Acute Care Utilization and Costs Up to 4 Years After Index Sleeve Gastrectomy or Roux-en-Y Gastric Bypass: A National Claims-based Study.

OBJECTIVE: To compare acute care utilization and costs following sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB). SUMMARY BACKGROUND DATA: Comparing postbariatric emergency department (ED) and inpatient care use patterns could assist with procedure choice and provide insights about complication risk. METHODS: We used a national insurance claims database to identify adults undergoing SG and RYGB between 2008 and 2016. Patients were matched on age, sex, calendar-time, diabetes, and baseline acute care use. We used adjusted Cox proportional hazards to compare acute care utilization and 2-part logistic regression models to compare annual associated costs (odds of any cost, and odds of high costs, defined as ≥80th percentile), between SG and RYGB, overall and within several clinical categories. RESULTS: The matched cohort included 4263 SG and 4520 RYGB patients. Up to 4 years after surgery, SG patients had slightly lower risk of ED visits [adjusted hazard ratio (aHR): 0.90; 95% confidence interval (CI): 0.85,0.96] and inpatient stays (aHR: 0.80; 95% CI: 0.73,0.88), especially for events associated with digestive-system diagnoses (ED aHR: 0.68; 95% CI: 0.62,0.75; inpatient aHR: 0.61; 95% CI: 0.53,0.72). SG patients also had lower odds of high ED and high total acute costs (eg, year-1 acute costs adjusted odds ratio (aOR) 0.77; 95% CI: 0.66,0.90) in early follow-up. However, observed cost differences decreased by years 3 and 4 (eg, year-4 acute care costs aOR 1.10; 95% CI: 0.92,1.31). CONCLUSIONS: SG may have fewer complications requiring emergency care and hospitalization, especially as related to digestive system disease. However, any acute care cost advantages of SG may wane over time.

The impact of high-deductible health plans on men and women: an analysis of emergency department care.

BACKGROUND: Prior studies show that men are more likely than women to defer essential care. Enrollment in high-deductible health plans (HDHPs) could exacerbate this tendency, but sex-specific responses to HDHPs have not been assessed. We measured the impact of an HDHP separately for men and women. METHODS: Controlled longitudinal difference-in-differences analysis of low, intermediate, and high severity emergency department (ED) visits and hospitalizations among 6007 men and 6530 women for 1 year before and up to 2 years after their employers mandated a switch from a traditional health maintenance organization plan to an HDHP, compared with contemporaneous controls (18,433 men and 19,178 women) who remained in an health maintenance organization plan. RESULTS: In the year following transition to an HDHP, men substantially reduced ED visits at all severity levels relative to controls (changes in low, intermediate, and high severity visits of -21.5% [-37.9 to -5.2], -21.6% [-37.4 to -5.7], and -34.4% [-62.1 to -6.7], respectively). Female HDHP members selectively reduced low severity emergency visits (-26.9% [-40.8 to -13.0]) while preserving intermediate and high severity visits. Male HDHP members also experienced a 24.2% [-45.3 to -3.1] relative decline in hospitalizations in year 1, followed by a 30.1% [2.1 to 58.1] relative increase in hospitalizations between years 1 and 2. CONCLUSIONS: Initial across-the-board reductions in ED and hospital care followed by increased hospitalizations imply that men may have foregone needed care following an HDHP transition. Clinicians caring for patients with HDHPs should be aware of sex differences in response to benefit design.

Association of Interprofessional Discharge Planning Using an Electronic Health Record Tool With Hospital Length of Stay Among Patients with Multimorbidity: A Nonrandomized Controlled Trial.

