Big Data, Predictive Analytics, and Quality Improvement in Kidney Transplantation: A Proof of Concept.

We sought proof of concept of a Big Data Solution incorporating longitudinal structured and unstructured patient-level data from electronic health records (EHR) to predict graft loss (GL) and mortality. For a quality improvement initiative, GL and mortality prediction models were constructed using baseline and follow-up data (0-90 days posttransplant; structured and unstructured for 1-year models; data up to 1 year for 3-year models) on adult solitary kidney transplant recipients transplanted during 2007-2015 as follows: Model 1: United Network for Organ Sharing (UNOS) data; Model 2: UNOS & Transplant Database (Tx Database) data; Model 3: UNOS, Tx Database & EHR comorbidity data; and Model 4: UNOS, Tx Database, EHR data, Posttransplant trajectory data, and unstructured data. A 10% 3-year GL rate was observed among 891 patients (2007-2015). Layering of data sources improved model performance; Model 1: area under the curve (AUC), 0.66; (95% confidence interval [CI]: 0.60, 0.72); Model 2: AUC, 0.68; (95% CI: 0.61-0.74); Model 3: AUC, 0.72; (95% CI: 0.66-077); Model 4: AUC, 0.84, (95 % CI: 0.79-0.89). One-year GL (AUC, 0.87; Model 4) and 3-year mortality (AUC, 0.84; Model 4) models performed similarly. A Big Data approach significantly adds efficacy to GL and mortality prediction models and is EHR deployable to optimize outcomes.

The association between antibiotic use and resistance: the role of secondary antibiotics.

Using susceptibility rates of Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae, and Enterobacter cloacae over time as markers, we assessed the significance of the change of susceptibility rates to imipenem, ceftriaxone, cefepime, piperacillin/tazobactam, and ciprofloxacin over time and the relationship to antibiotic use for the period 2000-2006. Antibiotic use-susceptibility relationships were assessed using longitudinal regression analysis. The variables "time" and define daily doses (DDD)/1,000 patient days for the specific drug related to the susceptibility rates of that particular model's dependent variable were considered as the main effects, with significance determined at the 0.05 level. Decreases in susceptibility of the target organisms were common over the period of observation. Decreasing susceptibility trends over time were not statistically associated with the primary drug (e.g., organism susceptibility rate to imipenem with imipenem usage). However, secondary drug use was associated with susceptibility rates (e.g., susceptibility of E. cloacae to cefepime with piperacillin/tazobactam usage). These results suggest that antibiotic use-resistance relationships are influenced by the use of secondary antibiotics. Thus, a resistance problem may not be adequately addressed by simply altering the utilization of the primary antibiotic.

Costs of revascularization over eight years in the randomized and eligible patients in the Emory Angioplasty versus Surgery Trial (EAST).

The Emory Angioplasty versus Surgery Trial (EAST) was a randomized trial that compared, by intention to treat, the clinical outcome and costs of percutaneous transluminal coronary angioplasty (PTCA) and coronary bypass grafting (CABG) for multivessel coronary artery disease. We present the findings of the economic analysis of EAST through 8 years of follow-up and compare the cost and outcomes of patients randomized in EAST versus patients eligible but not randomized (registry patients). Charges were assessed from hospital UB82 and UB92 bills and professional charges from the Emory Clinic. Hospital charges were reduced to cost through step-down accounting methods. All costs and charges were inflated to 1997 dollars. Costs were assessed for initial hospitalization and for cumulative costs of the initial hospitalization and additional revascularization procedures up to 8 years. Total 8-year costs were $46,548 for CABG and $44,491 for PTCA (p = 0.37). Cost of CABG in the eligible registry group showed a pattern similar to that for randomized patients, but total cost of PTCA was lower for registry patients than for randomized patients. Thus, the primary procedural costs of CABG are more than those for PTCA; this cost advantage, given the limits of measurement, is largely or even completely lost for randomized patients over the course of 8 years because of additional procedures after a first revascularization by PTCA.

