Cost-effectiveness of stereotactic laser ablation (SLA) for brain tumors.

BACKGROUND: Stereotactic laser ablation(SLA) or laser interstitial thermal therapy (LITT) has been increasingly adopted as a treatment for primary and metastatic brain cancers. Here, we examined the published economic assessments of SLA, and review the current state of knowledge. METHODS: The PubMed database was queried for articles investigating the cost-effectiveness of LITT. 3068 articles were screened. Two studies that met the inclusion criteria were included in this review. RESULTS: Cost-effectiveness analysis(CEA) favored SLA(n = 8) relative to craniotomy (n = 92) for brain metastases (Mean difference [MD]=-US$6522; 95% confidence interval (CI) -$11,911 to -$1133; p = 0.02). SLA (n = 19) was found to be cost equivalent to craniotomy (n = 248) (MD=-US$1669; 95%(CI) -$8192 to $4854, p = 0.62) for primary brain tumors in general. CEA favored SLA for a subset of primary brain cancers. SLA was found to be cost-effective for difficult to access high-grade gliomas(HGG). When compared to 'other' existing treatments, the cost per life-years gained (LYG) through SLA was ∼$29,340, a threshold below that set for new technology adaptation in the U.S. Factors contributing to these cost-effectiveness were: (1) SLA of HGGs was associated with three-months prolongation in survival; (2) SLA of brain metastasis was associated with (i) shorter average length of stay (SLA: 2.3 days; craniotomy: 4.7 days), (ii) decreased discharge to inpatient rehabilitation facility (IRF), skilled nursing facility (SNF), or home healthcare (SLA: 14.8%; craniotomy: 52%), (iii) lowered 30-day readmission (SLA: 0%; craniotomy: 14.1%). CONCLUSION: There is limited data on the cost-effectiveness of SLA. In the available literature, SLA compared favorably to craniotomy in terms of cost-effectiveness as a treatment for primary and metastatic brain cancers.

Reasons for readmission after hospital discharge in patients with chronic diseases-Information from an international dataset.

BACKGROUND: Chronic diseases are increasingly prevalent in Western countries. Once hospitalised, the chance for another hospitalisation increases sharply with large impact on well-being of patients and costs. The pattern of readmissions is very complex, but poorly understood for multiple chronic diseases. METHODS: This cohort study of administrative discharge data between 2009-2014 from 21 tertiary hospitals (eight USA, five UK, four Australia, four continental Europe) investigated rates and reasons of readmissions to the same hospital within 30 days after unplanned admission with one of the following chronic conditions; heart failure; atrial fibrillation; myocardial infarction; hypertension; stroke; chronic obstructive pulmonary disease (COPD); bacterial pneumonia; diabetes mellitus; chronic renal disease; anaemia; arthritis and other cardiovascular disease. Proportions of readmissions with similar versus different diseases were analysed. RESULTS: Of 4,901,584 admissions, 866,502 (17.7%) were due to the 12 chronic conditions. In-hospital, 43,573 (5.0%) patients died, leaving 822,929 for readmission analysis. Of those, 87,452 (10.6%) had an emergency 30-day readmission, rates ranged from 2.8% for arthritis to 18.4% for COPD. One third were readmitted with the same condition, ranging from 53% for anaemia to 11% for arthritis. Reasons for readmission were due to another chronic condition in 10% to 35% of the cases, leaving 30% to 70% due to reasons other than the original 12 conditions (most commonly, treatment related complications and infections). The chance of being readmitted with the same cause was lower in the USA, for female patients, with increasing age, more co-morbidities, during study period and with longer initial length of stay. CONCLUSION: Readmission in chronic conditions is very common and often caused by diseases other than the index hospitalisation. Interventions to reduce readmissions should therefore focus not only on the primary condition but on a holistic consideration of all the patient's comorbidities.

Targeting malnutrition: Nutrition programs yield cost savings for hospitalized patients.

