Evaluation of cost data associated with pediatric cochlear implantation (CI) throughout 2016-2021.

INTRODUCTION: Cochlear Implants (CI) are a mainstay in the treatment of severe sensorineural hearing loss with proven cost-effectiveness and improved quality of life. However, costs associated with CI are variable. During the Covid-19 pandemic, elective surgeries decreased. The investigation into how the pandemic affected CI procedures, costs, and demographic utilization has not been elucidated. METHODS: A retrospective cohort study using the Pediatric Health Information System® (PHIS) database, which consists of 50 children's hospitals, was performed. Regions were defined according to PHIS guidelines. We evaluated number of CIs, total charges and costs, Charge to Cost Ratios (CCR), demographic information, and subgrouped this analysis by region throughout 2016-2021. Charges were adjusted by CMS wage index for hospital location. RESULTS: During the years of 2016-2021, there was a rising number of CIs every year except for 2020 which had a decrease, largely driven by the southern and midwestern regions. The median number of cases did not differ between the years. The median adjusted charges increased every year, but not significantly ($103,883-$125,394). The median CCR also did not differ throughout the years (2.7-3.1). Still, there was a larger interquartile range in 2021 (2.3-4.4) for the median CCR compared to all other years (2.1-3.8), particularly in the South. The percentage of white, non-Hispanic/Latino patients who underwent CI was larger in 2020-2021 (78-79.8 %) compared to 2016-2019 (73.3-77.5 %). CONCLUSIONS: The number of CIs in 2020 was lower than in 2019 or 2021. The median CCR for CI procedures increased from 2016 to 2021 but not significantly. The range of CCR was larger in 2021 compared to the years prior, suggestive of cost shifting by some hospitals to offset the loss in revenue. There was a small but significant increase in white, non-Hispanic patients receiving CI in 2020 and 2021, suggestive of a socio-economic shift in care post pandemic.

Is Risk of Secondary Surgery for Oronasal Fistula Following Primary Cleft Palate Repair Associated With Hospital Case Volume and Cost-to-Charge Ratio?

OBJECTIVE: This study assesses the association between risk of secondary surgery for oronasal fistula following primary cleft palate repair and 2 hospital characteristics-cost-to-charge ratio (RCC) and case volume of cleft palate repair. DESIGN: Retrospective cohort study. SETTING: This study utilized the Pediatric Health Information System (PHIS) database, which consists of clinical and resource-utilization data from >49 hospitals in the United States. PATIENTS AND PARTICIPANTS: Patients undergoing primary cleft palate repair from 2004 to 2009 were abstracted from the PHIS database and followed up for oronasal fistula repair between 2004 and 2015. MAIN OUTCOME MEASURE(S): The primary outcome measure was whether patients underwent oronasal fistula repair after primary cleft palate repair. RESULTS: Among 5745 patients from 45 institutions whom met inclusion criteria, 166 (3%) underwent oronasal fistula repair within 6 to 11 years of primary cleft palate repair. Primary palatoplasty at high-RCC facilities was associated with a higher rate of subsequent oronasal fistula repair (odds ratio [OR] = 1.84 [1.32-2.56], adjusted odds ratio [AOR] = 1.81 [1.28-2.59]; P ≤ .001). Likelihood of surgery for oronasal fistula was independent of hospital case volume (OR = 0.83 [0.61-1.13], P = .233; AOR = 0.86 [0.62-1.20], P = .386). Patients with complete unilateral or bilateral cleft palate were more likely to receive oronasal fistula closure compared to those with unilateral-incomplete cleft palate (AOR = 2.09 [1.27-3.56], P = .005; AOR = 3.14 [1.80-5.58], P < .001). CONCLUSIONS: Subsequent need for oronasal fistula repair, while independent of hospital case volume for cleft palate repair, increased with increasing hospital RCC. Our study also corroborates complete cleft palate and cleft lip as risk factors for oronasal fistula.

Factors associated with high-cost hospitalization for peritonitis in children receiving chronic peritoneal dialysis in the United States.

