Incremental Cost-effectiveness Analysis on Length of Stay of an Enhanced Recovery After Spine Surgery Program: A Single-center, Retrospective Cohort Study.

BACKGROUND: Enhanced recovery after spine surgery (ERAS) is increasingly utilized to improve postoperative outcomes and reduce cost. There are limited data on the monetary benefits of ERAS when incorporating the costs of developing, operationalizing, and maintaining ERAS programs. The objective of this study was to calculate the incremental cost-effectiveness of a spine surgery ERAS program, modeling hospital and operational cost and length of stay (LOS). METHODS: The study included adult patients undergoing spine surgery before and after implementation of an ERAS program. Variables included individual patient-level and ERAS personnel costs, with LOS as the outcome utility of interest. Propensity score matching was used to create a quasi-experimental design to equate the standard care and ERAS groups. RESULTS: Four hundred and nine patients were included in the unmatched group, with 54 patients each in the standard care and ERAS groups after matching. In the matched cohort, the only imbalance in predictors (standard mean difference [SMD] >0.2) were race (SMD, 0.21), American Society of Anesthesiologist (ASA) physical status (SMD, 0.32), fluid balance in the operating room (SMD, 0.21), median (interquartile range) LOS (standard care, 2.0 [1.0, 3.75] days vs. ERAS, 4.0 [3.0, 5.0]; SMD, 0.81) and mean (±SD) total cost (standard care, $19,291.57±13,572.24 vs. ERAS, $24,363.45±26,352.45; SMD, 0.24). In the incremental cost effectiveness analysis, standard care was the dominant strategy in both 1-way and 2-way sensitivity analysis. CONCLUSIONS: We report a real-world, cost-effectiveness analysis following implementation of an ERAS program for spine surgery at a quaternary medical center. Our study demonstrated that considering LOS as the sole determinant, standard care is the dominant cost-effective strategy compared with the ERAS protocol.

Cost-effectiveness analysis: percutaneous microwave ablation vs robotic-assisted partial nephrectomy for small renal masses.

PURPOSE: The majority of newly diagnosed renal tumors are masses < 4 cm in size with treatment options, including active surveillance, partial nephrectomy, and ablative therapies. The cost-effectiveness literature on the management of small renal masses (SRMs) does not account for recent advances in technology and improvements in technical expertise. We aim to perform a cost-effectiveness analysis for percutaneous microwave ablation (MWA) and robotic-assisted partial nephrectomy (RA-PN) for the treatment of SRMs. METHODS: We created a decision analytic Markov model depicting management of the SRM incorporating costs, health utilities, and probabilities of complications and recurrence as model inputs using TreeAge. A willingness to pay (WTP) threshold of $100,000 and a lifetime horizon were used. Probabilistic and one-way sensitivity analyses were performed. RESULTS: Percutaneous MWA was the preferred treatment modality. MWA dominated RA-PN, meaning it resulted in more quality-adjusted life years (QALYs) at a lower cost. Cost-effectiveness analysis revealed a negative Incremental Cost-Effectiveness Ratio (ICER), indicating dominance of MWA. The model revealed MWA had a mean cost of $8,507 and 12.51 QALYs. RA-PN had a mean cost of $21,521 and 12.43 QALYs. Relative preference of MWA was robust to sensitivity analysis of all other variables. Patient starting age and cost of RA-PN had the most dramatic impact on ICER. CONCLUSION: MWA is more cost-effective for the treatment of SRM when compared with RA-PN and accounting for complication and recurrence risk.

Evaluating the Costs of Nurse Burnout-Attributed Turnover: A Markov Modeling Approach.