BACKGROUND & AIMS: Between 30 and 50% of Colombian patients are malnourished or at-risk of malnutrition on hospital admission. Malnutrition is associated with poor outcomes and increased costs. We used cost modeling to estimate savings that could be derived from implementation of a nutrition therapy program for patients at malnutrition risk. METHODS: The budget impact analysis was performed using previously-published outcomes data. Outcomes included length of stay, 30-day readmissions, and infectious/non-infectious complications. We developed a Markov model that compared patients who were assigned to receive early nutrition therapy (started within 24-48 h of hospital admission) with those assigned to receive standard nutrition therapy (not started early). Our model used a 60-day time-horizon and estimated event probabilities based on published data. RESULTS: Average total costs over 60 days were $3770 US dollars for patients with delayed nutrition therapy vs $2419 for patients with early nutrition therapy-a savings of $1351 (35.8% decrease) per nutrition-treated patient. Cost differences between the groups were: $2703 vs $1600 for hospital-associated costs; $883 vs $665 for readmissions; and $176 vs $94 for complications. Taken broadly, the potential costs savings from a nutrition care program for an estimated 638,318 hospitalized Colombian patients at malnutrition risk is $862.6 million per year. CONCLUSIONS: Our budget impact analysis demonstrated the potential for hospital-based nutrition care programs to improve health outcomes and reduce healthcare costs for hospitalized patients in Colombia. These findings provide a rationale for implementing comprehensive nutrition care in Colombian hospitals.

Similar health economic outcomes in low-risk and high-risk malnourished inpatients as screened by the Malnutrition Screening Tool after delivery of oral nutritional supplements.

OBJECTIVE: The aim of this study was to determine whether modified low- and high-risk Malnutrition Screening Tool (MST) scores (2 versus >2, respectively) were independently predictive of health economic outcomes. METHODS: We analyzed data from a recent nutrition-based quality improvement program (QIP) that prescribed daily oral nutritional supplements for all hospitalized adults at risk for malnutrition. In the original study, an electronic medical records-based MST was administered at the time of admission, and patients were classified as "low risk" or "high risk" for malnutrition based on MST scores (2 versus ≥2). We compared health economic outcomes for patients at low or high risk for malnutrition based on a modified score (MST = 2 versus >2, respectively), looking for between-group differences in length of stay (LOS) and unplanned 30-d readmissions. Analyses were additionally stratified by age (<65 versus ≥65 y of age). RESULTS: Of the 1269 patients enrolled in the QIP, 413 (32.5%) had MST of 2 and 856 (67.5%) had MST >2. Mean LOS was 5.19 d (±4.78) for patients with MST 2 and 4.49 d (±4.69) with MST >2 (non-statistically significant between-group difference; P = 0.277). There were no significant differences in unplanned 30-d readmission rates (14% for low-risk and 17.1% for high-risk patients; P = 0.171). These findings remained statistically insignificant when the low- and high-risk MST score groups were further stratified by age. CONCLUSIONS: Outcomes of hospitalized patients with MST 2 were not significantly different from those with an MST >2. This suggests that patients at both lower and higher risk for malnutrition (based on MST scores of 2 versus ≥3) were similar in terms of LOS and 30-d readmission rates. To avoid overlooking cases of malnutrition risk, the validated cutoff scores for the MST should be consistently implemented. Training that is consistent with the validated MST is recommended rather than attempting to reduce the case burden by "raising the bar" and attempting to classify patients with an MST = 2 as "low risk."

Effect of an Integrated Payment System on the Direct Economic Burden and Readmission of Rural Cerebral Infarction Inpatients: Evidence from Anhui, China.

