Economic Impact of Poststroke Delirium and Associated Risk Factors: Findings From a Prospective Cohort Study.

Background and Purpose: Delirium is a common severe complication of stroke. We aimed to determine the cost-of-illness and risk factors of poststroke delirium (PSD). Methods: This prospective single-center study included n=567 patients with acute stroke from a hospital-wide delirium cohort study and the Swiss Stroke Registry in 2014. Delirium was determined by Delirium Observation Screening Scale or Intensive Care Delirium Screening Checklist 3 times daily during the first 3 days of admission. Costs reflected the case-mix index and diagnosis-related groups from 2014 and were divided into nursing, physician, and total costs. Factors associated with PSD were assessed with multiple regression analysis. Partial correlations and quantile regression were performed to assess costs and other factors associated with PSD. Results: The incidence of PSD was 39.0% (221/567). Patients with delirium were older than non-PSD (median 76 versus 70 years; P<0.001), 52% male (115/221) versus 62% non-PSD (214/346) and hospitalized longer (mean 11.5 versus 9.3 days; P<0.001). Dementia was the most relevant predisposing factor for PSD (odds ratio, 16.02 [2.83­90.69], P=0.002). Moderate to severe stroke (National Institutes of Health Stroke Scale score 16­20) was the most relevant precipitating factor (odds ratio, 36.10 [8.15­159.79], P<0.001). PSD was a strong predictor for 3-month mortality (odds ratio, 15.11 [3.33­68.53], P<0.001). Nursing and total costs were nearly twice as high in PSD (P<0.001). There was a positive correlation between total costs and admission National Institutes of Health Stroke Scale (correlation coefficient, 0.491; P<0.001) and length of stay (correlation coefficient, 0.787; P<0.001) in all patients. Quantile regression revealed rising nursing and total costs associated with PSD, higher National Institutes of Health Stroke Scale, and longer hospital stay (all P<0.05). Conclusions: PSD was associated with greater stroke severity, prolonged hospitalization, and increased nursing and total costs. In patients with severe stroke, dementia, or seizures, PSD is anticipated, and additional costs are associated with hospitalization.

One-Year Medicare Costs Associated With Delirium in Older Patients Undergoing Major Elective Surgery.

Importance: Delirium is a common, serious, and potentially preventable problem for older adults, associated with adverse outcomes. Coupled with its preventable nature, these adverse sequelae make delirium a significant public health concern; understanding its economic costs is important for policy makers and health care leaders to prioritize care. Objective: To evaluate current 1-year health care costs attributable to postoperative delirium in older patients undergoing elective surgery. Design, Setting, and Participants: This prospective cohort study included 497 patients from the Successful Aging after Elective Surgery (SAGES) study, an ongoing cohort study of older adults undergoing major elective surgery. Patients were enrolled from June 18, 2010, to August 8, 2013. Eligible patients were 70 years or older, English-speaking, able to communicate verbally, and scheduled to undergo major surgery at 1 of 2 Harvard-affiliated hospitals with an anticipated length of stay of at least 3 days. Eligible surgical procedures included total hip or knee replacement; lumbar, cervical, or sacral laminectomy; lower extremity arterial bypass surgery; open abdominal aortic aneurysm repair; and open or laparoscopic colectomy. Data were analyzed from October 15, 2019, to September 15, 2020. Exposures: Major elective surgery and hospitalization. Main Outcomes and Measures: Cumulative and period-specific costs (index hospitalization, 30-day, 90-day, and 1-year follow-up) were examined using Medicare claims and extensive clinical data. Total inflation-adjusted health care costs were determined using data from Medicare administrative claims files for the 2010 to 2014 period. Delirium was rated using the Confusion Assessment Method. We also examined whether increasing delirium severity was associated with higher cumulative and period-specific costs. Delirium severity was measured with the Confusion Assessment Method-Severity long form. Regression models were used to determine costs associated with delirium after adjusting for patient demographic and clinical characteristics. Results: Of the 566 patients who were eligible for the study, a total of 497 patients (mean [SD] age, 76.8 [5.1] years; 281 women [57%]; 461 White participants [93%]) were enrolled after exclusion criteria were applied. During the index hospitalization, 122 patients (25%) developed postoperative delirium, whereas 375 (75%) did not. Patients with delirium had significantly higher unadjusted health care costs than patients without delirium (mean [SD] cost, $146 358 [$140 469] vs $94 609 [$80 648]). After adjusting for relevant confounders, the cumulative health care costs attributable to delirium were $44 291 (95% CI, $34 554-$56 673) per patient per year, with the majority of costs coming from the first 90 days: index hospitalization ($20 327), subsequent rehospitalizations ($27 797), and postacute rehabilitation stays ($2803). Health care costs increased directly and significantly with level of delirium severity (none-mild, $83 534; moderate, $99 756; severe, $140 008), suggesting an exposure-response relationship. The adjusted mean cumulative costs attributable to severe delirium were $56 474 (95% CI, $40 927-$77 440) per patient per year. Extrapolating nationally, the health care costs attributable to postoperative delirium were estimated at $32.9 billion (95% CI, $25.7 billion-$42.2 billion) per year. Conclusions and Relevance: These findings suggest that the economic outcomes of delirium and severe delirium after elective surgery are substantial, rivaling costs associated with cardiovascular disease and diabetes. These results highlight the need for policy imperatives to address delirium as a large-scale public health issue.

