Mental Practice: Applying Successful Strategies in Sports to the Practice of Emergency Medicine.

Emergency physicians are expected to learn and maintain a large and varied set of competencies for clinical practice. These include high acuity, low occurrence procedures that may not be encountered frequently in the clinical environment and are difficult to practice with high fidelity and frequency in a simulated environment. Mental practice is a form of a cognitive walk-through that has been shown to be an effective method for improving motor and cognitive skills, with literature in sports science and emerging evidence supporting its use in medicine. In this article, we review the literature on mental practice in sports and medicine as well as the underlying neuroscientific theories that support its use. We review best-known practices and provide a framework to design and use mental imagery scripts to augment learning and maintaining the competencies necessary for physicians at all levels of training and clinical environments in the practice of emergency medicine.

Cost-effectiveness analysis of LungLB for the clinical management of patients with indeterminate pulmonary nodules.

BACKGROUND: There is currently a need for additional diagnostic information to help guide treatment decisions and to properly determine the best treatment pathway for patients identified with indeterminate pulmonary nodules (IPNs). The aim of this study was to demonstrate the incremental cost-effectiveness of LungLB compared to the current clinical diagnostic pathway (CDP) in the management of patients with IPNs, from a US payer's perspective. METHODS: A decision tree and Markov model hybrid was chosen from a payer perspective in the US setting, based on published literature, to assess the incremental cost-effectiveness of LungLB compared to the current CDP in the management of patients with IPNs. Primary endpoints of the analysis include expected costs, life years (LYs), and quality-adjusted life years (QALYs) for each arm of the model, as well as an incremental cost-effectiveness ratio (ICER), which is calculated as the incremental costs per QALY, and net monetary benefit (NMB). RESULTS: We find that, with the inclusion of LungLB to the current CDP diagnostic pathway, expected LYs over the typical patient's lifespan increase by 0.07 years and QALYs increase by 0.06. The average patient in the CDP arm will pay approximately $44,310 over their lifespan, while a patient in the LungLB arm will pay $48,492, resulting in a difference of $4,182. The differentials between the CDP and LungLB arms of the model in costs and QALYs yield an ICER of $75,740 per QALY and an incremental NMB of $1,339. CONCLUSION: This analysis provides evidence that LungLB, in conjunction with CDP, is a cost-effective alternative compared to the current CDP alone in a US setting for individuals with IPNs.

Pancreatic stone protein point-of-care testing can reduce healthcare expenditure in sepsis.

BACKGROUND: Sepsis is a life-threatening organ dysfunction in response to infection. Early recognition and rapid treatment are critical to patient outcomes and cost savings, but sepsis is difficult to diagnose because of its non-specific symptoms. Biomarkers such as pancreatic stone protein (PSP) offer rapid results with greater sensitivity and specificity than standard laboratory tests. METHODS: This study developed a decision tree model to compare a rapid PSP test to standard of care in the emergency department (ED) and intensive care unit (ICU) to diagnose patients with suspected sepsis. Key model parameters included length of hospital and ICU stay, readmission due to infection, cost of sepsis testing, length of antibiotic treatment, antibiotic resistance, and clostridium difficile infections. Model inputs were determined by review of sepsis literature. RESULTS: The rapid PSP test was found to reduce costs by $1688 per patient in the ED and $3315 per patient in the ICU compared to standard of care. Cost reductions were primarily driven by the specificity of PSP in the ED and the sensitivity of PSP in the ICU. CONCLUSIONS: The results of the model indicate that PSP testing is cost saving compared to standard of care in diagnosis of sepsis. The abundance of sepsis cases in the ED and ICU make these findings important in the clinical field and further support the potential of sensitive and specific markers of sepsis to not only improve patient outcomes but also reduce healthcare expenditures.

Cost impact analysis of novel host-response diagnostic for patients with community-acquired pneumonia in the emergency department.

BACKGROUND: There is significant over-prescription of antibiotics for suspected community-acquired pneumonia (CAP) patients as bacterial and viral pathogens are difficult to differentiate. To address this issue, a host response diagnostic called MeMed BV (MMBV) was developed that accurately differentiates bacterial from viral infection at the point of need by integrating measurements of multiple biomarkers. A literature-based cost-impact model was developed that compared the cost impact and clinical benefits between using the standard of care diagnostics combined with MMBV relative to standard of care diagnostics alone. METHODS: The patient population was stratified according to the pneumonia severity index, and cost savings were considered from payer and provider perspectives. Four scenarios were considered. The main analysis considers the cost impact of differences in antibiotic stewardship and resulting adverse events. The first, second, and third scenarios combine the impacts on antibiotic stewardship with changes in hospital admission probability, length of hospital stay and diagnosis related group (DRG) reallocation, and hospital admission probability, length of stay, and DRG reallocation in combination, respectively. RESULTS: The main analysis results show overall per-patient savings of $37 for payers and $223 for providers. Scenarios 1, 2, and 3 produced savings of $137, $189, and $293 for payers, and $339, $713, and $809 for providers, respectively. LIMITATIONS: Models are simulations of real-world clinical processes, and are not sensitive to variations in clinical practice driven by differences in physician practice styles, differences in facility-level practice patterns, and patient comorbidities expected to exacerbate the clinical impact of CAP. Hospital models are limited to costs and do not consider differences in revenue associated with each approach. CONCLUSIONS: Introducing MMBV to the current SOC diagnostic process is likely to be cost-saving to both hospitals and payers when considering impacts on antibiotic distribution, hospital admission rate, hospital LOS, and DRG reallocation.