Rural China is piloting an integrated payment system, which prepays a budget to a medical alliance rather than a single hospital. This study aims to evaluate the effect of this reform on the direct economic burden and readmission rates of cerebral infarction inpatients. The settlement records of 78,494 cerebral infarction inpatients were obtained from the New Rural Cooperative Medical Scheme (NRCMS) database in Dingyuan and Funan Counties in the Anhui Province. The direct economic burden was estimated by total costs, out-of-pocket expenditures, the out-of-pocket ratio, and the compensation ratio of the NRCMS. Generalized additive models and multivariable linear/logistic regression were applied to measure the changes of the dependent variables along with the year. Within the county, the total costs positively correlated to the year (ß = 313.10 in 2015; 163.06 in 2016). The out-of-pocket expenditures, out-of-pocket ratios, and the length-of-stay positively correlated to the year in 2015 (ß = 105.10, 0.01, and 0.18 respectively), and negatively correlated to the year in 2016 (ß = -58.40, -0.03, and -0.30, respectively). The odds ratios of the readmission rates were less than one within the county (0.70 in 2015; 0.53 in 2016). The integrated payment system in the Anhui Province has considerably reduced the direct economic burden for the rural cerebral infarction inpatients, and the readmission rate has decreased within the county. Inpatients' health outcomes should be given further attention, and the long-term effect of this reform model awaits further evaluation.

Impact of the Southwark and Lambeth Integrated Care Older People's Programme on hospital utilisation and costs: controlled time series and cost-consequence analysis.

OBJECTIVES: To estimate the impact on hospital utilisation and costs of a multi-faceted primary care intervention for older people identified as being at risk of avoidable hospitalisation. DESIGN: Observational study: controlled time series analysis and estimation of costs and cost consequences of the Programme. General practitioner (GP)'s practice level data were analysed from 2009 to 2016 (intervention operated from 2012 to 2016). Mixed-effect Poisson regression models of hospital utilisation included comparisons with control practices and background trends in addition to within-practice comparisons. Cost estimation used standard tariff values. SETTING: 94 practices in Southwark and Lambeth and 263 control practices from other parts of England. MAIN OUTCOME MEASURES: Hospital utilisation: emergency department attendance, emergency admissions, emergency admissions for ambulatory sensitive conditions, outpatient attendance, elective admission and length of stay. RESULTS: By the fourth year of the Programme, there were reductions in accident and emergency (A&E) attendance (rate ratio 0.944, 95% CI 0.913 to 0.976), outpatient attendances (rate ratio 0.938, 95% CI 0.902 to 0.975) and elective admissions (rate ratio 0.921, 95% CI 0.908 to 0.935) but there was no evidence of reduced emergency admissions. The costs of the Programme were £149 per resident aged 65 and above but savings in hospital costs were only £86 per resident aged 65 and above, equivalent to a net increase in health service expenditure of £64 per resident though the Programme was nearly cost neutral if set-up costs were excluded. Holistic assessments carried out by GPs and consequent Integrated Care Management (ICM) plans were associated with increases in elective activity and costs; £126 increase in outpatient attendance and £936 in elective admission costs per holistic assessment carried out, and £576 increase in outpatient and £5858 in elective admission costs per patient receiving ICM. CONCLUSIONS: The Older People's Programme was not cost saving. Some aspects of the Programme were associated with increased costs of elective care, possibly through the identification of unmet need.

Prevalence and burden of illness of treated hemolytic neonatal hyperbilirubinemia in a privately insured population in the United States.