BACKGROUND: Although peritonitis causes significant morbidity and mortality in children receiving chronic peritoneal dialysis (CPD), little is known about costs associated with treatment. METHODS: We analyzed 246 peritonitis-related hospitalizations in the USA, linked by the Standardized Care to Improve Outcomes in Pediatric End Stage Renal Disease (SCOPE) and Pediatric Health Information Systems (PHIS) databases. Multivariable logistic regression was used to assess the relationship between high-cost hospitalizations (at or above the 75th percentile) and patient characteristics. Multivariable modeling was used to assess differences in the service-line specific geometric mean between (1) high- and low-cost (below the 75th percentile) hospitalizations and (2) fungal versus other types of peritonitis. Wage-adjusted hospitalization charges were converted to estimated costs using reported cost-to-charge ratios to estimate the cost of hospitalization. RESULTS: High-cost hospitalizations were associated with the following: age 3-12 years, Hispanic ethnicity, intensive care unit (ICU) stay, length of stay (LOS), and fungal peritonitis. Whereas absolute standardized cost by service line was significantly different when comparing high- and low-cost hospitalizations, the percentage of total cost by service line was similar in the two groups. Cost per case for fungal peritonitis was higher (p < 0.001) in every service line except pharmacy when compared to other peritonitis cases. The median (IQR) cost of hospitalization for the treatment of peritonitis was $13,655 ($7871, $28434) USD. CONCLUSIONS: Hospitalization-related costs for peritonitis treatment are substantial and arise from a variety of service lines. Fungal peritonitis is associated with high-cost hospitalization.

Cost of prenatal versus postnatal myelomeningocele closure for both mother and child at 1 year of life.

OBJECTIVE: Prenatal myelomeningocele (MMC) closure has been performed in the United States for 2 decades. While prior work has focused on clinical outcomes of prenatal MMC closure, the cost of this procedure in comparison with that of postnatal MMC closure is unclear. The authors' aim was to compare the cost of prenatal versus postnatal MMC closure for both the child and mother at 1 year. METHODS: A prospective database of patients undergoing prenatal and postnatal MMC closure between 2011 and 2018 with 1-year follow-up was retrospectively reviewed. Charge data for relevant admissions were converted to a cost estimate using the authors' institution's Medicare hospital-specific cost-to-charge ratio. Children, mothers, and mother/child pairs were considered separately. The primary outcome was cost. Secondary outcomes included the need for hydrocephalus treatment, length of stay (LOS), and readmissions. Other covariates included gestational age at birth, MMC lesion level, and obstetric complications. RESULTS: The median cost of care for children in the prenatal group was greater, although not significantly so, at $58,406.71 (IQR $16,900.24-$88,951.01) compared with $49,889.95 (IQR $38,425.18-$115,163.86) for children in the postnatal group (p = 0.204). The median cost for mothers in the prenatal group was significantly greater at $24,548.29 (IQR $20,231.55-$36,862.31) compared with $5087.30 (IQR $4430.72-$5362.56) (p < 0.001). The median cost for mother/child pairs in the prenatal group was $102,377.75 (IQR $37,384.30-$118,527.74) compared with $55,667.82 (IQR $42,840.78-$120,058.06) (p = 0.45). Children in the prenatal group had a lower gestational age at birth (235.81 days vs 265.77 days, p < 0.001) and fewer readmissions (33.3% vs 72.7%, p < 0.001), and hydrocephalus treatment was less common (33.3% vs 90.9%, p < 0.001). Index LOS did not differ between children in the prenatal and postnatal groups (26.8 days vs 23.5 days, p = 0.63). Mothers in the prenatal group had longer LOS (15.92 days vs 4.68 days, p < 0.001) and more readmissions (18.5% vs 0.0%, p = 0.06). CONCLUSIONS: The median cost of prenatal versus postnatal MMC closure did not significantly differ from a hospital perspective at 1 year, although variability in cost was high for both groups. When considering the mother alone, prenatal MMC closure was costlier. Future work is needed to assess cost from a patient and societal perspective both at 1 year and beyond.

Variations in cost calculations in spine surgery cost-effectiveness research.

OBJECT: Cost-effectiveness research in spine surgery has been a prominent focus over the last decade. However, there has yet to be a standardized method developed for calculation of costs in such studies. This lack of a standardized costing methodology may lead to conflicting conclusions on the cost-effectiveness of an intervention for a specific diagnosis. The primary objective of this study was to systematically review all cost-effectiveness studies published on spine surgery and compare and contrast various costing methodologies used. METHODS: The authors performed a systematic review of the cost-effectiveness literature related to spine surgery. All cost-effectiveness analyses pertaining to spine surgery were identified using the cost-effectiveness analysis registry database of the Tufts Medical Center Institute for Clinical Research and Health Policy, and the MEDLINE database. Each article was reviewed to determine the study subject, methodology, and results. Data were collected from each study, including costs, interventions, cost calculation method, perspective of cost calculation, and definitions of direct and indirect costs if available. RESULTS: Thirty-seven cost-effectiveness studies on spine surgery were included in the present study. Twenty-seven (73%) of the studies involved the lumbar spine and the remaining 10 (27%) involved the cervical spine. Of the 37 studies, 13 (35%) used Medicare reimbursements, 12 (32%) used a case-costing database, 3 (8%) used cost-to-charge ratios (CCRs), 2 (5%) used a combination of Medicare reimbursements and CCRs, 3 (8%) used the United Kingdom National Health Service reimbursement system, 2 (5%) used a Dutch reimbursement system, 1 (3%) used the United Kingdom Department of Health data, and 1 (3%) used the Tricare Military Reimbursement system. Nineteen (51%) studies completed their cost analysis from the societal perspective, 11 (30%) from the hospital perspective, and 7 (19%) from the payer perspective. Of those studies with a societal perspective, 14 (38%) reported actual indirect costs. CONCLUSIONS: Changes in cost have a direct impact on the value equation for concluding whether an intervention is cost-effective. It is essential to develop a standardized, accurate means of calculating costs. Comparability and transparency are essential, such that studies can be compared properly and policy makers can be appropriately informed when making decisions for our health care system based on the results of these studies.