OBJECTIVE: Burnout is a public health crisis that impacts 1 in 3 registered nurses in the United States and the safe provision of patient care. This study sought to understand the cost of nurse burnout-attributed turnover using hypothetical hospital scenarios. METHODS: A cost-consequence analysis with a Markov model structure was used to assess nurse burnout-attributed turnover costs under the following scenarios: (1) a hospital with "status quo" nurse burnout prevalence and (2) a hospital with a "burnout reduction program" and decreased nurse burnout prevalence. The model evaluated turnover costs from a hospital payer perspective and modeled a cohort of nurses who were new to a hospital. The outcome measures were defined as years in burnout among the nurse cohort and years retained/employed in the hospital. Data inputs derived from the health services literature base. RESULTS: The expected model results demonstrated that at status quo, a hospital spends an expected $16,736 per nurse per year employed on nurse burnout-attributed turnover costs. In a hospital with a burnout reduction program, such costs were $11,592 per nurse per year employed. Nurses spent more time in burnout under the status quo scenario compared with the burnout reduction scenario (1.5 versus 1.1 y of employment) as well as less time employed at the hospital (2.9 versus 3.5 y of employment). CONCLUSIONS: Given that status quo costs of burnout are higher than those in a hospital that invests in a nurse burnout reduction program, hospitals should strongly consider proactively supporting programs that reduce nurse burnout prevalence and associated costs.

The effects of state facial surgery mandates on timeliness of primary cleft repair surgery in the United States.

OBJECTIVE: This study examines the effects of state facial surgery mandates on the timeliness of primary cleft repair surgery for privately insured children with oral clefts in the United States. MATERIALS AND METHODS: Using IBM Health MarketScan® Database from 2001 to 2017, we estimate regression models separately for age at cleft lip repair and cleft palate repair by having a mandate while considering child-level factors and other state differences. The sample includes 1,451 children who had primary cleft lip repair by age 12 months, and 1,402 children who had primary cleft palate repair by age 18 months. RESULTS: A mandate was associated with earlier cleft lip repair by 13 days (95% CI, -21.5 to -4.7 days) when controlling for state differences, regardless if the child had other birth defects. For children needing cleft palate repair, a mandate was associated with earlier surgery by 87 days (95% CI, -136.1 to -38.4 days) only when no other birth defects were present. CONCLUSIONS: State facial surgery mandates were associated with earlier cleft lip repair for children with or without other birth defects, and earlier cleft palate repair for children without other birth defects (besides oral clefts). Findings suggest benefits to privately insured children with oral clefts from state mandates to cover needed services.

State-Mandated Coverage of Cleft Lip and Cleft Palate Treatment.

OBJECTIVE: We conducted a comprehensive review of state laws and regulations that require private health insurance plans to cover the services needed by children born with cleft lip and/or cleft palate (CL/P). The goal is to better understand how states are reducing the barriers children with CL/P face when seeking recommended health care services. DESIGN: We identified all state laws and regulations mandating insurance coverage of services for children with CL/P by private insurance carriers from 1999 through 2017 using Westlaw legal database. We categorized laws and regulations into ten services: facial surgery (facial, corrective, reconstructive), oral surgery, orthodontics, dental care, habilitation/rehabilitation/speech therapy, prosthetic treatment, audiology, nutrition counseling, genetic testing, and psychological counseling. We also captured broad mandates indicating coverage for all necessary treatments. RESULTS: There was a trend toward increased coverage of services for CL/P over time. In 1999, 27 states and Washington, DC did not have relevant laws or regulations. By 2017, there were 19 states without laws or regulations mandating services. The most common mandated service was facial surgery followed by habilitation/rehabilitation/speech therapy, orthodontics, dental care, and oral surgery. Nutrition, audiology, genetic testing and psychological counseling were rarely included in mandated services. CONCLUSIONS: States vary widely in their requirements for coverage of services needed by children with CL/P in private health insurance plans. There has been an increase in mandates over the past two decades to cover services, although significant variation continues to exist across states.

Cost-Effectiveness of Postoperative Drug Rehabilitation for Injection Drug Users.