Effects of pain, sedation and delirium monitoring on clinical and economic outcome: A retrospective study.

BACKGROUND: Significant improvements in clinical outcome can be achieved by implementing effective strategies to optimise pain management, reduce sedative exposure, and prevent and treat delirium in ICU patients. One important strategy is the monitoring of pain, agitation and delirium (PAD bundle). We hypothesised that there is no sufficient financial benefit to implement a monitoring strategy in a Diagnosis Related Group (DRG)-based reimbursement system, therefore we expected better clinical and decreased economic outcome for monitored patients. METHODS: This is a retrospective observational study using routinely collected data. We used univariate and multiple linear analysis, machine-learning analysis and a novel correlation statistic (maximal information coefficient) to explore the association between monitoring adherence and resulting clinical and economic outcome. For univariate analysis we split patients in an adherence achieved and an adherence non-achieved group. RESULTS: In total 1,323 adult patients from two campuses of a German tertiary medical centre, who spent at least one day in the ICU between admission and discharge between 1. January 2016 and 31. December 2016. Adherence to PAD monitoring was associated with shorter hospital LoS (e.g. pain monitoring 13 vs. 10 days; p<0.001), ICU LoS, duration of mechanical ventilation shown by univariate analysis. Despite the improved clinical outcome, adherence to PAD elements was associated with a decreased case mix per day and profit per day shown by univariate analysis. Multiple linear analysis did not confirm these results. PAD monitoring is important for clinical as well as economic outcome and predicted case mix better than severity of illness shown by machine learning analysis. CONCLUSION: Adherence to PAD bundles is also important for clinical as well as economic outcome. It is associated with improved clinical and worse economic outcome in comparison to non-adherence in univariate analysis but not confirmed by multiple linear analysis. TRIAL REGISTRATION: clinicaltrials.gov NCT02265263, Registered 15 October 2014.

Implementation of a multiprofessional, multicomponent delirium management guideline in two intensive care units, and its effect on patient outcomes and nurse workload: a pre-post design retrospective cohort study.

AIM OF THE STUDY: Delirium is a frequent intensive care unit (ICU) complication, affecting 26% to 80% of ICU patients, often with serious consequences. This study aimed to evaluate the effectiveness, costs and benefits of following a standardised multiprofessional, multicomponent delirium guideline on eight outcomes: delirium prevalence and duration, lengths of stay in ICU and hospital, in-hospital mortality, duration of mechanical ventilation, and cost and nursing hours per case. It also aimed to explore the associations of delirium with length of ICU stay, length of hospital stay and duration of mechanical ventilation. METHODS: This retrospective cohort study used a pre-post design. ICU patients in an historical control group (n = 1608) who received standard ICU care were compared with a postintervention group (n = 1684) who received standardised delirium management – delirium risk identification, preventive measures, screening and treatment – with regard to eight outcomes. The delirium management guideline was developed and implemented in 2012 by a group of experts from the study hospital. As appropriate, descriptive statistics and multivariate, multilevel models were used to compare the two groups and to explore the association between delirium occurrence and the selected outcomes. RESULTS: Twelve percent of the 1608 historical controls and 20% of the 1684 postintervention patients were diagnosed with delirium according to the ICD-10 delirium diagnosis codes. Patients being treated for heart disease, and those with septic shock, ARDS, renal insufficiency (acute or chronic), older age and higher numbers of comorbidities were significantly more likely to develop delirium during their stay. Multivariate models comparing the historical controls with the post intervention group indicated significant differences in delirium period prevalence (odds ratio 1.68, 95% confidence interval [CI] 1.38–2.06; p <0.001), length of stay in the ICU (time ratio [TR] 0.94, CI 0.89–1.00; p = 0.048), cost per case (median difference 3.83, CI 0.54–7.11; p = 0.023) and duration of mechanical ventilation (TR 0.84, CI 0.77–0.92; p <0.001). The observed differences in the other four outcomes – in-hospital mortality, delirium duration, length of stay in the hospital, and nursing hours per case – were not significant. Delirium was a significant predictor for prolonged duration of mechanical ventilation and for both ICU and hospital stay. CONCLUSION: Standardised delirium management, specifically delirium screening, supports timely detection of delirium in ICU patients. Increased awareness of delirium after the implementation of standardised multiprofessional, multicomponent management leads to increased therapeutic attention, a prolongation of ICU stay and increased costs, but with no influence on mortality.

