Beneficial effects of Wuzhi Capsule on tacrolimus blood concentrations in liver transplant patients with different donor-recipient CYP3A5 genotypes.

WHAT IS KNOWN AND OBJECTIVE: Tacrolimus (Tac) is an immunosuppressant that is widely used to prevent allograft rejection in patients after liver transplantation. Its metabolism mainly depends on the cytochrome P450 3A5 (CYP3A5), which has genetic polymorphisms. Recently, a Chinese herbal medicine known as Wuzhi Capsule (WZC) was shown to increase Tac blood concentrations by inhibiting the activity of CYP3A in animal studies in rats. To date, it remains unexplored whether WZC can be efficiently used to enhance the blood concentration of Tac in liver transplant patients with different donor-recipient CYP3A5 genotypes. METHODS: A total of 185 liver transplant patients were enrolled and two-way ANOVA was carried out, then they were divided into four groups according to the combinations of donor-recipient CYP3A5 phenotypes. WZC was given to patients when the dose of Tac was ≥4 mg, and the dose-adjusted C0 (C0 /D) of Tac measured twice in succession was ≤1 ng/ml/mg. The blood trough concentration of Tac (C0 ), C0 /D, and dose- and body weight-adjusted C0 (C0 /D/W) was analysed on days 7 and 14 after liver transplantation. RESULTS: The genotypes of donor and recipient or WZC had significant effects on C0, C0/D and C0/D/W. There were significant differences in the Tac blood concentrations between the groups. The recipient expression (*1)/donor expression (*1) (R+/D+) group had the lowest C0 , C0 /D and C0 /D/W among the four groups. Furthermore, a larger proportion of patients in the CYP3A5 expression groups required Tac dose adjustment to achieve a therapeutic effect and were given Tac with WZC. Notably, the use of WZC significantly increased the blood concentrations of Tac in the CYP3A5 expression groups and greater increases in the C0 /D and C0 /D/W were significantly associated with higher doses of WZC in the CYP3A5 expression groups. What is more, WZC reduced the hospitalization cost of patients to a certain extent. WHAT IS NEW AND CONCLUSION: WZC significantly increased the C0 , C0 /D and C0 /D/W in the CYP3A5 expression groups and reduced the hospitalization expenses of patients to a certain extent. What is more, greater increases in the C0 /D and C0 /D/W were significantly associated with higher doses of WZC.

Trends of Acute Kidney Injury Requiring Dialysis Among Hospitalized Patients Undergoing Invasive Electrophysiology Procedures.

Electrophysiology (EP) procedures carry the risk of kidney injury due to contrast/hemodynamic fluctuations. We aim to evaluate the national epidemiology of acute kidney injury requiring dialysis (AKI-D) in patients undergoing EP procedures. Using the National Inpatient Sample, we included 2,747,605 adult hospitalizations undergoing invasive diagnostic EP procedures, ablation and implantable device placement from 2006 to 2014. We examined the temporal trend of AKI-D and outcomes associated with AKI-D. The rate of AKI-D increased significantly in both diagnostic/ablation group (8-21/10,000 hospitalizations from 2006 to 2014, P = 0.02) and implanted device group (19-44/10,000 hospitalizations from 2006 to 2014, P < 0.01), but it was explained by temporal changes in demographics and comorbidities. Cardiac resynchronization therapy and pacemaker placement had higher risk of AKI-D compared to implantable cardioverter-defibrillator placement (23 vs. 31 vs. 14/10,000 hospitalizations in cardiac resynchronization therapy, pacemaker placement, and implantable cardioverter-defibrillator group, respectively). Development of AKI-D was associated with significant increase in in-hospital mortality (adjusted odds ratio, 9.6 in diagnostic/ablation group, P < 0.01; adjusted odds ratio, 5.1 in device implantation group, P < 0.01) and with longer length of stay (22.5 vs. 4.5 days in diagnostic/ablation group, 21.1 vs. 5.7 days in implanted device group) and higher cost (282,775 vs. 94,076 USD in diagnostic/ablation group, 295,660 vs. 102,007 USD in implanted device group). The incidence of AKI-D after EP procedures increased over time but largely explained by the change of demographics and comorbidities. This increasing trend, however, was associated with significant increase in resource utilization and in-hospital mortality in these patients.