Reimbursement for genetic variant reinterpretation: five questions payers should ask.

Reaching the goals set by the Health Care Payment and Learning Action Network requires an unyielding and unrelenting focus on encouraging providers to adopt advanced alternative payment models (APMs). Many of these models will continue to be voluntary because they either are in early stages or have not yet proven their effectiveness. The models that have proven their effectiveness should become permanent, comprising the new way that providers are paid in the Medicare program. Either way, getting today's high performers into those programs and keeping them engaged to continue to innovate and set new benchmarks is as important as attracting and improving the performance of poorer performers. That will require a shift in Medicare's policy on pricing and evaluating APMs.

Mendelian randomization: estimation of inpatient hospital costs attributable to obesity.

BACKGROUND: Mendelian Randomization is a type of instrumental variable (IV) analysis that uses inherited genetic variants as instruments to estimate causal effects attributable to genetic factors. This study aims to estimate the impact of obesity on annual inpatient healthcare costs in the UK using linked data from the UK Biobank and Hospital Episode Statistics (HES). METHODS: UK Biobank data for 482,127 subjects was linked with HES inpatient admission records, and costs were assigned to episodes of care. A two-stage least squares (TSLS) IV model and a TSLS two-part cost model were compared to a naïve regression of inpatient healthcare costs on body mass index (BMI). RESULTS: The naïve analysis of annual cost on continuous BMI predicted an annual cost of £21.61 [95% CI £20.33 - £22.89] greater cost per unit increase in BMI. The TSLS IV model predicted an annual cost of £14.36 [95% CI £0.31 - £28.42] greater cost per unit increase in BMI. Modelled with a binary obesity variable, the naïve analysis predicted that obese subjects incurred £205.53 [95% CI £191.45 - £219.60] greater costs than non-obese subjects. The TSLS model predicted a cost £201.58 [95% CI £4.32 - £398.84] greater for obese subjects compared to non-obese subjects. CONCLUSIONS: The IV models provide evidence for a causal relationship between obesity and higher inpatient healthcare costs. Compared to the naïve models, the binary IV model found a slightly smaller marginal effect of obesity, and the continuous IV model found a slightly smaller marginal effect of a single unit increase in BMI.

Cost-impact analysis of baroreflex activation therapy in chronic heart failure patients in the United States.

BACKGROUND: The study evaluated the cost of baroreflex activation therapy plus guideline directed therapy (BAT + GDT) compared to GDT alone for HF patients with reduced ejection fraction and New York Heart Association Class III or II (with a recent history of III). Baroreflex activation therapy (BAT) is delivered by an implantable device that stimulates the baroreceptors through an electrode attached to the outside of the carotid artery, which rebalances the autonomic nervous system to regain cardiovascular (CV) homeostasis. The BeAT-HF trial evaluated the safety and effectiveness of BAT. METHODS: A cost impact model was developed from a U.S. health care payer or integrated delivery network perspective over a 3-year period for BAT + GDT versus GDT alone. Expected costs were calculated by utilizing 6-month data from the BeAT-HF trial and existing literature. HF hospitalization rates were extrapolated based on improvement in NT-proBNP. RESULTS: At baseline the expected cost of BAT + GDT were $29,526 per patient more than GDT alone due to BAT device and implantation costs. After 3 years, the predicted cost per patient was $9521 less expensive for BAT + GDT versus GDT alone due to lower rates of significant HF hospitalizations, CV non-HF hospitalizations, and resource intensive late-stage procedures (LVADs and heart transplants) among the BAT + GDT group. CONCLUSIONS: BAT + GDT treatment becomes less costly than GDT alone beginning between years 1 and 2 and becomes less costly cumulatively between years 2 and 3, potentially providing significant savings over time. As additional BeAT-HF trial data become available, the model can be updated to show longer term effects.

Online Simulation Model to Estimate the Total Costs of Tobacco Product Waste in Large U.S. Cities.

Tobacco product waste (TPW) is one of the most ubiquitous forms of litter, accumulating in large amounts on streets, highways, sidewalks, beaches, parks, and other public places, and flowing into storm water drains, waste treatment plants, and solid waste collection facilities. In this paper, we evaluate the direct and indirect costs associated with TPW in the 30 largest U.S. cities. We first developed a conceptual framework for the analysis of direct and indirect costs of TPW abatement. Next, we applied a simulation model to estimate the total costs of TPW in major U.S. cities. This model includes data on city population, smoking prevalence rates, and per capita litter mitigation costs. Total annual TPW-attributable mean costs for large US cities range from US$4.7 million to US$90 million per year. Costs are generally proportional to population size, but there are exceptions in cities that have lower smoking prevalence rates. The annual mean per capita TPW cost for the 30 cities was US$6.46, and the total TPW cost for all 30 cities combined was US$264.5 million per year. These estimates for the TPW-attributable cost are an important data point in understanding the negative economic externalities created by cigarette smoking and resultant TPW cleanup costs. This model provides a useful tool for states, cities, and other jurisdictions with which to evaluate a new economic cost outcome of smoking and to develop new laws and regulations to reduce this burden.