BACKGROUND: Prevalence of hemolytic neonatal hyperbilirubinemia (NHB) is not well characterized, and economic burden at the population level is poorly understood. This study evaluated the prevalence, clinical characteristics, and economic burden of hemolytic NHB newborns receiving treatment in U.S. real-world settings. METHODS: This cohort study used administrative claims from 01/01/2011 to 08/31/2017. The treated cohort had hemolytic NHB diagnosis and received phototherapy, intravenous immunoglobulin, and/or exchange transfusions. They were matched with non-NHB newborns who had neither NHB nor related treatments on the following: delivery hospital/area, gender, delivery route, estimated gestational age (GA), health plan eligibility, and closest date of birth within 5 years. Inferential statistics were reported. RESULTS: The annual NHB prevalence was 29.6 to 31.7%; hemolytic NHB, 1.8 to 2.4%; treated hemolytic NHB, 0.46 to 0.55%, between 2011 and 2016. The matched analysis included 1373 pairs ≥35 weeks GA. The treated hemolytic NHB cohort had significantly more birth trauma and hemorrhage (4.5% vs. 2.4%, p = 0.003), vacuum extractor affecting newborn (1.9% vs. 0.8%, p = 0.014), and polycythemia neonatorum (0.8% vs. 0%, p = 0.001) than the matched non-NHB cohort. The treated hemolytic NHB cohort also had significantly longer mean birth hospital stays (4.5 vs. 3.0 days, p < 0.001), higher level 2-4 neonatal intensive care admissions (15.7% vs. 2.4, 15.9% vs. 2.8 and 10.6% vs. 2.5%, respectively, all p < 0.001) and higher 30-day readmission (8.7% vs. 1.7%, p < 0.001). One-month and one-year average total costs of care were significantly higher for the treated hemolytic NHB cohort vs. the matched non-NHB cohort, $14,405 vs. $5527 (p < 0.001) and $21,556 vs. $12,986 (p < 0.001), respectively. The average costs for 30-day readmission among newborns who readmitted were $13,593 for the treated hemolytic NHB cohort and $3638 for the matched non-NHB cohort, p < 0.001. The authors extrapolated GA-adjusted prevalence of treated hemolytic NHB in the U.S. newborn population ≥ 35 weeks GA and estimated an incremental healthcare expenditure of $177.0 million during the first month after birth in 2016. CONCLUSIONS: The prevalence of treated hemolytic NHB was 4.6-5.5 patients per 1000 newborns. This high-risk hemolytic NHB imposed substantial burdens of healthcare resource utilization and incremental costs on newborns, their caregivers, and the healthcare system.

Cost Implications of Anticoagulation Strategies After Percutaneous Coronary Intervention Among Patients With Atrial Fibrillation (A PIONEER-AF PCI Analysis).

The PIONEER AF-PCI trial demonstrated that in atrial fibrillation patients who underwent intracoronary stenting, either rivaroxaban 15 mg daily plus P2Y12 inhibitor monotherapy (Group 1) or 2.5 mg rivaroxaban twice daily plus dual antiplatelet therapy (DAPT) (Group 2) was associated with fewer recurrent hospitalizations, primarily for bleeding and cardiovascular events, compared with standard-of-care vitamin K antagonist and DAPT (Group 3). Associated costs are unknown. This study estimates costs associated with rivaroxaban strategies compared with vitamin K antagonist and DAPT. Medication costs were estimated using wholesale acquisition costs, medication discontinuation rates, and costs of monitoring. Using a large US healthcare claims database, the mean adjusted increase in 1-year cost of care for individuals with atrial fibrillation and percutaneous coronary intervention (PCI) rehospitalized for bleeding, cardiovascular, and other events was compared with those not rehospitalized. Using adjudicated rehospitalization rates from PIONEER AF-PCI, cost differences were estimated. Rates of rehospitalization for bleeding were 6.5%, 5.4%, 10.5%, and 20.3%, 20.3%, 28.4% for cardiovascular events in Groups 1, 2, and 3. Medication and monitoring costs were $3,942, $4,115, and $1,703. One-year costs for all recurrent hospitalization costs and/or patient for the groups were $24,535, $20,205, and $29,756. One-year cost increase associated with bleeding rehospitalizations and/or patient was $4,160, $3,212, and $6,876 and was $13,264, $11,545, and $17,220 for cardiovascular rehospitalizations and/or patient. Overall estimated cost per patient was $28,476, $24,320, and $31,458. Compared with warfarin, both rivaroxaban treatment strategies had higher medication costs, but these were more than accounted for by fewer hospitalizations.

Predictors and Cost of Readmission in Total Knee Arthroplasty.