Analysis of Outpatient Telemedicine Reimbursement in an Integrated Healthcare System.

BACKGROUND: Current reimbursement policy surrounding telemedicine has been cited as a barrier for the adaptation of this care model. The objective of this study is to analyze the reimbursement figures for outpatient telemedicine consultation in vascular surgery. METHODS: Patients first underwent synchronous telemedicine visits after receiving point-of-care ultrasound at one of 3 satellite locations of Henry Ford Health System in Michigan. Visit types included new, return, and postoperative patients. Reimbursement information related to payor, adjustment, denial, paid and outstanding balances were recorded for each telemedicine visit. Then, using an enterprise data warehouse, a retrospective analysis was performed for the aforementioned telemedicine visits. The data were analyzed to determine the outcome of total billed charges, number of denied claims, reimbursement per payor, reimbursement per patient, and out-of-pocket costs to the patients. RESULTS: Among 184 virtual clinical encounters, the payors included Aetna US Healthcare, Blue Advantage, Blue Cross Blue Shield, Cofinity Plan, Health Alliance Plan, HAP Medicare Advantage, Humana Medicare Advantage, Medicaid, Medicare, Molina Medicaid HMO, United Healthcare, Blue Care Network, Aetna Better Health of Michigan, Priority Health, and self-pay. Among the 15 payors, reimbursement ranged from 0% to 67% of the total charges billed. Among the 184 virtual visits, a grand total of $22,145 was collected or an average of $120.35 per virtual encounter. The breakdown of charges billed was 40% adjusted, 41% paid by insurance, 10% paid by patient, and 13% denied. There were 27 total denials (15%). Denial of payment included telehealth and nontelehealth reasons, citing noncovered charges, payment included for other prior services, new patient quality not met, and not covered by payor. The average out-of-pocket cost to patients was $12.59 per visit. CONCLUSIONS: These reimbursement data validate the economic potential within this new platform of healthcare delivery. As our experience with the business model grows, we expect to see an increase in reimbursement from private payors and acceptance from patients. Within a tertiary care system, telemedicine for chronic vascular disease has proven to be a viable means to reach a broader population base, and without significant cost to the patients.

Burn Injuries Resulting From Methamphetamine and Honey Oil Explosions: A Retrospective Cohort Study.

A high incidence of honey oil and methamphetamine production has led to an increase in burn victims presenting to this regional burn center in California. This study aims to compare patient outcomes resulting from burn injuries associated with honey oil and methamphetamine production. This is a retrospective cohort study using the regional burn registry to identify patients with burn injuries related to honey oil production or methamphetamine purification explosions from January 1, 2008 to December 31, 2017. Patient demographics and clinical outcomes data were abstracted from the burn registry and medical records. A total of 91 patients were included in the final analysis and 59.3% (n = 54) were related to honey oil injury. There was no statistically significant difference between honey oil and methamphetamine burn injuries in regard to clinical outcomes, including mortality (1.9% vs 8.1%, P = .1588), third-degree burn (47.2% vs 59.5%, P = .2508), mechanical ventilator usage (50% vs 69.4%, P = .0714), median hospital length of stay (LOS; 10 vs 11 days, P = .5308), ICU LOS (10 vs 11 days, P = .1903), total burn surface area (26.5% vs 28.3%, P = .8313), and hospital charge (median of US$85,561 vs US$139,028, P = .7215). Honey oil burn injuries are associated with similar hospital LOS, similar ICU LOS, similar total burn surface area, and present a costly public health concern. With the recent legalization of marijuana in California, commercial production of honey oil in addition to increasing education about the risks of illicit honey oil production may alleviate associated risks.

Retrospective evaluation of healthcare utilisation and mortality of two post-discharge care programmes in Singapore.