BACKGROUND: With the opioid crisis showing no sign of abating, strategies are needed to facilitate postoperative care for endocarditis related to injection drug use (IDU). The current standard, 6 weeks of intravenous antibiotics, yields frequent reoperation and IDU relapse. We examined the cost-effectiveness of inpatient drug rehabilitation (DR) postoperatively to optimize outcomes and costs. METHODS: Two postoperative strategies were assessed: hospital-only care (HC) vs HC plus inpatient DR. Monte Carlo simulation evaluated effectiveness in quality-adjusted life-years (QALY) and cost per patient calculated over a 20-year time horizon in 100,000 iterations. Willingness to pay was set to $100,000/QALY. To determine probabilities of continued postoperative IDU, recurrent infection, and death, best available evidence was combined with institutional data from IDU patients. Baseline probability of postoperative IDU was set to 35% after DR vs 60% after HC, and the cost of inpatient rehabilitation to $30,000. RESULTS: Addition of inpatient DR to standard HC is the favorable strategy, with incremental per-patient cost of $36,920 and 0.93 QALYs gained over 20 years. Sensitivity analysis demonstrates DR is within our willingness-to-pay of $100,000/QALY if postoperative IDU is reduced by at least 7% (from 60% to 53%). CONCLUSIONS: Addition of postoperative inpatient DR for IDU-related endocarditis is cost-effective even if only a modest reduction in IDU is achieved. Collaboration between hospitals and payors to launch pilot programs that provide postoperative addiction treatment and intravenous antibiotics after cardiac operations could dramatically improve endocarditis care.

Cost-Effectiveness of Negative Pressure Incision Management System in Cardiac Surgery.

BACKGROUND: Sternal wound infections (SWIs) can be a devastating long-term complication with significant morbidity and health care cost. The purpose of this analysis was to evaluate the cost-effectiveness of negative pressure incision management systems (NPIMS) in cardiac surgery. MATERIALS AND METHODS: All cardiac surgery cases at an academic hospital with risk scores available (2009-2017) were extracted from an institutional database (n = 4455). Patients were stratified by utilization of NPIMS, and high risk was defined as above the median. Costs included infection-related readmissions and were adjusted for inflation. Multivariable regression models assessed the risk-adjusted cost of SWI and efficacy of NPIMS use. Cost-effectiveness was modeled using TreeAge Pro using institutional results. RESULTS: The rate of deep SWI was 0.9% with an estimated cost of $111,175 (P < 0.0001). The rate of superficial SWI was 0.8% at a cost of $7981 (P = 0.08). Risk-adjusted NPIMS use was not significantly associated with reduced SWI (OR 1.2, P = 0.62) and thus not cost-effective. However, in the high-risk cohort with an OR 0.84 (P = 0.72) and SWI rate of 2.3%, NPIMS use cost $205 per patient with an incremental cost-effectiveness ratio of $179,092. Therefore, NPIMS is estimated to be cost-effective with a deep SWI rate over 1.3% or improved efficacy (OR < 0.83). CONCLUSIONS: SWIs are extremely expensive complications with estimates of $111,175 for deep yet only $7981 for superficial. Although NPIMS was not cost-effective for SWI prevention as currently utilized, a protocol for use on patients with a higher risk of sternal infection could be cost-effective.

When Would a Metal-Backed Component Become Cost-Effective Over an All-Polyethylene Tibia in Total Knee Arthroplasty?

The importance of cost control in total knee arthroplasty is increasing in the United States secondary to both changing economic realities of healthcare and the increasing prevalence of joint replacement. Surgeons play a critical role in cost containment and may soon be incentivized to make cost-effective decisions under proposed gainsharing programs. The purpose of this study is to examine the cost-effectiveness of all-polyethylene tibial (APT) components and determine what difference in revision rate would make modular metal-backed tibial (MBT) implants a more cost-effective intervention. Markov models were constructed using variable implant failure rates and previously published probabilities. Cost data were obtained from both our institution and published United States implant list prices, and modeled with a 3.0% discount rate. The decision tree was continued over a 20-year timeframe. Using our institutional cost data and model assumptions with a 1.0% annual failure rate for MBT components, an annual failure rate of 1.6% for APT components would be required to achieve equivalency in cost. Over a 20-year period, a failure rate of >27% for the APT component would be necessary to achieve equivalent cost compared with the proposed failure rate of 18% with MBT components. A sensitivity analysis was performed with different assumptions for MBT annual failure rates. Given our assumptions, the APT component is cost-saving if the excess cumulative revision rate increases by <9% in 20 years compared with that of the MBT implant. Surgeons, payers, and hospitals should consider this approach when evaluating implants. Consideration should also be given to the decreased utility associated with revision surgery.

Amiodarone Protocol Provides Cost-Effective Reduction in Postoperative Atrial Fibrillation.