Determining cost savings from attempted cephalic version in an inner city delivering population.

The use of external cephalic version (ECV) is increasingly seen as an important clinical management strategy for breech presentation infants. Currently, 75% of women with breech presentation at term undergo Cesarean delivery risking adverse outcomes and incurring higher costs. ECV, if successful, reduces the rate of breech presentation at delivery and the need for Cesarean delivery. Data from an inner-city population of delivering women were examined to determine the effectiveness of ECV among these minority, low income women. Hospital clinical and Medicaid claims data for 679 deliveries with breech presentation were studied. Decision tree analysis indicated ECV was successful for 48% of those attempted. Based on amounts billed Medicaid, attempting ECV reduced the use of resources by a little over $3,000 per delivery. Sensitivity analysis showed, however, that the savings may be as low as $906. Multivariate analysis confirmed the independent effect of attempting ECV on the probability of Cesarean delivery.

Applying the resource-based relative value scale to the Emory angioplasty versus surgery trial.

The resource-based relative value scale developed for use in the Medicare fee schedule can also be very useful in profiling and comparing physicians' cardiovascular utilization across different medical activities. This article applies relative value units (RVUs) to data from the Emory Angioplasty versus Surgery Trial. The Emory Angioplasty versus Surgery Trial was a randomized clinical trial to determine the efficacy of percutaneous transluminal coronary angioplasty (PTCA) versus coronary artery bypass surgery (CABG). All physician services in the clinical trial provided to 2 groups of patients--those undergoing CABG and those receiving PTCA-over the course of 4 years were assigned physician work RVUs (representing the intensity of physician work required) and total RVUs (representing both the intensity and practice costs). Physician charges were also compiled. These data were used to profile and compare physician services to the 2 groups of patients by type of service, distribution over time, and clinical department. Comparisons based on RVUs contrast sharply with differences based on charges. Mean physician charges, in 1996 dollars, were $27,158 for CABG patients and $21,491 for PTCA patients, a 26% difference (p <0.001). Physician work RVUs generated an 18.3% difference (p = <0.001). Using total RVUs, the difference between the 2 groups was 3.3% (p = 0.249). Resource-based relative value weights are a valuable tool for analyzing and comparing physicians' use of cardiovascular resource. The results suggest that conclusions about physician resource utilization based on physician charges should be carefully evaluated. When possible, physician work RVUs should be compiled and evaluated along with physician charges.

Bile duct stones and laparoscopic cholecystectomy: a decision analysis to assess the roles of intraoperative cholangiography, EUS, and ERCP.

BACKGROUND: The least costly management strategy for patients undergoing laparoscopic cholecystectomy is unclear. METHODS: A decision model incorporating cost ratios, test accuracy, complication, and failure rates was used to determine the costs of 4 peri-laparoscopic cholecystectomy strategies: endoscopic retrograde cholangiopancreatography (ERCP), intraoperative cholangiography (IOCG), endoscopic ultrasound (EUS), and expectant management. RESULTS: Expert IOCG is least costly for intermediate-risk patients when the risk of stones is between 17% and 34%. If expert EUS is available, 0% to 10% ("low" risk) merits expectant management; 11% to 55% ("intermediate" risk) merits EUS; and greater than 55% ("high" risk) merits ERCP. Thresholds were most sensitive to changes in the risks of symptoms and complications due to retained stones; and to procedural costs, sensitivity, and success rates. Neither IOCG nor EUS appears likely to reduce overall costs unless their accuracy and success rates are greater than 90% and their procedural cost is less than 60% to 70% that of ERCP. When neither are available, ERCP is preferable when the risk of stones is greater than 22%. Thresholds were relatively insensitive to changes in the risk and severity of ERCP-induced pancreatitis. CONCLUSIONS: The least costly strategy for laparoscopic cholecystectomy patients depends primarily on the risk of stones and stone-related symptoms, but procedural costs and operator expertise are also critical.

The changing healthcare market and how it has influenced the treatment of cardiovascular disease--Part 1.