Economic impact of delirium in Australia: a cost of illness study.

OBJECTIVES: To estimate the economic impact of delirium in the Australian population in 2016-2017, including financial costs, and its burden on health. DESIGN, SETTING AND PARTICIPANTS: A cost of illness study was conducted for the Australian population in the 2016-2017 financial year. The prevalence of delirium in 2016-2017 was calculated to inform cost estimations. The costs estimated in this study also include dementia attributable to delirium. MAIN OUTCOME MEASURES: The total and per capita costs were analysed for three categories: health systems costs, other financial costs including productivity losses and informal care and cost associated with loss of well-being (burden of disease). Costs were expressed in 2016-2017 pound sterling (£) and Australian dollars ($A). RESULTS: There were an estimated 132 595 occurrences of delirium in 2016-2017, and more than 900 deaths were attributed to delirium in 2016-2017. Delirium causes an estimated 10.6% of dementia in Australia. The total costs of delirium in Australia were estimated to be £4.3 billion ($A8.8 billion) in 2016-2017, ranging between £2.6 billion ($A5.3 billion) and £5.9 billion ($A12.1 billion). The total estimated costs comprised financial costs of £1.7 billion and the value of healthy life lost of £2.5 billion. Dementia attributable to delirium accounted for £2.2 billion of the total cost of delirium. CONCLUSIONS: These findings highlight the substantial burden that delirium imposes on Australian society-both in terms of financial costs associated with health system expenditure and the increased need for residential aged care due to the functional and cognitive decline associated with delirium and dementia. To reduce the substantial well-being costs of delirium, further research should seek to better understand the potential pathways from an episode of delirium to subsequent mortality and reduced cognitive functioning outcomes.

Influence of hospital adverse events and previous diagnoses on hospital care cost of patients with hip fracture.

Previous diagnoses of patients with hip fracture influence the hospitalization cost of these patients, either directly or by increasing the risk of in-hospital adverse events associated with increased costs. PURPOSE: To investigate how previous diagnoses influence the occurrence of in-hospital adverse events and how both factors impact on hospital costs. METHODS: This is a retrospective analysis of the hospital Minimum Basic Data Set. Patients aged 70 years or older admitted for hip fracture (HF) at a single University Hospital between January 2012 and December 2016. Both, previous diagnoses and adverse events, were defined according to the International Classification of Diseases (ICD-9/ICD-10). The anticipated cost of each admission was calculated based on diagnosis-related groups and using the "all patients refined" method (APR-DRG). The occurrence of adverse events during hospital stay was assessed by excluding all diagnoses present on admission. RESULTS: The record included 1571 patients with a mean (SD) age of 84 years. The most frequent previous diagnoses were diabetes (n = 432, 27.5%) and dementia (n = 251, 16.0%), and the most frequent adverse events were delirium (n = 238, 15.1%) and anemia (n = 188, 12.0%). The mean (SD) total acute care costs per patient were €8752.1 (1864.4). The presence of heart failure, COPD, and kidney disease at admission significantly increased the hospitalization cost. In-hospital adverse events of delirium, cardiac events, anemia, urinary tract infection, and digestive events significantly increased costs. The multivariate analyses identified kidney disease as a previous diagnosis significantly contributing to explain an increase in hospitalization costs, and delirium, cardiac disease, anemia, urinary infection, respiratory event, and respiratory infection as in-hospital adverse events significantly contributing to an increase of hospitalization costs. CONCLUSIONS: Although few baseline comorbidities have a direct impact on hospitalization costs, most previous diagnoses increase the risk of in-hospital adverse events, which ultimately influence the hospitalization cost.

Evaluation of a method to estimate the point prevalence of cognitive impairment and delirium in a multi-campus Australian health service.