OBJECTIVE: To evaluate the impact on healthcare utilisation frequencies and charges, and mortality of a programme for frequent hospital utilisers and a programme for patients requiring high acuity post-discharge care as part of an integrated healthcare model. DESIGN: A retrospective quasi-experimental study without randomisation where patients who received post-discharge care interventions were matched 1:1 with unenrolled patients as controls. SETTING: The National University Health System (NUHS) Regional Health System (RHS), which was one of six RHS in Singapore, implemented the NUHS RHS Integrated Interventions and Care Extension (NICE) programme for frequent hospital utilisers and the NUHS Transitional Care Programme (NUHS TCP) for high acuity post-discharge care. The programmes were supported by the Ministry of Health in Singapore, which is a city-state nation located in Southeast Asia with a 5.6 million population. PARTICIPANTS: Linked healthcare administrative data, for the time period of January 2013 to December 2016, were extracted for patients enrolled in NICE (n=554) or NUHS TCP (n=270) from June 2014 to December 2015, and control patients. INTERVENTIONS: For both programmes, teams conducted follow-up home visits and phone calls to monitor and manage patients' post-discharge. PRIMARY OUTCOME MEASURES: One-year pre- and post-enrolment healthcare utilisation frequencies and charges of all-cause inpatient admissions, emergency admissions, emergency department attendances, specialist outpatient clinic (SOC) attendances, total inpatient length of stay and mortality rates were compared. RESULTS: Patients in NICE had lower mortality rate, but higher all-cause inpatient admission, emergency admission and emergency department attendance charges. Patients in NUHS TCP did not have lower mortality rate, but had higher emergency admission and SOC attendance charges. CONCLUSIONS: Both NICE and NUHS TCP had no improvements in 1 year healthcare utilisation across various setting and metrics. Singular interventions might not be as impactful in effecting utilisation without an overhauling transformation and restructuring of the hospital and healthcare system.

Image Guidance for Ventricular Shunt Surgery: An Analysis of Hospital Charges.

BACKGROUND: Image guidance for shunt surgery results in more accurate proximal catheter placement. However, reduction in shunt failure remains unclear in the literature. There have been no prior studies evaluating the cost effectiveness of neuronavigation for shunt surgery. OBJECTIVE: To perform a cost analysis using available hospital charges of hypothetical shunt surgery performed with/without electromagnetic neuronavigation (EMN). METHODS: Hospital charges were collected for physician fees, radiology, operating room (OR) time and supplies, postanesthesia care unit, hospitalization days, laboratory, and medications. Index shunt surgery charges (de novo or revision) were totaled and the difference calculated. This difference was compared with hospital charges for shunt revision surgery performed under 2 clinical scenarios: (1) same hospital stay as the index surgery; and (2) readmission through the emergency department. RESULTS: Costs for freehand de novo and revision shunt surgery were $23 946.22 and $23 359.22, respectively. For stealth-guided de novo and revision surgery, the costs were $33 646.94 and $33 059.94, a difference of $9700.72. The largest charge increase was due to additional OR time (34 min; $4794), followed by disposable EMN equipment ($2672). Total effective charges to revise the shunt for scenarios 1 and 2 were $34 622.94 and $35 934.94, respectively. The cost ratios between the total revision charges for both scenarios and the difference in freehand vs EMN-assisted shunt surgery ($9700.72) were 3.57 and 3.70, respectively. CONCLUSION: From an economic standpoint and within the limitations of our models, the number needed to prevent must be 4 or less for the use of neuronavigation to be considered cost effective.

A comparative analysis of treatment costs for home-based care and hospital-based care in enteral nutrition patients: A retrospective analysis of claims data.

OBJECTIVE: To explore the differences in mean treatment costs between home-based care and hospital-based care in enteral nutrition patients in Japan. METHODS: Using claims data from September 2013 to August 2014, we analyzed patients with recorded reimbursements for enteral nutrition at home or in a hospital. Treatment costs were compared using a panel data analysis with an individual fixed effects model that adjusted for the number of comorbidities and fiscal year. Costs were compared for all patients, as well as for specific diseases (pneumonia, sequelae of cerebrovascular disease, and dementia). RESULTS: The study sample comprised 7,783 patients with a cumulative total of 33,751 person-months of data. The mean patient age was 84.4 years for home-based care, 83.7 years for hospital-based care. The panel data analysis found that the cost estimates for hospital-based care were consistently higher than those for home-based care; the difference in adjusted treatment costs were $4,894 for all patients, $5,315 for pneumonia patients, $4,481 for sequelae of cerebrovascular disease patients, and $4,519 for dementia patients (all P < 0.001). Hospital-based care was still more expensive even when long-term care services were included in home-based care treatment cost estimates. CONCLUSION: Home-based care was consistently and substantially cheaper than hospital-based care in enteral nutrition patients in Japan.

Hospitals Using Bundled Payment Report Reducing Skilled Nursing Facility Use And Improving Care Integration.