The dramatic transformations taking place in the healthcare environment have created a new paradigm for healthcare and pose far-reaching changes for cardiovascular care. This 2-part paper reviews these changes and discusses the major implications for cardiovascular specialists, based on literature reviews and summaries of legislative initiatives. The new healthcare paradigm focuses on a continuum of care, wellness maintenance and promotion, accountability for the healthcare of defined populations, and provider differentiation based on ability to add 'value' to the patient's healthcare outcome. This paradigm will become 'standard operating procedure' in the cardiovascular market. As a result, major areas of change in the cardiovascular environment include: continuing growth of managed care arrangements, expanding physician and other payment reforms, growing influence of state and private payer initiatives, expanding role of 'centers of excellence,' continuing surplus of physicians, growth in pharmaceuticals and new technologies, and extension of evidence-based guidelines. Practice guidelines, in particular, will become an integral part of medical practice and will represent the standards against which medical practice will be measured. Given the prominent position of cardiovascular disease in healthcare, cardiovascular specialists will remain in the forefront of these developments.

The changing healthcare market: outlook for the future of cardiovascular disease treatment--Part 2.

This paper, the second in a series of 2, reviews major developments and trends in the current healthcare arena that will affect cardiovascular disease (CVD) treatment over the next 10 years. The paper also discusses the implications and future outlook for cardiovascular services in a managed care environment.

Pancreatic stenting prevents pancreatitis after biliary sphincterotomy in patients with sphincter of Oddi dysfunction.

BACKGROUND & AIMS: Patients with sphincter of Oddi dysfunction are at high risk of developing pancreatitis after endoscopic biliary sphincterotomy. Impaired pancreatic drainage caused by pancreatic sphincter hypertension is the likely explanation for this increased risk. A prospective, randomized controlled trial was conducted to determine if ductal drainage with pancreatic stenting protects against pancreatitis after biliary sphincterotomy in patients with pancreatic sphincter hypertension. METHODS: Eligible patients with pancreatic sphincter hypertension were randomized to groups with pancreatic duct stents (n = 41) or no stents (n = 39) after biliary sphincterotomy. The primary measured outcome was pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). RESULTS: Pancreatic stenting significantly decreased the risk of pancreatitis from 26% to 7% (10 of 39 in the no stent group and 3 of 41 in the stent group; P = 0.03). Only 1 patient in the stent group developed pancreatitis after sphincterotomy, and 2 others developed pancreatitis at the time of stent extraction. Patients in the no stent group were 10 times more likely to develop pancreatitis immediately after sphincterotomy than those in the stent group (relative risk, 10.5; 95% confidence interval, 1.4-78.3). CONCLUSIONS: Pancreatic duct stenting protects significantly against post-ERCP pancreatitis in patients with pancreatic sphincter hypertension undergoing biliary sphincterotomy. Stenting of the pancreatic duct should be strongly considered after biliary sphincterotomy for sphincter of Oddi dysfunction; pancreatic sphincter of Oddi manometry identifies which high-risk patients may benefit from pancreatic stenting.

Cost-effective delivery management of the vertex and nonvertex twin gestation.