OBJECTIVE: To design, test (pilot) and implement a study to estimate the point prevalence of cognitive impairment (CI) and delirium in a multi-site health service. METHODS: Clinicians were trained to use the 4 A's Test (4AT) to screen for cognitive impairment and delirium, and the 3-minute Diagnostic Interview for the Confusion Assessment Method (3D-CAM) to detect delirium in those with abnormal 4AT results. Outcomes of interest were as follows: (a) rates of cognitive impairment and delirium and (b) feasibility of the approach measured by participation rate, "direct survey activity" time, cost and surveyor preparation. RESULTS: The rates of cognitive impairment and delirium were 43.8% (245/559) and 16.3% (91/559), respectively. 90.5% (563/622) of eligible adult patients from 25 acute and subacute wards were seen. "Direct survey activities" averaged 14 minutes (range 2-45) and cost $11.48 per patient. Training evaluation indicated additional education in the 4AT and 3D-CAM was needed. CONCLUSION: Health services could use this streamlined, inexpensive method to estimate the point prevalence of cognitive impairment and delirium.

The proactive elderly care team: dementia screening of over 20 000 patients.

The proactive elderly care team was introduced at Lancashire Teaching Hospitals NHS Foundation Trust in October 2012. This article describes how the team performed over 5 years (up to the end of December 2017). The proactive elderly care team had three broad aims related to all non-elective patients over the age of 75 years who either came to accident and emergency or were admitted into the hospital, irrespective of speciality: To screen all patients over the age of 75 years for delirium and dementia To identify patients over 75 years who were the most frail, and would benefit from a comprehensive geriatric assessment and targeted interventions To reduce length of stay for patients over the age of 75 years without any increase in their readmission rate. Following the introduction of the proactive elderly care team, length of stay and the readmission rate of patients who were seen by the service fell by about 50%. Almost £10 million has been saved and for every £1 invested in the proactive elderly care team service, over £12 was saved.

The effect of preoperative cognitive impairment and type of vascular surgery procedure on postoperative delirium with associated cost implications.

OBJECTIVE: Postoperative delirium (POD) has a high prevalence among vascular surgery patients, increasing morbidity, mortality, and length of stay. We prospectively studied preoperative risk factors for delirium that can be assessed by the surgical team to identify high-risk patients and assessed its impact on hospital costs. METHODS: There were 173 elective vascular surgery patients assessed preoperatively for cognitive function using the Montreal Cognitive Assessment (MoCA) and the Confusion Assessment Method for POD, which was verified by chart and clinical review. Demographic information, medications, and a history of substance abuse, psychiatric disorders, and previous delirium were prospectively recorded. An accompanying retrospective chart review of an additional 434 (elective and emergency) vascular surgery patients provided supplemental cost information related to sitter use and prolonged hospitalization secondary to three factors: delirium alone, dementia alone, and delirium and dementia. RESULTS: Prospective screening of 173 patients (73.4% male; age, 69.9 ± 10.97 years) identified that 119 (68.8%) had MoCA scores <24, indicating cognitive impairment, with 7.5% having severe impairment (dementia). Patients who underwent amputation had significantly (P < .000) lower MoCA scores (17 of 30) compared with open surgery and endovascular aneurysm repair patients (23.7 of 30). The incidence of delirium was 11.6% in the elective cohort. Regression analysis identified predictors of delirium to be type of surgical procedure, including lower limb amputation (odds ratio [OR], 16.67; 95% confidence interval [CI], 3.41-71.54; P < .000) and open aortic repair (OR, 5.33; 95% CI, 1.91-14.89; P < .000); cognitive variables (dementia: OR, 5.63; 95% CI, 2.08-15.01; P < .001); MoCA scores ≤15, indicating moderate to severe impairment (OR, 6.13; 95% CI, 1.56-24.02; P = .02); and previous delirium (OR, 2.98; 95% CI, 1.11-7.96; P = .03). Retrospective review (N = 434) identified differences in sitter needs for patients with both delirium and dementia (mean, 13.6 days), delirium alone (mean, 3.9 days), or dementia alone (mean, <1 day [17.7 hours]). Fifteen patients required >200 hours (8.3 days), accounting for 69.7% of sitter costs for the surgical unit; 43.7% of costs were accounted for by patients with pre-existing cognitive impairment. CONCLUSIONS: POD is predicted by type of vascular surgery procedure, impaired cognition (MoCA), and previous delirium. Costs and morbidity related to delirium are greatest for those with impaired cognitive burden. Preoperative MoCA screening can identify those at highest risk, allowing procedure modification and informed care.

Systems Delivery Innovation for Alzheimer Disease.

