of stay and increased hospital volume, and discontinuation was associated with longer lengths of stay and decreased hospital volume. In-hospital mortality and emergency readmission rates did not significantly change after discontinuation of DRGs.

Construction of Risk Assessment Model for Venous Thromboembolism After Colorectal Cancer Surgery: A Chinese Single-Center Study.

OBJECTIVE: A retrospective study was carried out to construct a postoperative venous thromboembolism (VTE) risk assessment model (RAM) applicable for Chinese colorectal cancer patients. METHODS: 541 Patients who underwent colorectal cancer surgery from June 2019 to May 2020 at Sir-Run-Run-Shaw Hospital affiliated to Zhejiang University School of Medicine were enrolled in this study. Multi-factor analysis was used to determine the independent risk factors of VTE. A novel RAM of VTE which we called Sir-Run-Run-Shaw VTE RAM were constructed basing on the independent risk factors. Another study cohort consisted of 287 colorectal cancer patients underwent surgery from January 2021 to June 2021was used for model evaluation. RESULTS: The incidence of VTE after colorectal cancer surgery was 12.0%(65/541). Among the 65 VTE Patients, DVT accounted for 92.3% (60/65) and DVT + PE accounted for 7.7% (5/65). Multi-factor analysis showed that age ≥ 69 years (P < 0.01), preoperative plasma D-dimer ≥ 0.49 mg/L (P = .004), stage IV of cancer (P = .018) and transfusion (P = .004) are independent risk factors of VTE after surgery. Sir-Run-Run-Shaw VTE RAM includes the above 4 factors, and the total score is 4 points. The score of the low, medium and high risk groups are 0, 1 and ≥2 points. The area under the ROC curve (AUC) of Sir-Run-Run-Shaw VTE RAM is 0.769, while Caprini RAM is 0.656. There is statistical difference between the two risk score tables (Z = 2.337, P = .0195). CONCLUSION: A VTE RAM is constructed basing on a single center retrospective study. This score table may be applicable for Chinese patients with colorectal cancer surgery.

Assessment of Clinical Outcomes Among Children and Adolescents Hospitalized With COVID-19 in 6 Sub-Saharan African Countries.

IMPORTANCE: Little is known about COVID-19 outcomes among children and adolescents in sub-Saharan Africa, where preexisting comorbidities are prevalent. OBJECTIVE: To assess the clinical outcomes and factors associated with outcomes among children and adolescents hospitalized with COVID-19 in 6 countries in sub-Saharan Africa. DESIGN, SETTING, AND PARTICIPANTS: This cohort study was a retrospective record review of data from 25 hospitals in the Democratic Republic of the Congo, Ghana, Kenya, Nigeria, South Africa, and Uganda from March 1 to December 31, 2020, and included 469 hospitalized patients aged 0 to 19 years with SARS-CoV-2 infection. EXPOSURES: Age, sex, preexisting comorbidities, and region of residence. MAIN OUTCOMES AND MEASURES: An ordinal primary outcome scale was used comprising 5 categories: (1) hospitalization without oxygen supplementation, (2) hospitalization with oxygen supplementation, (3) ICU admission, (4) invasive mechanical ventilation, and (5) death. The secondary outcome was length of hospital stay. RESULTS: Among 469 hospitalized children and adolescents, the median age was 5.9 years (IQR, 1.6-11.1 years); 245 patients (52.4%) were male, and 115 (24.5%) had comorbidities. A total of 39 patients (8.3%) were from central Africa, 172 (36.7%) from eastern Africa, 208 (44.3%) from southern Africa, and 50 (10.7%) from western Africa. Eighteen patients had suspected (n = 6) or confirmed (n = 12) multisystem inflammatory syndrome in children. Thirty-nine patients (8.3%) died, including 22 of 69 patients (31.9%) who required intensive care unit admission and 4 of 18 patients (22.2%) with suspected or confirmed multisystem inflammatory syndrome in children. Among 468 patients, 418 (89.3%) were discharged, and 16 (3.4%) remained hospitalized. The likelihood of outcomes with higher vs lower severity among children younger than 1 year expressed as adjusted odds ratio (aOR) was 4.89 (95% CI, 1.44-16.61) times higher than that of adolescents aged 15 to 19 years. The presence of hypertension (aOR, 5.91; 95% CI, 1.89-18.50), chronic lung disease (aOR, 2.97; 95% CI, 1.65-5.37), or a hematological disorder (aOR, 3.10; 95% CI, 1.04-9.24) was associated with severe outcomes. Age younger than 1 year (adjusted subdistribution hazard ratio [asHR], 0.48; 95% CI, 0.27-0.87), the presence of 1 comorbidity (asHR, 0.54; 95% CI, 0.40-0.72), and the presence of 2 or more comorbidities (asHR, 0.26; 95% CI, 0.18-0.38) were associated with reduced rates of hospital discharge. CONCLUSIONS AND RELEVANCE: In this cohort study of children and adolescents hospitalized with COVID-19 in sub-Saharan Africa, high rates of morbidity and mortality were observed among infants and patients with noncommunicable disease comorbidities, suggesting that COVID-19 vaccination and therapeutic interventions are needed for young populations in this region.