BACKGROUND: The Comprehensive Care for Joint Replacement bundle was created to decrease total knee arthroplasty (TKA) cost. To help accomplish this, there is a focus on reducing TKA readmissions. However, there is a lack of national representative sample of all-payer hospital admissions to direct strategy, identify risk factors for readmission, and understand actual readmission cost. METHODS: We used the Nationwide Readmission Database to examine national readmission rates, predictors of readmission, and associated readmission costs for elective TKA procedures. We fit a multivariable logistic regression model to examine factors associated with readmission. Then, we determined mean readmission costs and calculated the readmission cost when distributed across the entire TKA population. RESULTS: We identified 224,465 patients having TKA across all states participating in the Nationwide Readmission Database. The mean unadjusted 30-day TKA readmission rate was 4%. The greatest predictors of readmission were congestive heart failure (odds ratio [OR] 2.51, 95% confidence interval [CI] 2.62-2.80), renal disease (OR 2.19, 95% CI 2.03-2.37), and length of stay greater than 4 days (OR 2.4, 95% CI 2.25-2.61). The overall median cost for each readmission was $6753 ± 175. Extrapolating the readmission cost for the entire TKA population resulted in the readmission cost being 2% of the overall 30-day procedure cost. CONCLUSIONS: A major focus of the Comprehensive Care for Joint Replacement bundle is improving cost and quality by limiting readmission rates. TKA readmissions are low and comprise a small percentage of total TKA cost, suggesting that they may not be the optimal measure of quality care or a significant driver of overall cost.

Is treatment of geriatric hip fracture patients cost-covering? Results of a prospective study conducted at a German University Hospital.

INTRODUCTION: Hip fractures have increased medical and socio-economic importance due to demographic transition. Information concerning direct treatment costs and their reimbursement in Germany is lacking. MATERIALS AND METHODS: Four hundred two hip fracture patients older than 60 years of age were observed prospectively at a German University Hospital. Treatment costs were determined with up to 196 cost factors and compared to the reimbursement. Finally, statistical analysis was performed to identify clinical parameters influencing the cost-reimbursement relation. RESULTS: Treatment costs were 8853 € (95% CI 8297-9410 €), while reimbursement was 8196 € (95% CI 7707-8772 €), resulting in a deficit of 657 € (95% CI 143-1117 €). Bivariate analysis showed that the cost-reimbursement relation was negatively influenced mainly by higher age, higher ASA score, readmission to the intensive care unit (ICU) and red blood cell transfusion. Adjusted for other parameters, readmission to the ICU was a significant negative predictor (- 2669 €; 95% CI - 4070 to - 1268 €; p < 0.001), while age of 60-75 years was a positive predictor for the cost-reimbursement relation (1373 €; 95% CI 265-2480 €; p = 0.015). CONCLUSIONS: Treatment of geriatric hip fracture patients in a university hospital in Germany does not seem to be cost-covering. Adjustment of the reimbursement for treatment of complex hip fracture patients should be considered.

Is Orthopedic Department Teaching Status Associated With Adverse Outcomes Of Primary Total Hip Arthroplasty?

BACKGROUND: Although resident physicians play a vital role in the US health care system, they are believed to create inefficiencies in the delivery of care. Under the regional component of the Comprehensive Care for Joint Replacement model, teaching hospitals are forced to compete on efficiency and outcomes with nonteaching hospitals. METHODS: We identified 86,021 patients undergoing elective primary total hip arthroplasty in New York State between January 1, 2009, and September 30, 2014. Outcomes included length and cost of the index admission, disposition, and 90-day readmission. Mixed-effects regression models compared teaching vs nonteaching orthopedic hospitals after adjusting for patient demographics, comorbidities, hospital, surgeon, and year of surgery. RESULTS: Patients undergoing surgery at teaching hospitals had longer lengths of stay (ß = 3.2%; P < .001) and higher costs of admission (ß = 13.6%; P < .001). There were no differences in disposition status (odds ratio = 1.03; P = .779). The risk of 90-day readmission was lower for teaching hospitals (odds ratio = 0.89; P = .001). CONCLUSION: Primary total hip arthroplasty at teaching orthopedic hospitals is characterized by greater utilization of health care resources during the index admission. This suggests that teaching hospitals may be adversely affected by reimbursement tied to competition on economic and clinical metrics. Although a certain level of inefficiency is inherent during the learning process, these policies may hinder learning opportunities for residents in the clinical setting.