OBJECTIVE: The authors describe a comprehensive care model for Alzheimer disease (AD) that improves value within 1-3 years after implementation by leveraging targeted outpatient chronic care management, cognitively protective acute care, and timely caregiver support. METHODS: Using current best evidence, expert opinion, and macroeconomic modeling, the authors designed a comprehensive care model for AD that improves the quality of care while reducing total per capita healthcare spending by more than 15%. Cost savings were measured as reduced spending by payers. Cost estimates were derived from medical literature and national databases, including both public and private U.S. payers. All estimates reflect the value in 2015 dollars using a consumer price index inflation calculator. Outcome estimates were determined at year 2, accounting for implementation and steady-state intervention costs. RESULTS: After accounting for implementation and recurring operating costs of approximately $9.5 billion, estimated net cost savings of between $13 and $41 billion can be accomplished concurrently with improvements in quality and experience of coordinated chronic care ($0.01-$6.8 billion), cognitively protective acute care ($8.7-$26.6 billion), timely caregiver support ($4.3-$7.5 billion), and caregiver efficiency ($4.1-$7.2 billion). CONCLUSION: A high-value care model for AD may improve the experience of patients with AD while significantly lowering costs.

Differences in healthcare outcomes between teaching and non teaching hospitals for patients with delirium: a retrospective cohort study.

BACKGROUND: The physician workforce at teaching hospitals differs compared to non-teaching hospitals, and data suggest that patient outcomes may also be dissimilar. Delirium is a common, costly disorder among hospitalized patients and approaches to care are not standardized. OBJECTIVE: This study set out to explore differences in healthcare outcomes between teaching and non-teaching hospitals for patients admitted with delirium. DESIGN: Retrospective cohort analysis. SETTING AND PARTICIPANTS: We used the 2014 Nationwide Inpatient Sample database. Adult patients (≥18 years of age) hospitalized in acute-care hospitals in the USA with delirium (defined with ICD-9 code) were studied. MAIN OUTCOME MEASURES: The primary outcome was in-hospital all-cause mortality. Secondary outcomes were discharge status and several measures of healthcare resource utilization: length of stay, total hospitalization costs and multiple procedures performed. RESULTS: In 2014, out of 57 460 adult patients admitted to hospitals with delirium, 58.4% were hospitalized at teaching hospitals and the remainder 41.6% at non-teaching hospitals. The in-hospital mortality of delirium patients in teaching hospitals was 1.33% (95% CI 1.08%-1.63%), and 1.26% (95% CI 0.97%-1.63%) in non-teaching hospitals. The mean total hospital costs were $7642 (95% CI 7384-7900) in teaching hospitals, and $6650 (95% CI 6460-6840) in non-teaching hospitals. After adjustment for confounders, total hospitalization costs were statistically significantly different between the hospitals types-with non-teaching providing less expensive care. CONCLUSIONS: Patients with delirium admitted to non-teaching hospitals had comparable clinical and process outcomes achieved at lower costs. Further research can be conducted to explore the contextual issues and reasons for these differences in healthcare costs.

Incremental cost and length of stay associated with postprocedure delirium in transcatheter and surgical aortic valve replacement patients in the United States.

OBJECTIVES: To explore the impact of post-procedure delirium on resource utilization following transcatheter and surgical aortic valve replacement (TAVR and SAVR, respectively). BACKGROUND: Postprocedure delirium is associated with worse long-term survival after TAVR and SAVR. However, its effect on resource utilization has been understudied. METHODS: Using the 2015 Medicare Provider Analysis and Review File (MedPAR), we retrospectively analyzed elderly (≥80 years) Medicare beneficiaries receiving either SAVR or endovascular TAVR in the United States. Multivariate regression models estimating hospitalization cost and length of stay (LoS) were adjusted for patient demographics, comorbidities, and nondelirium complications. RESULTS: A total of 21,088 discharges were available for analysis (12,114 TAVR and 8,974 SAVR). TAVR patients were older (87 ± 3.8 vs. 84 ± 2.7 years; P < 0.001) with a higher comorbidity burden (Charlson index 3.0 ± 1.8 vs. 2.1 ± 1.7; P < 0.0001). Despite this, fewer TAVR patients (1.6%) experienced postoperative delirium during the index hospitalization compared to surgical patients (3.6%; P < 0.0001). Delirium was associated with a 4.16 [3.51-4.81] day longer hospital LoS and $15,592 ($12,849-$18,334) higher incremental hospitalization cost. When stratified by treatment approach, the adjusted incremental cost of delirium was +$13,862 ($9,431-$18,292) with TAVR and +$16,656 ($13,177-$20,136) with SAVR with an additional hospital LoS of +3.39 (2.34-4.43) days and +4.63 (3.81-5.45) days for TAVR and SAVR, respectively. CONCLUSIONS: Postprocedure delirium is associated with significantly increased hospitalization costs and LoS following AVR. TAVR was associated with a lower postoperative delirium rate compared to SAVR. Post-TAVR delirium may be associated with less resource consumption than post-SAVR delirium.