A goal of Medicare's bundled payment models is to improve quality and control costs after hospital discharge. Little is known about how participating hospitals are focusing their efforts to achieve these objectives, particularly around the use of skilled nursing facilities (SNFs). To understand hospitals' approaches, we conducted semistructured interviews with an executive or administrator in each of twenty-two hospitals and health systems participating in Medicare's Comprehensive Care for Joint Replacement model or its Bundled Payments for Care Improvement initiative for lower extremity joint replacement episodes. We identified two major organizational responses. One principal strategy was to reduce SNF referrals, using risk-stratification tools, patient education, home care supports, and linkages with home health agencies to facilitate discharges to home. Another was to enhance integration with SNFs: fifteen hospitals or health systems in our sample had formed networks of preferred SNFs to exert influence over SNF quality and costs. Common coordination strategies included sharing access to electronic medical records, embedding providers across facilities, hiring dedicated care coordination staff, and creating platforms for data sharing. As hospitals presumably move toward home-based care and more selective SNF referrals, more evidence is needed to understand how these discharge practices affect the quality of care and patient outcomes.

Distribution and predictors of hospital charges for haemorrhagic stroke patients in Beijing, China, March 2012 to February 2015: a retrospective study.

OBJECTIVES: The purpose of this study is to analyse hospital charges for patients with haemorrhagic stroke in China and investigate potential factors associated with inpatient charges. METHODS: The study participants were in-hospital patients with a primary diagnosis of haemorrhagic stroke from all the secondary and tertiary hospitals in Beijing during the period from 1 March 2012 to 28 February 2015. Distribution characteristics of detailed hospital charges were analysed. The influence of potential factors on hospital charges was researched using a stepwise multiple regression model. RESULTS: A total of 34 890 patients with haemorrhagic stroke of mean age 61.19±14.37 years were included in the study, of which 37.2% were female. Median length of hospital stay (LOHS) was 15 days (IQR 9-23) and median hospital cost was 18 577 Chinese yuan (CNY) (IQR 10 442-39 784). The hospital costs for patients in Western medicine hospitals (median 19 651 CNY) were significantly higher (P<0.01) than those in traditional Chinese medicine hospitals (median 14 560 CNY), and were significantly higher (P<0.01) for Level 3 hospitals (median 20 029 CNY) than for Level 2 hospitals (median 16 095 CNY). The proportion of medicine fees and bed fees within total hospital charges showed a decreasing trend during the study period. With stepwise multiple regression, the major factors associated with hospital charges were LOHS, surgery, pulmonary infection, ventilator usage, hospital level, occupation, hyperlipidaemia, hospital type, in-hospital death, sex and age. CONCLUSION: We conclude that medicines form the largest part of hospital charges but are showing a decreasing trend, and LOHS is strongly associated with patient charges for haemorrhagic stroke in China. This implies that the cost structure is very unreasonable in China and medical technology costs fail to be fully manifested. A reasonable decrease in medicine charges and shortening LOHS may be effective ways to reduce hospital charges.

Neonatal Jaundice: Improved Quality and Cost Savings After Implementation of a Standard Pathway.

OBJECTIVES: Seattle Children's Hospital sought to optimize the value equation for neonatal jaundice patients by creating a standard care pathway. METHODS: An evidence-based pathway for management of neonatal jaundice was created. This included multidisciplinary team assembly, comprehensive literature review, creation of a treatment algorithm and computer order sets, formulation of goals and metrics, roll-out of an education program for end users, and ongoing pathway improvement. The pathway was implemented on May 31, 2012. Quality metrics before and after implementation were compared. External data were used to analyze cost impacts. RESULTS: Significant improvements were achieved across multiple quality dimensions. Time to recovery decreased: mean length of stay was 1.30 days for 117 prepathway patients compared with 0.87 days for 69 postpathway patients (P < .001). Efficiency was enhanced: mean time to phototherapy initiation was 101.26 minutes for 14 prepathway patients compared with 54.67 minutes for 67 postpathway patients (P = .03). Care was less invasive: intravenous fluid orders were reduced from 80% to 44% (P < .001). Inpatient use was reduced: 66% of prepathway patients were admitted from the emergency department to inpatient care, compared with 50% of postpathway patients (P = .01). There was no increase in the readmission rate. These achievements translated to statistically significant cost reductions in total charges, as well as in the following categories: intravenous fluids, laboratory, room cost, and emergency department charges. CONCLUSIONS: An evidence-based standard care pathway for neonatal jaundice can significantly improve multiple dimensions of value, including reductions in cost and length of stay.