BACKGROUND: Postoperative atrial fibrillation (POAF) after cardiac operations results in a significant increase in morbidity, mortality, and health care costs. Prophylactic amiodarone has been shown to reduce the incidence of POAF; however, the cost-effectiveness of a protocol-driven approach remains unknown. METHODS: All patients with a Society of Thoracic Surgeons risk score enrolled in a prophylactic amiodarone protocol (n = 153) were propensity score matched 1:3 with patients before protocol implementation (n = 3,574). Multivariate logistic and linear regressions assessed the relative risks (POAF reduction and adverse medication effects) in the matched cohort of amiodarone therapy and costs, respectively. TreeAge cost-effectiveness software (TreeAge Software, Inc, Williamstown, MA) modeled the effects of prophylactic amiodarone costs, complication rates, and quality of life. RESULTS: Of patients eligible for the prophylactic amiodarone protocol, 94.3% (281 of 298) were enrolled. Prophylactic amiodarone significantly reduced the rate of POAF (25.7% vs 16.8%, p < 0.0001). A total of 600 matched patients demonstrate no baseline differences in demographics, comorbidities, disease state, or operative factors, with a significant reduction in POAF without an increase in other associated complications. With the use these adjusted estimates, the prophylactic amiodarone protocol demonstrated a cost savings of $458 per patient. Sensitivity analysis confirmed the protocol is cost-effective for all protocol-related POAF risk reductions below an odds ratio of 0.726. CONCLUSIONS: Implementation of a prophylactic amiodarone protocol significantly reduced risk-adjusted rates of POAF, with a cost savings of $458 per patient. This analysis demonstrates how rigorous quantitative analysis can evaluate the benefits of quality improvement projects.

Annual ADEA Survey of Dental School Seniors: 2016 Graduating Class.

This report examines the results of the American Dental Education Association (ADEA) Survey of Dental School Seniors graduating in 2016. Data were collected from 4,558 respondents at all 59 U.S. dental schools with graduating classes that year. This annual survey asks graduating students about a variety of topics in order to understand their motivation for attending dental school, educational experiences while in school, debt incurred, and plans following graduation. Motivations for choosing to attend dental school typically involved family or friends who were dentists or students' personal experiences. The timing of the decision to enter dentistry has been getting earlier over time. Similar to previous years, the average graduating student had above $200,000 in student debt. However, for the first time in two decades, inflation-adjusted debt decreased slightly. The reduction in debt was due to students from private schools reducing their average debt by $23,401. Immediately after graduation, most seniors planned to enter private practice (50.5%) or advanced dental education (33.8%). Approximately half of the respondents planned to work in underserved areas at some point in their careers. These findings underscore the continued value of the senior survey to offer a unique view of the diverse characteristics and career paths of the future dental workforce.

Dental School Vacant Budgeted Faculty Positions, Academic Years 2011-12 Through 2013-14.

The American Dental Education Association (ADEA) Survey of Dental School Faculty is conducted annually to provide an overview of the hiring and retention activity of U.S. dental school faculty. The survey collects data on the dental faculty workforce, including vacant budgeted positions by appointment and discipline, number of new and lost positions, sources of new hires, and reasons for faculty separations. This report highlights the results of three years of survey data, from the 2011-12 academic year through the 2013-14 academic year. After declining in previous years, the number of vacant faculty positions in U.S. dental schools has begun to increase, rising to 242 full-time and 55 part-time positions in 2013-14. Additionally, the number of schools having more than ten vacancies increased from five to 12. Although the number of vacancies has increased, the length of faculty searches that took more than one year declined from 25% to 16% in the same period. Retirements as a share of full-time faculty separations increased from 14% in 2008-09 to 31% in 2013-14. The current average retirement age of dental school faculty members is 69.7 years. The percentage of full-time faculty members leaving for the private sector remained constant over the last three years at approximately 16%. Full-time faculty members were more likely to be recruited from other dental schools, while part-time faculty members were more likely to come from the private sector.

The effect of education debt on dentists' career decisions.