The Cost of ICU Delirium and Coma in the Intensive Care Unit Patient.

RATIONALE: Intensive care unit (ICU) delirium is highly prevalent and a potentially avoidable hospital complication. The current cost of ICU delirium is unknown. OBJECTIVES: To specify the association between the daily occurrence of delirium in the ICU with costs of ICU care accounting for time-varying illness severity and death. RESEARCH DESIGN: We performed a prospective cohort study within medical and surgical ICUs in a large academic medical center. SUBJECTS: We analyzed critically ill patients (N=479) with respiratory failure and/or shock. MEASURES: Covariates included baseline factors (age, insurance, cognitive impairment, comorbidities, Acute Physiology and Chronic Health Evaluation II Score) and time-varying factors (sequential organ failure assessment score, mechanical ventilation, and severe sepsis). The primary analysis used a novel 3-stage regression method: first, estimation of the cumulative cost of delirium over 30 ICU days and then costs separated into those attributable to increased resource utilization among survivors and those that were avoided on the account of delirium's association with early mortality in the ICU. RESULTS: The patient-level 30-day cumulative cost of ICU delirium attributable to increased resource utilization was $17,838 (95% confidence interval, $11,132-$23,497). A combination of professional, dialysis, and bed costs accounted for the largest percentage of the incremental costs associated with ICU delirium. The 30-day cumulative incremental costs of ICU delirium that were avoided due to delirium-associated early mortality was $4654 (95% confidence interval, $2056-7869). CONCLUSIONS: Delirium is associated with substantial costs after accounting for time-varying illness severity and could be 20% higher (∼$22,500) if not for its association with early ICU mortality.

A hospital-wide evaluation of delirium prevalence and outcomes in acute care patients - a cohort study.

BACKGROUND: Delirium is a well-known complication in cardiac surgery and intensive care unit (ICU) patients. However, in many other settings its prevalence and clinical consequences are understudied. The aims of this study were: (1) To assess delirium prevalence in a large, diverse cohort of acute care patients classified as either at risk or not at risk for delirium; (2) To compare these two groups according to defined indicators; and (3) To compare delirious with non-delirious patients regarding hospital mortality, ICU and hospital length of stay, nursing hours and cost per case. METHODS: This cohort study was performed in a Swiss university hospital following implementation of a delirium management guideline. After excluding patients aged < 18 years or with a length of stay (LOS) < 1 day, 29'278 patients hospitalized in the study hospital in 2014 were included. Delirium period prevalence was calculated based on a Delirium Observation Scale (DOS) score ≥ 3 and / or Intensive Care Delirium Screening Checklist (ICDSC) scores ≥4. RESULTS: Of 10'906 patients admitted, DOS / ICDSC scores indicated delirium in 28.4%. Delirium was most prevalent (36.2-40.5%) in cardiac surgery, neurosurgery, trauma, radiotherapy and neurology patients. It was also common in geriatrics, internal medicine, visceral surgery, reconstructive plastic surgery and cranio-maxillo-facial surgery patients (prevalence 21.6-28.6%). In the unadjusted and adjusted models, delirious patients had a significantly higher risk of inpatient mortality, stayed significantly longer in the ICU and hospital, needed significantly more nursing hours and generated significantly higher costs per case. For the seven most common ICD-10 diagnoses, each diagnostic group's delirious patients had worse outcomes compared to those with no delirium. CONCLUSIONS: The results indicate a high number of patients at risk for delirium, with high delirium prevalence across all patient groups. Delirious patients showed significantly worse clinical outcomes and generated higher costs. Subgroup analyses highlighted striking variations in delirium period-prevalence across patient groups. Due to the high prevalence of delirium in patients treated in care centers for radiotherapy, visceral surgery, reconstructive plastic surgery, cranio-maxillofacial surgery and oral surgery, it is recommended to expand the current focus of delirium management to these patient groups.

A contemporary population-based analysis of the incidence, cost, and outcomes of postoperative delirium following major urologic cancer surgeries.