Risk of Catastrophic Health Expenditure in Rwandan Surgical Patients with Peritonitis.

BACKGROUND: Surgical procedures are cost-effective compared with various medical and public health interventions. While peritonitis often requires surgery, little is known regarding the associated costs, particularly in low- and middle-income countries. The aim of this study was to determine in-hospital charges for patients with peritonitis and if patients are at risk of catastrophic health expenditure. METHODS: As part of a larger study examining the epidemiology and outcomes of patients with peritonitis at a referral hospital in Rwanda, patients undergoing operation for peritonitis were enrolled and hospital charges were examined. The primary outcome was the percentage of patients at risk for catastrophic health expenditure. Logistic regression was used to determine the association of various factors with risk for catastrophic health expenditure. RESULTS: Over a 6-month period, 280 patients underwent operation for peritonitis. In-hospital charges were available for 245 patients. A total of 240 (98%) patients had health insurance. Median total hospital charges were 308.1 USD, and the median amount paid by patients was 26.9 USD. Thirty-three (14%) patients were at risk of catastrophic health expenditure based on direct medical expenses. Estimating out-of-pocket non-medical expenses, 68 (28%) patients were at risk of catastrophic health expenditure. Unplanned reoperation was associated with increased risk of catastrophic health expenditure (p < 0.001), whereas patients with community-based health insurance had decreased risk of catastrophic health expenditure (p < 0.001). CONCLUSIONS: The median hospital charges paid out-of-pocket by patients with health insurance were small in relation to total charges. A significant number of patients with peritonitis are at risk of catastrophic health expenditure.

Association of Preoperative Calcium and Calcitriol Therapy With Postoperative Hypocalcemia After Total Thyroidectomy.

Importance: Hypocalcemia is the most common complication after total thyroidectomy and can result in prolonged hospital admissions and increased hospital charges. Objective: To determine the effectiveness of preoperative calcium and calcitriol supplementation in reducing hypocalcemia following total thyroidectomy. Design, Setting, and Participants: A retrospective cohort study was conducted at a tertiary care center in 65 patients undergoing total thyroidectomy by a single surgeon. Patients were divided into 2 groups: those receiving preoperative as well as postoperative supplementation with calcium carbonate, 1000 to 1500 mg, 3 times daily and calcitriol, 0.25 to 0.5 µg, twice daily, and those receiving only postoperative supplementation with those agents at the same dosages. Data on patients who underwent surgery between January 1, 2008, and December 31, 2011, were acquired, and data analyses were conducted from March through June 2012, and from October through December 2016. Interventions: Calcium and calcitriol therapy. Main Outcomes and Measures: Postoperative serum calcium levels and development of postoperative hypocalcemia. Results: Of the 65 patients who underwent total thyroidectomy 27 (42%) were men; mean (SD) age was 49.7 (16.7) years. Thirty-three patients received preoperative calcium and calcitriol supplementation, and 32 patients received only postoperative therapy. In the preoperative supplementation group, 15 of 33 (45%) patients underwent complete central compartment neck dissection and 11 of 33 (33%) had lateral neck dissection, compared with 16 of 32 (50%) and 12 of 32 (38%), respectively, patients without preoperative supplementation. The mean measured serum calcium level in those without preoperative supplementation vs those with supplementation are as follows: preoperative, 9.6 vs 9.4 mg/dL (absolute difference, 0.16; 95% CI, -0.12 to 0.49 mg/dL); 12 hours postoperative, 8.3 vs 8.6 mg/dL (absolute difference, -0.30; 95% CI, -0.63 to 0.02 mg/dL); and 24 hours postoperative, 8.4 vs 8.5 mg/dL (absolute difference, -0.13; 95% CI, -0.43 to 0.16 mg/dL). In patients not receiving preoperative supplementation, 5 of 32 (16%) individuals became symptomatically hypocalcemic vs 2 of 33 (6%) in the preoperative supplementation group; an absolute difference of 10% (95% CI, -6.6% to 26.3%). Compared with the group not receiving preoperative supplementation, the mean [SD] length of stay was significantly shorter in the preoperative supplementation group (3.8 [1.8] vs 2.9 [1.4] days; absolute difference, -0.9; 95% CI, -1.70 to -0.105 days). Preoperative supplementation resulted in an estimated $2819 savings in charges per patient undergoing total thyroidectomy. Conclusions and Relevance: Preoperative calcium and calcitriol supplementation, in addition to routine postoperative supplementation, was associated with a reduced incidence of symptomatic hypocalcemia, length of hospital stay, and overall charges following total thyroidectomy.