OBJECTIVE: The aim of the study was to determine the most cost-effective delivery management of vertex and nonvertex twin pair gestations. STUDY DESIGN: Two hundred sixty-six consecutive twin gestations were followed up prospectively in a special antepartum Twins Clinic directed by the Maternal-Fetal Medicine Division. Maternal demographic, obstetric, and neonatal data were compiled prospectively. Information regarding 84 vertex and nonvertex twin pair gestations was extracted for review. Comparison groups included 41 twin pairs managed by spontaneous vaginal delivery and breech extraction (group A), 19 twin pairs managed by spontaneous vaginal delivery and external cephalic version (group B), and 24 twin pairs managed by primary cesarean delivery (group C). In-hospital financial data were retrieved and adjusted for inflation to 1996 constant dollars (data from a single institution allow comparison of charges). The Kruskal-Wallis chi2 test, the Fisher exact test, and analysis of variance were used for statistical analysis. RESULTS: The 3 groups did not differ with respect to maternal demographics, medical complications, gestational age, birth weight, fetal sex, or intrauterine growth restriction. Maternal and neonatal hospital charges were both significantly lower (P = .01 and P = .0001, respectively) in the breech extraction group A ($5890 +/- $2304 and $3526 +/- $5017, respectively) than in either group B ($8638 +/- $4175 and $11,754 +/- $15,457, respectively) or group C ($7,608 +/- $3,256 and $36,994 +/- $54,318, respectively). Although maternal morbidity was similar among the 3 groups, length of stay was shorter for mothers in group A. The infants delivered by spontaneous vaginal delivery and breech extraction (group A) had significantly lower rates of pulmonary disease (7% vs 24% vs 31% for groups A, B, and C, respectively; P = .002) and neonatal infectious disease (1% vs 0% vs 16%; P = .0005). These infants required the use of a ventilator less frequently (5% vs 12% vs 24%; P = .01), were more likely to be admitted to the normal newborn nursery (71% vs 51% vs 50%; P = .0001), and had a significantly shorter length of hospitalization (4.8 vs 12.4 vs 17.8 days; P = .0001). CONCLUSIONS: There is no medical consensus regarding delivery management for vertex and nonvertex presenting twin pairs. When hospital charges are examined with clinical data, however, breech extraction of the nonvertex second twin is the most cost-effective delivery management strategy.

Cost-effectiveness analysis in the nursing literature, 1992-1996.

PURPOSE: To review the recommendations by the U.S. Panel on Cost-Effectiveness in Health and Medicine (panel) for use in future nursing research. The review (a) provides a critique of the nursing cost-effectiveness and cost utility literature from the perspective of the recommendations set forth by the panel and other recognized authorities in cost-effectiveness analysis (CEA), (b) constructs an interdisciplinary framework to show the steps in the conduct of CEA, (c) makes the techniques and major findings of nursing CEA studies available and understandable, and (d) offers guidelines for the incorporation of CEA into the evaluation of future nursing intervention and research. DATA SOURCES: Seven nursing studies published between 1992 and 1996 that compared two or more interventions for costs and outcomes. ORGANIZING FRAMEWORK: For each study, the (a) perspective, (b) net costs, (c) net effect, (d) analysis of costs and effects, and (e) decision outcomes were analyzed. FINDINGS: If the panel's recommendations reflect the problems in the health care CEA literature in general, then on balance, the nursing CEA 1992-1996 studies are no more or less flawed than CEA studies in the health or medical care fields. CONCLUSIONS: Methodologic guidelines and interdisciplinary strategies are needed to advance the progress of nursing cost-effectiveness research.

Economic winners and losers after introduction of an effective new therapy depend on the type of payment system.

An effective therapy for a costly illness has economic consequences. There may also be differences between provider costs and payer costs and initial versus long-term costs; costs may also vary with the reimbursement scheme. Consider the case of an effective therapy to prevent restenosis after coronary angioplasty. Assume that the initial provider cost of angioplasty is $12,000 and that restenosis within 6 months results in repeat angioplasty in 20% of cases, with a follow-up cost of $2,400, or $14,400 total. Assume that a therapy costs $1,000 per angioplasty and decreases restenosis by 50%, resulting in repeat angioplasty in 10% of cases. This will result in an initial cost of $13,000 and a follow-up cost of $1,300, or $14,300 total. The total societal costs will be -$100, a slight savings. Thus, the $1,100 cost of therapy is offset by reduced costs associated with restenosis, and the societal costs are almost neutral. Assume that under fee for service providers charge costs plus 10% and that without the new therapy either a package price or a capitated system is revenue neutral. Changes in costs resulting from therapy to prevent restenosis are as follows (plus sign indicates cost or loss; minus sign indicates savings or profit): [table: see text] Under fee for service, the payer takes the risks, and the economic consequences to providers are minimal. The situation is reversed under capitation. For whoever takes the risk, there is an initial loss to pay for the therapy, but a long-term gain due to less restenosis. Under package pricing, the providers lose because of the cost of therapy and fewer procedures, while the payers gain. A new therapy, even if it is revenue neutral to society overall, may have considerable economic consequences, which vary with time and with the different perspectives of providers and payers.