PURPOSE: Postoperative delirium (PD) is associated with poor outcomes and increased health care costs. The incidence, outcomes, and cost of delirium for major urologic cancer surgeries have not been previously characterized in a population-based analysis. MATERIALS AND METHODS: We performed a population-based, retrospective cohort study of patients with PD at 490 US hospitals between 2003 and 2013 to evaluate the incidence, outcomes, and cost of delirium after radical prostatectomy, radical nephrectomy, partial nephrectomy, and radical cystectomy (RC). Delirium was defined using ICD-9 codes in combination with postoperative antipsychotics, sitters, and restraints. Regression models were constructed to assess mortality, discharge disposition, length of stay (LOS), and direct hospital admission costs. Survey-weighted adjustment for hospital clustering achieved estimates generalizable to the US population. RESULTS: We identified 165,387 patients representing a weighted total of 1,097,355 patients. The overall incidence of PD was 2.7%, with the greatest incidence occurring after RC, with 6,268 cases (11%). Delirious patients had greater adjusted odds of in-hospital mortality (odds ratio [OR] = 3.65, P<0.001), 90-day mortality (OR = 1.47, P = 0.013), discharge with home health services (OR = 2.25, P<0.001), discharge to skilled nursing facilities (OR = 4.64, P<0.001), and a 0.9-day increase in median LOS (P<0.001). Patients with delirium also experienced a $2,697 increase in direct admission costs (P<0.001), with the greatest costs incurred in RC patients ($30,859 vs. $26,607; P<0.001). CONCLUSIONS: Patients with PD after urologic cancer surgeries experienced worse outcomes, prolonged LOS, and increased admission costs. The greatest incidence and costs were seen after RC. Further research is warranted to identify high-risk patients and devise preventative strategies.

Predicting excess cost for older inpatients with clinical complexity: A retrospective cohort study examining cognition, comorbidities and complications.

BACKGROUND: Hospital-acquired complications increase length of stay and contribute to poorer patient outcomes. Older adults are known to be at risk for four key hospital-acquired complications (pressure injuries, pneumonia, urinary tract infections and delirium). These complications have been identified as sensitive to nursing characteristics such as staffing levels and level of education. The cost of these complications compared to the cost of admission severity, dementia, other comorbidities or age has not been established. METHOD: To investigate costs associated with nurse-sensitive hospital-acquired complications in an older patient population 157,178 overnight public hospital episodes for all patients over age 50 from one Australian state, 2006/07 were examined. A retrospective cohort study design with linear regression analysis provided modelling of length-of-stay costs. Explanatory variables included patient age, sex, comorbidities, admission severity, dementia status, surgical status and four complications. Extra costs were based on above-average length-of-stay for each patient's Diagnosis Related Group from hospital discharge data. RESULTS: For adults over 50 who have length of stay longer than average for their diagnostic condition, comorbid dementia predicts an extra cost of A$874, (US$1,247); any one of four key complications predicts A$812 (US$1,159); each increase in admission severity score predicts A$295 ($US421); each additional comorbidity predicts A$259 (US$370), and for each year of age above 50 predicts A$20 (US$29) (all estimates significant at p<0.0001). DISCUSSION: Hospital-acquired complications and dementia cost more than other kinds of inpatient complexity, but admission severity is a better predictor of excess cost. Because complications are potentially preventable and dementia care in hospitals can be improved, risk-reduction strategies for common complications, particularly for patients with dementia could be cost effective. CONCLUSIONS: Complications and dementia were found to cost more than other kinds of inpatient complexity.

Risk factors and clinical outcomes of delirium in osteoporotic hip fractures.

PURPOSE: This study is performed to identify risk factors for delirium in osteoporotic hip fractures and to evaluate the hospitalization cost and clinical outcomes of delirium in osteoporotic hip. METHODS: A total of 221 patients with osteoporotic hip fractures were assessed for eligibility between 2010 and 2014. Among them, 37 patients with delirium were allocated into the delirium group (group D) and 37 patients without delirium were allocated into the non-delirium group (group ND) by matching demographic factors. Risk factors such as time between admission and operation, body mass index, American Society of Anesthesiologists status, cognitive impairment, preoperative urinary catheter, electrolyte imbalance, preoperative hemoglobin, polymedication (medications > 5), pneumonia, anesthesia time, operation time, estimated blood loss, and total amount of transfusion were evaluated for correlation with incidence of delirium. The hospitalization cost was evaluated, and clinical outcomes such as readmission, mortality, and activity level at 1-year follow-up were evaluated. RESULTS: In multivariate analysis, polymedication ( p = 0.028) and preoperative indwelling urinary catheter insertion status ( p = 0.007) were related to the incidence of delirium in patients with osteoporotic hip fractures. Group D showed a significantly higher hospitalization cost compared to group ND. However, delirium did not have a significant effect on length of hospital stay, readmission rate, postoperative 1-year mortality, and activity level. CONCLUSIONS: Polymedication and preoperative urinary catheter were related to perioperative delirium. In addition, delirium in osteoporotic hip fractures may not have a detrimental effect on clinical outcomes; however, hospitalization cost seemed to be increased due to delirium.

Poorer outcomes and greater healthcare costs for hospitalised older people with dementia and delirium: a retrospective cohort study.