A Multi-Disciplinary Review of Time-Driven Activity-Based Costing: Practical Considerations for Spine Surgery.

STUDY DESIGN: A multi-disciplinary review. OBJECTIVES: To provide a roadmap for implementing time-driven activity-based costing (TDABC) for spine surgery. This is achieved by organizing and scrutinizing publications in the spine, neurosurgical, and orthopedic literature which utilize TDABC and related methodologies. METHODS: PubMed and Google Scholar were searched for relevant articles. The articles were selected by two independent researchers. After article selection, data was extracted and summarized into research domains. Preferred reporting items for systematic reviews and meta-analyses (PRISMA) systematic review process was followed. RESULTS: Of the 524 articles screened, thirty-five articles met the inclusion criteria. Each included article was examined and reviewed to define the primary research question and objective. Comparing different procedures was the most common primary objective. Direct observation along with one other strategy (surveys, interviews, surgical database, or EMR) was most commonly employed during process map development. Across all surgical subspecialties (spine, neurologic, and orthopedic surgery), costs were divided into direct cost, indirect cost, cost to patient, and total costs. The most commonly calculated direct costs included personnel and supply costs. Facility costs, hospital overhead costs, and utilities were the most commonly calculated indirect costs. Transportation costs and parental lost wages were considered when calculating cost to patient. The total cost was a sum of direct costs, indirect costs, and costs to the patient. CONCLUSION: TDABC provides a common platform to accurately estimate costs of care delivery. Institutions embarking on TDABC for spine surgery should consider the breadth of methodologies highlighted in this review to determine which type of calculations are appropriate for their practice.

Evaluating the financial impact of utilizing recombinant porcine factor VIII or recombinant FVIIa for patients with acquired hemophilia A.

OBJECTIVE: To evaluate the financial impact of utilizing rpFVIII or rFVIIa during a hospital admission for the diagnosis of acquired hemophilia A (AHA) by reviewing the margin between the cost to the hospital for providing care and the amount the hospital is reimbursed by the Centers for Medicare & Medicaid Services (CMS) in the US. METHODS: Data source was the Medicare Limited Data Set, which contains claims for hospitalizations, charges, and amounts reimbursed by CMS. Study patients were hospitalized with AHA and treated with rpFVIII and/or rFVIIa between 1/1/2015 and 12/31/2019. CMS Fiscal Year 2020 Impact Files, with hospital-level cost-to-charge ratios (CCRs), were used to estimate hospital costs. Sensitivity analyses were conducted to estimate margins at different CCRs. RESULTS: Hospital margins were, on average, positive with use of either rpFVIII or rFVIIa (rpFVIII: $51,548.89; rFVIIa: $35,943.80). Sensitivity analysis results suggest that the use of rpFVIII is similiar, compared with rFVIIa for a large majority of hospitals. CONCLUSIONS: While there may be higher reimbursement for rpFVIII hospitalizations, this analysis suggests that the use of rpFVIII, compared to rFVIIa, may have no impact on hospital finances for the majority of hospitals, despite rpFVIII's higher per unit cost.

Characteristics of Hospitalized Adults with Opioid Use Disorder in the United States: Nationwide Inpatient Sample.