Effectiveness and efficacy of nutritional therapy: A systematic review following Cochrane methodology.

BACKGROUND & AIMS: Disease-related malnutrition has deleterious consequences on patients' outcome and healthcare costs. The demonstration of improved outcome by appropriate nutritional management is on occasion difficult. The European Society of Clinical Nutrition and Metabolism (ESPEN) appointed the Nutrition Education Study Group (ESPEN-NESG) to increase recognition of nutritional knowledge and support in health services. METHODS: To obtain the best available evidence on the potential effects of malnutrition on morbidity, mortality and hospital stay; cost of malnutrition; effect of nutritional treatment on outcome parameters and pharmaco-economics of nutritional therapy, a systematic review of the literature was performed following Cochrane methodology, to answer the following key questions: Q1) Is malnutrition an independent predictive factor for readmission within 30 days from hospital discharge? Q2) Does nutritional therapy reduce the risk of readmission within 30 days from hospital discharge? Q3) Is nutritional therapy cost-effective/does it reduce costs in hospitalized patients? and Q4) Is nutritional therapy cost effective/does it reduce costs in outpatients? RESULTS: For Q1 six of 15 identified observational studies indicated that malnutrition was predictive of re-admissions, whereas the remainder did not. For Q2 nine randomized controlled trials and two meta-analyses gave non-conclusive results whether re-admissions could be reduced by nutritional therapy. Economic benefit and cost-effectiveness of nutritional therapy was consistently reported in 16 identified studies for hospitalized patients (Q3), whereas the heterogeneous and limited corresponding data on out-patients (Q4) indicated cost-benefits in some selected sub-groups. CONCLUSIONS: This result of this review supports the use of nutritional therapy to reduce healthcare costs, most evident from large, homogeneous studies. In general, reports are too heterogeneous and overall of limited quality for conclusions on impact of malnutrition and its treatment on readmissions.

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.

Is Orthopaedic Department Teaching Status Associated with Adverse Outcomes of Primary Total Knee Arthroplasty?

INTRODUCTION: Although resident physicians have a critical role in the daily management of patients, based on their limited experiences, they are thought to potentially create inefficiencies in the hospital. With changes set forth by the Comprehensive Care for Joint Replacement (CJR) program, both teaching and non-teaching hospitals are directly compared on efficiency and outcomes. Therefore, the purpose of this study was to compare outcomes between teaching and non-teaching hospitals in the state of New York. Specifically, we compared: (1) duration of stay; (2) cost of admission; (3) disposition; and (4) 90-day readmission for elective primary total knee arthroplasty (TKA). MATERIALS AND METHODS: Using the New York Statewide Planning and Research Cooperative System (SPARCS) database, 133,489 patients undergoing primary total knee arthroplasty (TKA) between January 1, 2009 and September 30, 2014 were identified. Outcomes assessed included lengths-of-stay and cost of the index admission, disposition, and 90-day readmission. To compare the above outcomes between the hospital systems, mixed effects regression models were used, which were adjusted for patient demographics, comorbidities, hospital, surgeon, and year of surgery. RESULTS: Patients who underwent surgery at teaching hospitals were found to have longer lengths of stay (b=3.4%, p<0.001) and higher costs of admission (b=14.7%; p<0.001). Patients were also more likely to be readmitted within 90 days of discharge (OR=1.64; p<0.001). No differences were found in discharge disposition status for teaching versus non-teaching hospitals (OR=0.92; p=0.081. CONCLUSIONS: The results from this study indicate that at teaching hospitals, a greater number of resources are needed for primary TKA than at non-teaching hospitals. Therefore, teaching hospitals might be inappropriately reimbursed when compensation is linked to competition on economic and clinical metrics. Furthermore, based on this, optimizing reimbursement might inadvertently come at the expense of resident training and education. While some inefficiencies exist as an inherent part of resident training, limiting learning opportunities to optimize compensation can potentially have greater future consequences.