Importance: Whether interprofessional collaboration is effective and safe in decreasing hospital length of stay remains controversial. Objective: To evaluate the outcomes and safety associated with an electronic interprofessional-led discharge planning tool vs standard discharge planning to safely reduce length of stay among medical inpatients with multimorbidity. Design, Setting, and Participants: This multicenter prospective nonrandomized controlled trial used interrupted time series analysis to examine medical acute hospitalizations at 82 hospitals in Switzerland. It was conducted from February 2017 through January 2019. Data analysis was conducted from March 2021 to July 2022. Intervention: After a 12-month preintervention phase (February 2017 through January 2018), an electronic interprofessional-led discharge planning tool was implemented in February 2018 in 7 intervention hospitals in addition to standard discharge planning. Main Outcomes and Measures: Mixed-effects segmented regression analyses were used to compare monthly changes in trends of length of stay, hospital readmission, in-hospital mortality, and facility discharge after the implementation of the tool with changes in trends among control hospitals. Results: There were 54 695 hospitalizations at intervention hospitals, with 27 219 in the preintervention period (median [IQR] age, 72 [59-82] years; 14 400 [52.9%] men) and 27 476 in the intervention phase (median [IQR] age, 72 [59-82] years; 14 448 [52.6%] men) and 438 791 at control hospitals, with 216 261 in the preintervention period (median [IQR] age, 74 [60-83] years; 109 770 [50.8%] men) and 222 530 in the intervention phase (median [IQR] age, 74 [60-83] years; 113 053 [50.8%] men). The mean (SD) length of stay in the preintervention phase was 7.6 (7.1) days for intervention hospitals and 7.5 (7.4) days for control hospitals. During the preintervention phase, population-averaged length of stay decreased by -0.344 hr/mo (95% CI, -0.599 to -0.090 hr/mo) in control hospitals; however, no change in trend was observed among intervention hospitals (-0.034 hr/mo; 95% CI, -0.646 to 0.714 hr/mo; difference in slopes, P = .09). Over the intervention phase (February 2018 through January 2019), length of stay remained unchanged in control hospitals (slope, -0.011 hr/mo; 95% CI, -0.281 to 0.260 hr/mo; change in slope, P = .03), but decreased steadily among intervention hospitals by -0.879 hr/mo (95% CI, -1.607 to -0.150 hr/mo; change in slope, P = .04, difference in slopes, P = .03). Safety analyses showed no change in trends of hospital readmission, in-hospital mortality, or facility discharge over the whole study time. Conclusions and Relevance: In this nonrandomized controlled trial, the implementation of an electronic interprofessional-led discharge planning tool was associated with a decline in length of stay without an increase in hospital readmission, in-hospital mortality, or facility discharge. Trial Registration: isrctn.org Identifier: ISRCTN83274049.

Two-year trends in colorectal cancer screening after switch to a high-deductible health plan.

BACKGROUND: Recent health reform laws might accelerate high-deductible health plan (HDHP) growth. The impact of HDHPs on long-term colorectal cancer screening rates and low socioeconomic status (SES) members is unknown. METHODS: We studied colorectal cancer screening rates among 1306 Health Maintenance Organization (HMO) members for 1 year before and 2 years after an employer-mandated switch to HDHPs, compared with 1306 propensity score-matched controls who remained in HMOs by employer choice. HDHP members had full coverage of fecal occult blood testing (FOBT) but colonoscopy, flexible sigmoidoscopy, and double-contrast barium enema were subject to $500 to $2000 annual deductibles. HMO members had full coverage of these tests. We used generalized estimating equations to adjust screening rates for member characteristics. We stratified analyses by SES. RESULTS: Overall colorectal cancer screening rates in the HDHP group relative to the control group trended down from baseline to the first and second follow-up years [ratios of change, 0.88, (95% confidence interval, 0.73 to 1.06) and 0.83, (0.69 to 1.00), respectively]. Low SES HDHP members experienced a statistically significant relative decrease in colonoscopy in both follow-up years [0.65, (0.48 to 0.88) and 0.59, (0.42 to 0.84), respectively] and a trend toward increased FOBT [1.26, (0.92 to 1.72) and 1.30, (0.95 to 1.77), respectively] to maintain stable overall colorectal cancer screening rates [1.01, (0.77 to 1.32) and 0.93, (0.71 to 1.22), respectively]. High SES members experienced less pronounced decrease in colonoscopy [0.89, (0.67 to 1.18) and 0.87, (0.62 to 1.21), respectively] but FOBT rates did not increase [0.83, (0.62 to 1.11 and 0.81), (0.60 to 1.11), respectively]. CONCLUSIONS: Switching to a HDHP was associated with a downward trend in overall colorectal cancer screening rates after 2 years. Low SES HDHP members maintained stable rates, but substituted FOBT for colonoscopy and other tests now more widely recommended. Further research should investigate whether such reduced adherence to screening guidelines adversely affects health outcomes.