BACKGROUND: Although the clinical significance and treatment management of opioid use disorder (OUD) is sufficiently discussed, utilization of healthcare services associated with OUD has not been adequately studied in the United States. OBJECTIVE: To provide a descriptive assessment of the utilization of health care services for adults with OUD in the United States. STUDY DESIGN: A retrospective cross-sectional study design based on the National Inpatient Sample (NIS) developed by the Healthcare Cost and Utilization Project. SETTING: All OUD cases included in the 2016 NIS database. Adults aged 18 years or older were included in the study. METHODS: We analyzed a stratified probability sampling of 7.1 million hospital discharges weighted to 35.7 million national discharges. We used ICD-10-CM codes to identify OUD cases. Groups were compared using the Student's t-test for continuous variables and the chi-square test for categorical variables. Total cost per hospital discharge was determined by converting the total per case hospital charge to a hospital cost estimate (estimate = total charges X hospital cost-to-charge ratio). RESULTS: In 2016, an estimated 741,275 Americans were associated with OUD. Among patients with OUD, 73% were White, 12% were African-American, 8% were Hispanic, 0.6% Asian-American/Pacific Islander, 0.9% were Native Americans, and 2% were other race; 49% of patients with OUD were women. A large proportion (43%) of the OUD hospitalizations were billed to Medicaid. The average hospital length of stay for all OUD patients was 5.6 days, and the average cost per discharge was $11,233. A higher average LOS was observed for patients who died during hospitalization (8.4 days), Asian-American/Pacific Islander patients (6.8 days), patients covered by self-pay (6.8 days), patients with median household income of 71,000 or more (5.8 days), patients discharged from hospitals in the Northeast ($10,540) and patients discharged from hospitals in large hospitals ($12,570). The most frequently observed diagnosis associated with patients with OUD were alcohol/drug abuse or dependence, psychosis, and septicemia. LIMITATIONS: These data sources are comprised of hospital discharge records, originally collected for billing purposes, and may be subject to provider biases and variations in coding practices. CONCLUSIONS: In the United States, very few health issues have garnered the attention of such diverse sectors as the opioid crisis. Our analysis of 2016 NIS data found that patients with OUD accounted for approximately 740,000 discharges that year. This represents about a 55% increase over 2015. We also demonstrate that inpatient settings provide a unique opportunity for targeting evidence-based, comprehensive interventions at patients with OUD. Key words: Opioid use disorder, discharge diagnosis, hospital resource utilization, cost-to-charge ratio, HCUP, NIS, AHRQ.

Evaluation of techniques for handling missing cost-to-charge ratios in the USA Nationwide Inpatient Sample: a simulation study.

AIM: Evaluate performance of techniques used to handle missing cost-to-charge ratio (CCR) data in the USA Healthcare Cost and Utilization Project's Nationwide Inpatient Sample. METHODS: Four techniques to replace missing CCR data were evaluated: deleting discharges with missing CCRs (complete case analysis), reweighting as recommended by Healthcare Cost and Utilization Project, reweighting by adjustment cells and hot deck imputation by adjustment cells. Bias and root mean squared error of these techniques on hospital cost were evaluated in five disease cohorts. RESULTS & CONCLUSION: Similar mean cost estimates would be obtained with any of the four techniques when the percentage of missing data is low (<10%). When total cost is the outcome of interest, a reweighting technique to avoid underestimation from dropping observations with missing data should be adopted.

Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 3: assessment of economic outcome.

A comprehensive economic analysis generally involves the calculation of indirect and direct health costs from a societal perspective as opposed to simply reporting costs from a hospital or payer perspective. Hospital charges for a surgical procedure must be converted to cost data when performing a cost-effectiveness analysis. Once cost data has been calculated, quality-adjusted life year data from a surgical treatment are calculated by using a preference-based health-related quality-of-life instrument such as the EQ-5D. A recent cost-utility analysis from a single study has demonstrated the long-term (over an 8-year time period) benefits of circumferential fusions over stand-alone posterolateral fusions. In addition, economic analysis from a single study has found that lumbar fusion for selected patients with low-back pain can be recommended from an economic perspective. Recent economic analysis, from a single study, finds that femoral ring allograft might be more cost-effective compared with a specific titanium cage when performing an anterior lumbar interbody fusion plus posterolateral fusion.

Effect of health information technology expenditure on patient level cost.

OBJECTIVES: This study investigate the effect of health information technology (IT) expenditure on individual patient-level cost using California Office of Statewide Health Planning and Development (OSHPD) data obtained from 2000 to 2007. METHODS: We used a traditional cost function and applied hospital fixed effect and clustered error within hospitals. RESULTS: We found that a quadratic function of IT expenditure best fit the data. The quadratic function in IT expenditure predicts a decrease in cost of up to US$1,550 of IT labor per bed, US$27,909 of IT capital per bed, and US$28,695 of all IT expenditure per bed. Moreover, we found that IT expenditure reduced costs more quickly in medical conditions than surgical diseases. CONCLUSIONS: Interest in health IT is increasing more than ever before. Many studies examined the effect of health IT on hospital level cost. However, there have been few studies to examine the relationship between health IT expenditure and individual patient-level cost. We found that IT expenditure was associated with patient cost. In particular, we found a quadratic relationship between IT expenditure and patient-level cost. In other word, patient-level cost is non-linearly (or a polynomial of second-order degree) related to IT expenditure.