Osteopathic manipulative treatment showed reduction of length of stay and costs in preterm infants: A systematic review and meta-analysis.

BACKGROUND: Osteopathic medicine is an emerging and complementary method used in neonatology. METHODS: Outcomes were the mean difference in length of stay (LOS) and costs between osteopathy and alternative treatment group. A comprehensive literature search of (quasi)- randomized controlled trials (RCTs), was conducted from journal inception to May, 2015. Eligible studies must have treated preterm infants directly in the crib or bed and Osteopathic Manipulative Treatment (OMT) must have been performed by osteopaths. A rigorous Cochrane-like method was used for study screening and selection, risk of bias assessment and data reporting. Fixed effect meta-analysis was performed to synthesize data. RESULTS: 5 trials enrolling 1306 infants met our inclusion criteria. Although the heterogeneity was moderate (I = 61%, P = 0.03), meta-analysis of all five studies showed that preterm infants treated with OMT had a significant reduction of LOS by 2.71 days (95% CI -3.99, -1.43; P < 0.001). Considering costs, meta-analysis showed reduction in the OMT group (-1,545.66&OV0556;, -1,888.03&OV0556;, -1,203.29&OV0556;, P < 0.0001). All studies reported no adverse events associated to OMT. Subgroup analysis showed that the benefit of OMT is inversely associated to gestational age. CONCLUSIONS: The present systematic review showed the clinical effectiveness of OMT on the reduction of LOS and costs in a large population of preterm infants.

Vascular surgeon-hospitalist comanagement improves in-hospital mortality at the expense of increased in-hospital cost.

OBJECTIVE: We have shown that vascular surgeon- hospitalist co management resulted in improved in-hospital mortality rates. We now aim to assess the impact of the hospitalist co management service (HCS) on healthcare cost. METHODS: A total of 1558 patients were divided into three cohorts and compared: 516 in 2012, 525 in 2013, and 517 in 2014. The HCS began in January 2013. Data were standardized for six vascular surgeons that were present 2012-2014. New attendings were excluded. Ten hospitalists participated. Case mix index (CMI), contribution margin, total hospital charges (THCs), length of stay (LOS), actual direct costs (ADCs), and actual variable indirect costs (AVICs) were compared. Analysis of variance with post-hoc tests, t-tests, and linear regressions were performed. RESULTS: THC rose by a mean difference of $14,578.31 between 2012 and 2014 (P < .001) with a significant difference found between all groups during the study period (P = .0004). ADC increased more than AVIC; however, both significantly increased over time (P = .0002 and P = .014, respectively). A mean $3326.63 increase in ADC was observed from 2012 to 2014 (P < .0001). AVIC only increased by an average $392.86 during the study period (P = .01). This increased cost was observed in the context of a higher CMI and longer LOS. CMI increased from 2.25 in 2012 to 2.53 in 2014 (P = .006). LOS increased by a mean 1.02 days between 2012 and 2014 (P = .016), and significantly during the study period overall (P = .018). After adjusting for CMI, LOS increases by only 0.61 days between 2012 and 2014 (P = .07). In a final regression model, THC is independently predicted by comanagement, CMI, and LOS. After adjusting for CMI and LOS, the increase in THC because of comanagement (2012 vs 2014) accounts for only $4073.08 of the total increase (P < .001). During this time, 30-day readmission rates decreased by ∼7% (P = .005), while related 30-day readmission rates decreased by ∼2% (P = .32). Physician contribution margin remained unchanged over the 3-year period (P = .76). The most prevalent diagnosis-related group was consistent across all years. Variation in the principal diagnosis code was observed with the prevalence of circulatory disorders because of type II diabetes replacing atherosclerosis with gangrene as the most prevalent diagnosis in 2013 and 2014 compared with 2012. CONCLUSIONS: In-hospital cost is significantly higher since the start of the HCS. This surge may relate to increased CMI, LOS, and improved coding. This increase in cost may be justified as we have observed sustained reduction in in-hospital mortality and slightly improved readmission rates.