OBJECTIVE: To compare healthcare utilisation outcomes among older hospitalised patients with and without cognitive impairment, and to compare the costs associated with these outcomes. METHODS: Retrospective cohort study of administrative data from a large teaching hospital in Melbourne, Australia from 1 July 2006 to 30 June 2012. People with cognitive impairment were defined as having dementia or delirium coded during the admission. Outcome measures included length of stay, unplanned readmissions within 28 days and costs associated with these outcomes. Regression analysis was used to compare differences between those with and without cognitive impairment. RESULTS: There were 93 300 hospital admissions included in the analysis. 6459 (6.9%) involved cognitively impaired patients. The adjusted median length of stay was significantly higher for the cognitively impaired group compared with the non-cognitively impaired group (7.4 days 6.7-10.0 vs 6.6 days, interquartile range 5.7-8.3; p < 0.001). There were no differences in odds of 28-day readmission. When only those discharged back to their usual residence were included in the analysis, the risk of 28-day readmission was significantly higher for those with cognitive impairment compared with those without. The cost of admissions involving patients with cognitive impairment was 51% higher than the cost of those without cognitive impairment. CONCLUSIONS: Hospitalised people with cognitive impairment experience significantly greater length of stay and when discharged to their usual residence are more likely to be readmitted to hospital within 28 days compared with those without cognitive impairment. The costs associated with hospital episodes and 28-day readmissions are significantly higher for those with cognitive impairment. Copyright © 2016 John Wiley & Sons, Ltd.

Delirium After Spine Surgery in Older Adults: Incidence, Risk Factors, and Outcomes.

OBJECTIVES: To characterize the incidence, risk factors, and consequences of delirium in older adults undergoing spine surgery. DESIGN: Prospective observational study. SETTING: Academic medical center. PARTICIPANTS: Individuals aged 70 and older undergoing spine surgery (N = 89). MEASUREMENTS: Postoperative delirium and delirium severity were assessed using validated methods, including the Confusion Assessment Method (CAM), CAM for the Intensive Care Unit, Delirium Rating Scale-Revised-98, and chart review. Hospital-based outcomes were obtained from the medical record and hospital charges from data reported to the state. RESULTS: Thirty-six participants (40.5%) developed delirium after spine surgery, with 17 (47.2%) having purely hypoactive features. Independent predictors of delirium were lower baseline cognition, higher average baseline pain, more intravenous fluid administered, and baseline antidepressant medication. In adjusted models, the development of delirium was independently associated with higher quintile of length of stay (odds ratio (OR) = 3.66, 95% confidence interval (CI) = 1.48-9.04, P = .005), higher quintile of hospital charges (OR = 3.49, 95% CI = 1.35-9.00, P = .01), and lower odds of discharge to home (OR = 0.22, 95% CI = 0.07-0.69, P = .009). Severity of delirium was associated with higher quintile of hospital charges and lower odds of discharge to home. CONCLUSION: Delirium is common after spine surgery in older adults, and baseline pain is an independent risk factor. Delirium is associated with longer stay, higher charges, and lower odds of discharge to home. Thus, prevention of delirium after spine surgery may be an important quality improvement goal.

Underreporting of Delirium in Statewide Claims Data: Implications for Clinical Care and Predictive Modeling.

BACKGROUND: Delirium is an acute neuropsychiatric syndrome that portends poor prognosis and represents a significant burden to the health care system. Although detection allows for efficacious treatment, the diagnosis is frequently overlooked. This underdiagnosis makes delirium an appealing target for translational predictive algorithmic modeling; however, such approaches require accurate identification in clinical training datasets. METHODS: Using the Massachusetts All-Payers Claims Database, encompassing health claims for Massachusetts residents for 2012, we calculated the rate of delirium diagnosis in index hospitalizations by reported ICD-9 diagnosis code. We performed a review of published studies formally assessing delirium to establish an expected rate of delirium when formally assessed. Secondarily, we reported a sociodemographic comparison of cases and noncases. RESULTS: Rates of delirium reported in the literature vary widely, from 3.6-73% with a mean of 23.6%. The statewide claims data (Massachusetts All-Payers Claims Database) identified the rate of delirium among index hospitalizations to be only 2.1%. For Massachusetts All-Payers Claims Database hospitalizations, delirium was coded in 2.8% of patients >65 years old and for 1.2% of patients ≤65. CONCLUSION: The lower incidence of delirium in claims data may reflect a failure to diagnose, a failure to code, or a lower rate in community hospitals. The relative absence of the phenotype from large databases may limit the utility of data-driven predictive modeling to the problem of delirium recognition.