Publications concerning costs of various cardiovascular procedures and drugs.

The following is a compendium of economic articles considered to be the most important and informative in the field of mechanical and pharmacologic treatment of coronary artery disease. This reference list was compiled from the literature and the MEDLINE database and includes citations before 1996.

A study on the cost-effectiveness of coronary revascularization: introducing the simultaneous mimic health status model.

An econometric model is presented to compare the cost-effectiveness of two alternative procedures, percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass surgery (CABG), for the treatment of multivessel coronary artery disease. This study utilizes the MIMIC (multiple indicator multiple cause) health model in a simultaneous equation system to analyse Emory Angioplasty Surgery Trial (EAST) data. This method eliminates the possibility of endogeneity bias, which may have affected the results of previous cost-effectiveness analyses on this topic. The empirical results indicate that neither procedure proves more cost-effective at 3 year follow-up.

Determining the clinical efficacy and cost savings of successful external cephalic version.

OBJECTIVE: The aim of this study was to determine predictors of successful external cephalic version and to calculate the associated cost savings achieved with success. STUDY DESIGN: A retrospective study of 203 women with singleton gestations who underwent external cephalic version was performed. Descriptive, univariate, and multivariate analyses were performed on patient-specific risk data to predict successful version. National claims data were used for the cost simulation. RESULTS: Higher parity (p = 0.02), transverse-oblique presentation (p = 0.001), posterior placenta (p = 0.001), and a longer duration of pregnancy (p = 0.001) significantly increased the likelihood of a successful version. Heavier maternal weight was negatively associated with successful version (p = 0.05). The cost simulation revealed an average savings of $2462 for each successful version. CONCLUSION: This study identifies clinical variables associated with an increased external cephalic version success rate. If, in fact, successful external cephalic version reduces both maternal and fetal morbidity associated with cesarean delivery and, as demonstrated in this analysis, the costs associated with the delivery, then greater effort should be made to maximize the success rate of external cephalic version.

Resource utilization and stage of illness: a study of an outpatient AIDS clinic.

Since the early 1990s, the trend in AIDS patient care has been to increase utilization of outpatient services, resulting in less frequent aggressive and lengthy hospital stays. This study retrospectively analyzes financial and sociodemographic data of 240 HIV/AIDS patients in a large, infectious disease program in Atlanta, GA. The results indicated the total cost of care per year for AIDS patients (alive or recently deceased) was $24,108 per year. Approximately 58% of this cost was attributable to inpatient care, 34% to outpatient care, and 8% to physician services. African-American race and IV drug use were negatively related to outpatient costs during the healthiest stage of illness. These demographics gave no prediction to the amount of cost consumed during clinical AIDS. On the other hand, males and patients on Medicaid were positive predictors of inpatient services, while homosexual patients were associated with fewer inpatient services. This study complements other projects, yet some questions remain unanswered. For example, does the seemingly low cost of care negatively impinge upon the overall care of the patient? This and further questions will have to be addressed in future studies.

Cost and therapeutic modification of intracoronary ultrasound-assisted coronary angioplasty.