Impact of Neuromuscular Electrical Stimulation (NMES) on 90-Day Episode Costs and Post-Acute Care Utilization in Total Knee Replacement Patients with Disuse Atrophy.

INTRODUCTION: This study evaluated differences in: 1) total episode payments, 2) probability of hospital readmission, 3) probability of inpatient rehab facility (IRF) and utilization, and 4) probability of skilled nursing care facility (SNF) utilization in patients who had disuse atrophy and underwent a total knee arthroplasty (TKA) and either did, or did not, receive preoperative home-based neuromuscular electrical stimulation (NMES) therapy. MATERIALS AND METHODS: We used the Medicare limited dataset for a 5% sample of beneficiaries from 2014 and 2015 to construct episodes-of-care for TKA (DRG-470) patients with disuse atrophy who underwent a TKA during the 30 days prior to hospital admission and 90 days post-discharge. Patients were stratified into those who either did or did not receive pre- and postoperative NMES therapy. An ordinary least square (OLS) model was used to estimate the impact of NMES on total episode. Linear probability models were used to estimate the impact of NMES on SNF or IRF utilization and readmission. RESULTS: A $3,274 reduction in episode payments for patients who used preoperative NMES versus those who did not (p<0.001) was demonstrated. The probability of readmission was 12.7% lower for those who used preoperative NMES therapy versus those who did not (p=0.609). The probability of utilizing IRF and SNF was 56.7% (p=0.061) and 46.4% (p=<0.001) lower for those who used pre- and postoperative NMES versus those who did not, respectively. CONCLUSION: Significant reduction in total episode payments and SNF utilization for TKA patients with disuse atrophy who had NMES therapy was demonstrated.

Making the Case for Palliative Care at the System Level: Outcomes Data.

BACKGROUND: A recent trend in health care is to integrate palliative care (PC) programs across multiple hospitals to reduce variation, improve quality, and reduce cost. OBJECTIVE: The study objective was to demonstrate the benefits of PC for a system. METHODS: The study was a descriptive study using retrospective medical records in seven federated hospitals where PC developed differently before system integration. Measured were length of stay (LOS), mortality, readmissions, saved intensive care unit (ICU) days, cost avoidance, and hospice referrals. RESULTS: PC services within the first 48 hours of admission demonstrate a shorter LOS (5.08 days), reduced costs 40% ($2,362 per day), and decreased mortality (1.01 versus 1.10) for one hospital. Readmissions at 30, 60, and 90 days after a PC consult decreased (61.5%, 47.0%, and 42.1%, respectively). Annual pre- and postprogram referrals to hospice increased (65 to 107). Using modified matched pairs, LOS of PC patients seen within 48 hours of admission average 1.67 days less compared to non-PC patients. LOS for ICU patients with PC services in the ICU within the first 48 hours decreased by 1.12 days. Overall cost avoidance was 1.5 times total cost for PC programs systemwide. One pilot project using a full-time physician in the ICU reduced cost more than $600,000, with 315 saved ICU days, annualized. Systemwide, 69.3% of all referrals to hospice were made by the PC service. CONCLUSION: Early involvement of PC services emerged as advantageous to the net benefit. Given that health care's changing landscape will increasingly include bundled payment and risk holding strategies to improve quality and reduce cost in health care systems, systemwide PC will play a vital role.

Cost Analysis of an Advanced Practice Registered Nurse Transitional Care Model for Cardiac Patients.