BACKGROUND: The purpose of the study was to determine whether there is an association between the amount of education debt on completing dental school (initial debt) and certain career decisions. METHODS: The authors surveyed 1,842 practicing dentists who completed dental school between 1996 and 2011 to ascertain their initial education debt, the balance on their debt in 2013, and a variety of specialization and practice decisions made during their careers. Data also included demographic characteristics and parental income and education levels. RESULTS: Dentists with higher initial debt were less likely to specialize and more likely to enter private practice, accept high-paying jobs on graduation, and work longer hours. Choice of employment setting, practice ownership, and whether to provide Medicaid and charity care were associated with dentists' sexes and races but not debt. CONCLUSIONS: High debt levels influenced some career decisions, but the magnitude of these effects was small compared with the effects of demographic characteristics, including race and sex, on career choices. PRACTICAL IMPLICATIONS: Policy makers concerned about the influence of student debt on the professional decisions of dental school graduates should recognize that students' demographic characteristics may be more powerful in driving career choices.

U.S. Dental School Applicants and Enrollees, 2014 Entering Class.

This report analyzes data collected annually by the American Dental Education Association (ADEA) on the characteristics of applicants to and first-year enrollees in dental schools. Among the key findings this year are that, since 2010, there has been a gradual decline in the number of individuals taking the Dental Admission Test (DAT), while the number applying to dental schools has remained relatively flat. During the same five-year time period, the number of first-year dental students has continuously increased. The result is an increasing rate of enrollment among applicants. While the overwhelming majority of dental schools utilize some aspect of a holistic admissions process, the DAT scores and grade point averages of applicants and enrollees continue to rise. Unlike a decade ago, women now account for nearly half of all applicants and enrollees. At least part of the gain has come from a decline in the number of men applicants, rather than a change in the enrollment rate. Among underrepresented minorities, there remains a relatively low number of applicants and a lower than average enrollment rate. Overall, by analyzing data about individuals applying to and matriculating in dental schools, this report provides a window into the future dental workforce.

Educational debt and intended employment choice among dental school seniors.

BACKGROUND: The authors examined the association between educational debt and dental school seniors' intended activity after graduation. METHODS: The authors used multinomial logit regression analysis to estimate the relationship between dental educational debt and intended activity after graduation, controlling for potentially confounding variables. They used data from the 2004 through 2011 ADEA (American Dental Education Association) Survey of Dental School Seniors. RESULTS: Fourth-year dental school students with high levels of educational debt were more likely to express an interest in choosing to go into private practice, although the magnitude of this effect was relatively small. For each $10,000 increase in debt, the likelihood of choosing advanced education relative to private practice was 1.5 percent lower (relative risk ratio [RRR], 0.985 [95 percent confidence interval {CI}, 0.978-0.991]). For the same $10,000 increase in debt, the probability of choosing teaching, research and administration was 3.1 percent lower than that for choosing private practice (RRR, 0.969 [95 percent CI, 0.954-0.986]) and was 8.4 percent lower than that for choosing a government service position (RRR, 0.916 [95 percent CI, 0.908-0.924]). CONCLUSIONS: Although educational debt was statistically significant for predicting intended activity after graduation, the magnitude of influence of other variables such as sex, race and whether a parent is a dentist was substantially larger. Practical Implications Concerns regarding rising educational debt and its effect on the dental labor market may be misplaced. The characteristics of the dental school student body may be a more accurate predictor of employment choices that dental school seniors are making than are total educational debt levels.

Cost-analysis of percutaneous pulmonary valve implantation compared to surgical pulmonary valve replacement.

OBJECTIVES: To perform cost evaluation and economic modeling of percutaneous pulmonary valve implantation (PPVI) compared to surgical revision. BACKGROUND: While, PPVI appears to be a viable alternative to surgical conduit revision in select patients with right ventricular outflow tract anomalies, its overall economic burden has yet to be determined. METHODS AND RESULTS: We examined the first 17 patients who underwent PPVI at our institution and compared them with the most-recently placed surgical valves. Economic data were obtained from the actual procedural and in-hospital charges and used as the base estimates for 5- and 10-year future modeling with appropriate sensitivity analysis. Median total hospital and procedural charges incurred by the patient were significantly higher for the surgical valve compared with PPVI ($126,406 ± $38,772 vs. $80,328 ± $17,387, P < 0.001). Median total societal charges were also higher for the surgical valve ($129,519 ± $39,021 vs. $80,939 ± $17,334, P < 0.001) owing to an average wage loss of $3,113 for surgical patients, contrasted to $611 who underwent PPVI, and a shorter length of stay (1.0 ± 0 vs. 5.7 ± 2.2, P <0.001) for PPVI. Sensitivity analysis determined that PPVI would need to fail at a rate of 17% per year (or 93% at 10 years) to lose its cost advantage. CONCLUSIONS: PPVI holds a significant cost advantage over the surgical approach, fewer hospital days, and incurs less patient wage loss. Furthermore, it would need to have a very high failure rate at 10 years to lose its cost advantage.