Intracoronary ultrasound is used to define plaque morphology and quantitative characteristics before and after coronary angioplasty. The cost of the technique was defined in 87 patients who underwent elective, noncomplex procedures: group A was composed of 37 patients without intracoronary ultrasound, who served as a control group; group B comprised 23 patients who had only postcoronary angioplasty ultrasound; and group C was 27 patients who had pre-and postangioplasty ultrasound. Economic analysis was done for the hospital ("bottom-up" methodology of equipment, supplies, support personnel, post-PTCA room) and physician costs (using resource-based relative value scale). The cost in the cardiac catheterization laboratory was: group A = $3,679 +/- $688; group B = $4,650 +/- $457; and group C = $5,301 +/- $835, p < 0.0001. The postprocedure cost for all groups was similar. The total cost was: group A = $5,326 +/- $1,135; group B = $6,815 +/- $1,276; and group C = $7,240 +/- $1,494, p < 0.0001. Intracoronary ultrasound modified the coronary angioplasty procedure in 36% of patients. Precoronary angioplasty intracoronary ultrasound defined the luminal diameter, precluding the use of additional balloons, and thus decreased the cost approximately $650. Use of ultrasound after the procedure increases the cost approximately $200 as a result of performing additional interventions. For intracoronary ultrasound to be economically viable, the change in angioplasty technique will need to be accompanied by improved clinical outcome.

Using physician work relative value units to profile surgical packages: methods and results for kidney transplant surgery.

BACKGROUND: This investigation outlines an approach for using the physician work relative value units (RVUs) in the Medicare Fee Schedule (MFS) to profile physician clinical activities. These techniques were then used to profile the physician services associated with kidney transplant patients at Emory University System of Health Care. METHODS: All physician services associated with 179 patients who had kidney transplant surgery in 1993 were studied. By using billing data, physician work RVUs were assigned to each service and the results were analyzed by type of service and the hospital department providing the service for physician work RVUs and physician charges. RESULTS: A mean of 130.4 physician work RVUs were involved in the 179 episodes of care. Surgical services represented 48.7% of the physician work activity in the kidney transplant. Visit and consultative services make up the next highest share with 25.5% of the physician work RVUs, whereas anesthesia makes up 13.3% of physician work RVUs. Physician charges totaled $16,249 for kidney transplants in 1993 dollars. Surgical services accounted for 54.2% of physician charges connected with kidney transplants, whereas visits and consultative services represented 20.6% of physician charges. CONCLUSIONS: Physician work RVUs in the MFS offer a unique and much needed perspective on physician clinical activities. Physician work RVUs are an important new tool for healthcare and researchers and their use needs to be more fully explored and benchmarks developed for all major medical and surgical services.

Access to and participation in breast cancer screening: a review of recent literature.

Recently, attention has been focused on the incentives for access to and participation in breast cancer screening programs. The Healthy People 2000 health goals for the nation calls for 60% of women aged 50 years and older to have had mammograms and clinical breast exams within the preceding 2 years. To achieve this objective, the incentives for access to and participation in breast cancer screening programs must be identified. The present review examines incentive-based hypotheses dealing with lower socioeconomic status, lack of insurance coverage, physician referral, and self-referral. Policy-oriented solutions that have attempted to correct the disincentives associated with low access and participation were analyzed. The sophistication of screening technology is of primary importance; however, this review provides additional information that can be used to ensure the implementation of quality mammography screening programs.

Economic and angiographic factors in determining optimal catheter size in performing outpatient left-sided heart and coronary angiography.

A prospective randomized trial was performed in 300 patients to establish the optimal catheter size (5.2, 6, or 7Fr) in performing outpatient left heart and coronary arteriography. A secondary randomization was performed between an attending physician and cardiovascular fellow to determine if the experience level of the operator was an important factor when using smaller French-sized catheters. The primary end point of the trial was total resource utilization of the patient's hospitalization. Hospital cost was calculated with cost accounting methodology using a "bottom-up" approach, and physician "cost" was determined with the Resource-Based Relative Value Scale. Angiographic quality was graded with qualitative and quantitative methods. Procedures were faster and time to hemostasis shorter with smaller catheters. The more experienced operators performed faster procedures and used less fluoroscopy. In the cardiac catheterization laboratory, health-care personnel cost was higher with the 6Fr catheters and when the attending physician was the primary operator. Postprocedure care was slightly less expensive with the smaller catheters. Overall, there was no difference in total cost between the catheter sizes and primary operators. Angiographic quality was similar between the catheter sizes. Smaller catheters used in performing outpatient left-sided heart and coronary arteriography are not associated with cost savings but do not compromise angiographic quality.