Interest in care transitions has intensified in light of emphasis placed on hospital readmissions. This study provides a comparative analysis of the costs of providing transitional care through a program for cardiac patients against hospital readmission costs. The advanced practice registered nurse-managed BRIDGE model reduced health care costs associated with readmissions that were in excess of program costs. On average, there was a per-patient savings of $4,944 in avoided readmissions within 30 days of hospital discharge. Over the duration of the program, this equates to a $306,537 savings in patients with acute coronary syndrome. Nurse practitioners have a unique, holistic, and supportive approach to providing care that may make them ideal for the transitional care setting.

Integrated Medicare and Medicaid managed care and rehospitalization of dual eligibles.

OBJECTIVES: Healthcare expenditures for dually eligible individuals covered by both Medicare and Medicaid constitute a disproportionate share of spending for the 2 programs. Fragmentation, inefficiency, and low-quality care have been long standing issues for this population. The objective of this study was to conduct an early evaluation of an innovative program that coordinates benefits for elderly dual eligibles. STUDY DESIGN: Longitudinal cohort study. METHODS: Comparable sources of administrative claims from 2007 to 2009 were used to examine differences in 30-day rehospitalization between dual eligibles in Massachusetts participating in Senior Care Options (SCO), an integrated managed care program, and dual eligibles in Medicare fee-for-service. Multivariable logistic regression models with county and time fixed effects were used for estimation. RESULTS: We found no statistically significant effect of SCO on rehospitalization, an area where coordinated care would be expected to make a substantial difference. CONCLUSIONS: Our results suggest that coordinating the financing and delivery of services through an integrated managed program may not sufficiently address the problems of inefficiency and fragmentation in care for hospitalized dual eligible enrollees.

Effectiveness of a discharge planning and community support programme in preventing readmission of high-risk older patients.

OBJECTIVE: To examine the effectiveness of Integrated Care and Discharge Support for elderly patients in reducing accident and emergency department attendance, acute hospital admissions, and hospital bed days after discharge. Factors that compromise its effectiveness were investigated and cost analysis was performed. DESIGN: Cohort prospective study. SETTING: Integrated Care and Discharge Support for elderly patients in Hong Kong West Cluster. PARTICIPANTS: Home-dwelling patients recruited between April 2012 and March 2013 into Integrated Care and Discharge Support for elderly patients in Hong Kong West Cluster. RESULTS: A total of 1090 older patients were studied. The Integrated Care and Discharge Support for elderly patients programme reduced accident and emergency department attendance by 40% (P<0.001), acute hospital admissions by 47% (P<0.001), and hospital bed days by 31% (P<0.001) at 6 months after implementation. Improvements in Barthel Index 20 (P<0.001) and Modified Functional Ambulation Category scale (P<0.001) were observed. Of the patients, 85 (7.8%) died within 6 months of initiation of the programme. Only 26 (2.4%) older patients required institutionalisation in residential care homes within 6 months after the programme. Increasing age (P=0.025) and high Charlson Comorbidity Index score (P=0.001) were positive predictors for accident and emergency department attendance. A high albumin level (P=0.001) and living alone (P=0.033) were negative predictors for accident and emergency department attendance. Of the patients, 310 (28.4%) had no reduction in bed days after the programme. Increasing age (P=0.025) and number of medications (P=0.003) were positive predictors for no reduction in bed days; while higher haemoglobin level (P=0.034) was a negative predictor. There was a potential annual cost-saving of HK$22.5 million (approximately US$2.9 million). CONCLUSION: The Integrated Care and Discharge Support for elderly patients programme reduced accident and emergency department attendance, acute hospital admissions and hospital bed days, and was potentially cost-saving. Age, Charlson Comorbidity Index, albumin level, and living alone were factors associated with accident and emergency department attendance. Age, number of medications, and haemoglobin level were associated with no reduction in bed days. Further study of the cost-effectiveness of such programme is warranted.