Effects of a proposed rural dental school on regional dental workforce and access to care.

INTRODUCTION: Southwest Virginia is a rural, low-income region with a relatively small dentist workforce and poor oral health outcomes. The opening of a dental school in the region has been proposed by policy-makers as one approach to improving the size of the dentist workforce and oral health outcomes. METHODS: A policy simulation was conducted to assess how a hypothetical dental school in rural Southwest Virginia would affect the availability of dentists and utilization levels of dental services. The simulation focuses on two channels through which the dental school would most likely affect the region. First, the number of graduates who are expected to remain in the region was varied, based on the extensiveness of the education pipeline used to attract local students. Second, the number of patients treated in the dental school clinic under different dental school clinical models, including the traditional model, a patient-centered clinic model and a community-based clinic model, was varied in the simulation to obtain a range of additional dentists and utilization rates under differing dental school models. RESULTS: Under a set of plausible assumptions, the low yield scenario (ie private school with a traditional clinic) would result in three additional dentists residing in the region and a total of 8090 additional underserved patients receiving care. Under the high yield scenario (ie dental pipeline program with community based clinics) nine new dentists would reside in the region and as many as 18 054 underserved patients would receive care. Even with the high yield scenario and the strong assumption that these patients would not otherwise access care, the utilization rate increases to 68.9% from its current 60.1%. CONCLUSIONS: While the new dental school in Southwest Virginia would increase the dentist workforce and utilization rates, the high cost combined with the continued low rate of dental utilization suggests that there may be more effective alternatives to improving oral health in rural areas. Alternative policies that have shown considerable promise in expanding access to disadvantaged populations include virtual dental homes, enhanced Medicaid reimbursement programs, and school-based dental care systems.

Decisions to initiate involuntary commitment: the role of intensive community services and other factors.

OBJECTIVE: This study examined the predictors of actions to initiate involuntary commitment of individuals experiencing a mental health crisis. METHODS: Emergency services clinicians throughout Virginia completed a questionnaire following each face-to-face evaluation of individuals experiencing a mental health crisis. Over a one-month period in 2007, a total of 2,624 adults were evaluated. Logistic hierarchical multiple regression was used to analyze the relationship between demographic, clinical, and service-related variables and outcomes of the emergency evaluations. RESULTS: Several factors predicted 84% of the actions taken to initiate involuntary commitment. These included unavailability of alternatives to hospitalization, such as temporary housing or residential crisis stabilization; evaluation of the client in a hospital emergency room or police station or while in police custody; current enrollment in treatment; and clinical factors related to the commitment criteria, including risk of self-harm or harm to others, acuity and severity of the crisis, and current drug abuse or dependence. CONCLUSIONS: A lack of intensive community-based treatment and support in lieu of hospitalization accounted for a significant portion of variance in actions to initiate involuntary commitment. Comprehensive community services and supports for individuals experiencing mental health crises may reduce the rate of involuntary hospitalization. There is a need to enrich intensive community mental health services and supports and to evaluate the impact of these enhancements on the frequency of involuntary mental health interventions.

A survey of stakeholder knowledge, experience, and opinions of advance directives for mental health in Virginia.

An innovative Virginia health care law enables competent adults with serious mental illness to plan for treatment during incapacitating crises using an integrated advance directive with no legal distinction between psychiatric or other causes of decisional incapacity. This article reports results of a survey of 460 individuals in five stakeholder groups during the initial period of the law's implementation. All respondents held favorable views of advance directives for mental health care. Identified barriers to completing and using advance directives varied by group. We conclude that relevant stakeholders support implementation of advance directives for mental health, but level of baseline knowledge and perception of barriers vary. A multi-pronged approach will be needed to achieve successful implementation of advance directives for mental health.