[Regional Budgets in Psychiatry: An Alternative to Hospital per Diem Charges and the New Reimbursement System? - A Case Study from the District of Dithmarschen]. / Regionalbudgets in der Psychiatrie: Eine Alternative zu tagesgleichen Pflegesätzen und zum zukünftigen Finanzierungssystem?

Objective The study looked at the impact that the switch from a reimbursement system with hospital per diem charges to a regional budget had on treatment. Methods Routine data from two clinics over a period of ten years were evaluated. Results Treatment took place in day clinics and on an outpatient basis to an increased extent after the change. Conclusion The change in reimbursement system was the cause of the change in treatment. Since similar effects can also be expected when switching from the new reimbursement system for psychiatry and psychosomatic medicine to a regional budget system, regional budgets are a reasonable alternative.

Does Acupuncture Treatment Affect Utilization of Other Hospital Services at an Urban Safety-Net Hospital?

BACKGROUND: Little is known regarding the interaction between acupuncture and biomedical healthcare among vulnerable patient populations. In particular, the association between acupuncture and total cost of healthcare has not been characterized. METHODS: Total hospital system visits and associated charges were retrospectively reviewed among patients who received acupuncture at a large safety-net hospital system from 2007 to 2014. Inclusion criteria were Medicare or Medicaid insurance coverage, older than age 18 years, and one or more on-site acupuncture appointments. Patients were stratified into five groups based on the number of acupuncture visits: 1-3, 4-6, 7-9, 10-12, or 13-15 treatments. The total number of biomedical hospital visits and total associated charges were compared 6 months before and 6 months after initiation of acupuncture. RESULTS: A total of 329 patients met our inclusion criteria. Although not statistically significant, there appeared to be an association between acupuncture treatment and a decrease in total hospital charges. The group receiving 1-3 acupuncture treatments showed a per-patient average increase in total charges in the 6-month period after acupuncture ($1771.34; p = 0.38). The patients who received 7-9 treatments showed the largest average decrease in total charges ($8967.24; p = 0.17). CONCLUSION: This study shows a previously unreported aggregate relationship between number of treatments and total healthcare charges in a single urban safety-net hospital. Given the sample size available and the heterogeneity of the patient population, no statistically significant associations could be established between initiation of acupuncture treatment and charges. However, some suggestive patterns were observed. Further prospective studies with a matched-group control are warranted to further explore this relationship. Additional study across wider locations is warranted to best guide practitioners and hospitals in designing efficacious, high-value integrative medicine programs.

Economic outcomes in clinical studies assessing hyperbaric oxygen in the treatment of acute and chronic wounds.

INTRODUCTION: Hyperbaric oxygen treatment (HBOT) is used to treat acute and chronic wounds. This systematic review was conducted to summarise and evaluate existing evidence on the costs associated with HBOT in the treatment of wounds. METHODS: We searched multiple electronic databases in March 2015 for cohort studies and randomised clinical trials (RCTs) that reported on the clinical effectiveness and treatment costs of HBOT in the treatment of acute or chronic wounds. RESULTS: One RCT and three cohort studies reported on economic as well as clinical outcomes. These studies comprised different disorders (ischaemic diabetic foot ulcers, thermal burns, Fournier's gangrene and necrotising soft tissue infections) and employed different clinical and economic outcome measures. Only the RCT had a good methodological quality. Three of the included studies reported that their primary clinical outcomes (wound healing, hospital stay, complications) improved in the HBOT group. The effects of HBOT on costs were variable. CONCLUSIONS: Currently, there is little direct evidence on the cost-effectiveness of HBOT in the treatment of acute and chronic wounds. Although there is some evidence suggesting effectiveness of HBOT, further studies should include economic outcomes in order to make recommendations on the cost-effectiveness of applying HBOT in wound care.

Addressing Pricing Power in Integrated Delivery: The Limits of Antitrust.

Prices are the major driver of why the United States spends so much more on health care than other countries do. The pricing power that hospitals have garnered recently has resulted from consolidated delivery systems and concentrated markets, leading to enhanced negotiating leverage. But consolidation may be the wrong frame for viewing the problem of high and highly variable prices; many "must-have" hospitals achieve their pricing power from sources other than consolidation, for example, reputation. Further, the frame of consolidation leads to unrealistic expectations for what antitrust's role in addressing pricing power should be, especially because in the wake of two periods of merger "manias" and "frenzies" many markets already lack effective competition. It is particularly challenging for antitrust to address extant monopolies lawfully attained. New payment and delivery models being pioneered in Medicare, especially those built around accountable care organizations (ACOs), offer an opportunity to reduce pricing power, but only if they are implemented with a clear eye on the impact on prices in commercial insurance markets. This article proposes approaches that public and private payers should consider to complement the role of antitrust to assure that ACOs will actually help control costs in commercial markets as well as in Medicare and Medicaid.

To heal and restore broken bodies: a retrospective, descriptive study of the role and impact of pastoral care in the treatment of patients with burn injury.

INTRODUCTION: Despite advances in resuscitation, resurfacing, and reconstruction, recovery in burn patients often depends upon emotional, psychosocial, and spiritual healing. We characterized the spiritual needs of burn patients to help identify resources necessary to optimize recovery. METHODS: We performed a retrospective review of all patients admitted to a regional, accredited burn center, in 2011. We accessed multiple clinical, financial, and administrative databases, collected demographic data, including religious affiliation, and recorded the number and type of pastoral care visits. Outcome measures included length of stay (LOS), physician and facility charges, and mortality. We compared patients who had a pastoral care visit with those who did not, as well as patients with a religious affiliation with those who had no or an unknown affiliation. RESULTS: During the study period, our burn center admitted 1338 patients, 314 of whom were visited by chaplains, for a total of 1077 encounters (3.43 visits per patient seen). Most frequent interventions were prayer, social support, and spiritual counseling. Compared to patients who had no visit, patients who saw a chaplain had a larger total body surface area burn, longer LOS, higher charges, and higher mortality (10.2% vs. 0.78%, P < 0.001). Patients who had a religious affiliation had slightly lower mortality than patients with unknown or no religious affiliation (0.87% vs. 3.19%), but this did not reach statistical significance. CONCLUSIONS: In burn patients, utilization of pastoral care appears to be linked to size of burn, financial charges, and length of stay, with religious affiliation serving as a possible marker for improved survival. Plastic surgeons and burn providers should consider and address the spiritual needs of burn patients, as a component of recovery.

Variation in practice patterns and resource utilization surrounding management of intussusception at freestanding Children's Hospitals.

PURPOSE: To characterize variation in practice patterns and resource utilization associated with the management of intussusception at Children's Hospitals. METHODS: A retrospective cohort study (1/1/09-6/30/11) of 27 Children's Hospitals participating in the Pediatric Health Information System database was performed. Hospitals were compared with regard to their rates of operative management following attempted enema reduction, prophylactic antibiotic utilization, same-day discharge for those successfully managed non-operatively, 48-h readmission rates, and case-related cost and charges. RESULTS: 2544 patients were identified (median: 93 cases/center) with a median age of 17 months. The rate of operation following attempted enema reduction varied significantly across hospitals (overall rate: 21.1%: range: 11%-62.8%; p<0.0001). For patients managed non-operatively, significant variability was found for prophylactic antibiotic utilization (overall rate: 23.3%; range: 1.4%-93.2%; p<0.0001), same-day discharge (overall rate: 15.2%; range: 0%-83.8%; p<0.0001), readmission rates (overall rate: 17.5%; range: 5.3%-32.1%; p<0.0001), treatment-related costs (overall median: $2490; range: $829-$5905; p<0.0001), and charges (overall median: $6350; range: $2497-$10,306; p<0.0001). Variability in costs and charges was even greater when analyzing all patients (operative and non-operative) with intussusception (overall cost median: $2865; range: $1574-$6763; p<0.0001; overall charge median: $7110; range: $3544-$22,097; p<0.0001). CONCLUSION: Significant variation in practice patterns and resource utilization exists between Children's Hospitals in the management of intussusception. Prospective analysis of practice variation and appropriately risk-adjusted outcomes through a collaborative quality-improvement platform could accelerate the dissemination of best-practice guidelines for optimizing cost-effective care.