Cost Impact Model of a Novel Multi-mRNA Host Response Assay for Diagnosis and Risk Assessment of Acute Respiratory Tract Infections and Sepsis in the Emergency Department.

BACKGROUND: Early identification of acute infections and sepsis remains an unmet medical need. While early detection and initiation of treatment reduces mortality, inappropriate treatment leads to adverse events and the development of antimicrobial resistance. Current diagnostic and prognostic solutions, including procalcitonin, lack required accuracy. A novel blood-based host response test, HostDx™ Sepsis by Inflammatix, Inc., assesses the likelihood of a bacterial infection, the likelihood of a viral infection, and the severity of the condition. OBJECTIVES: We estimated the economic impact of adopting HostDx Sepsis testing among patients with suspected acute respiratory tract infection (ARTI) in the emergency department (ED). METHODS: Our cost impact model estimated costs for adult ED patients with suspected ARTI under the standard of care versus with the adoption of HostDx Sepsis from the perspective of US payers. Included costs were those assumed to be associated with an episode of sepsis diagnosis, management, and treatment. Projected accuracies for test predictions, disease prevalence, and clinical parameters was derived from patient-level meta-analysis data of randomized trials, supplemented with published performance data for HostDx Sepsis. One-way sensitivity analysis was performed on key input parameters. RESULTS: Compared to standard of care including procalcitonin, the superior test characteristics of HostDx Sepsis resulted in an average cost savings of approximately US$1974 per patient (-31.3%) exclusive of the cost of HostDx Sepsis. Reductions in hospital days (-0.80 days, -36.7%), antibiotic days (-1.49 days, -29.5%), and percent 30-day mortality (-1.67%, -13.64%) were driven by HostDx Sepsis providing fewer "noninformative" moderate risk predictions and more "certain" low- or high-risk predictions compared to standard of care, especially for patients who were not severely ill. These results were robust to changes in key parameters, including disease prevalence. CONCLUSIONS: Our model shows substantial savings associated with introduction of HostDx Sepsis among patients with ARTIs in EDs. These results need confirmation in interventional trials.

Application of a simple point-of-care test to reduce UK healthcare costs and adverse events in outpatient acute respiratory infections.

Background: Acute respiratory infection (ARI) accounts for over two-thirds of total antibiotic prescriptions although most are caused by viruses that do not benefit from antibiotics. Most antibiotics are prescribed in the outpatients setting. Antibiotic overuse leads to antibiotic-related adverse events (AEs), inclusive of secondary infections, resistance, and increased costs. Point-of-care tests (POCT) may reduce unnecessary antibiotics. A cost analysis was performed to assess diagnostic POCT options to identify patients with an ARI that may benefit from antibiotics in a United Kingdom (UK) outpatient setting.Methods: Healthcare savings were estimated using a budget impact analysis based on UK National Institute for Health and Care Excellence (NICE) data and direct costs (antibiotics, AEs, POCTs) derived from published literature. Otitis media, sinusitis, pharyngitis and bronchitis were considered the most common ARIs. Antibiotic-related AE costs were calculated using re-consultation costs for anaphylaxis, Stevens-Johnson syndrome, allergies/diarrhea/nausea, C. difficile infection (CDI). Potential cost-savings from POCTs was assessed by evaluating NICE guideline-referenced POCTs (CRP, FebriDx, Sarasota, FL) as well as a target product profile (TPP).Results: Fifty-percent (7,718,283) of ARI consultations resulted in antibiotics while guideline-based prescribing suggest appropriate antibiotic prescriptions are warranted 9% (1,444,877) of ARI consultations. Direct antibiotic costs for actual ARI consultations associated with antibiotics was £24,003,866 vs. £4,493,568 for guideline-based, "appropriate" antibiotic prescriptions. Antibiotic-related AEs and re-consultations for actual vs. appropriate prescribing totaled £302,496,486 vs. £63,854,269. ARI prescribing plus AE costs totaled £326,729,943 annually without the use of delayed prescribing practices or POCT while the addition of delayed prescribing plus POCT totaled £60,114,564-£78,148,933 depending on the POCT.Conclusions: Adding POCT to outpatient triage of ARI can reduce unnecessary antibiotics and antibiotic-related AEs, resulting in substantial cost savings. Further, near patient diagnostic testing can benefit health systems and patients by avoiding exposure to unnecessary drugs, side effects and antibiotic resistant pathogens.Key points for decision makersMany patients are unnecessarily treated with antibiotics for respiratory infections.Antibiotic misuse leads to unnecessary adverse events, secondary infections, re-consultations, antimicrobial resistance and increased costs.Point-of-care diagnostic tests used to guide antibiotic prescriptions will avoid unnecessary adverse health effects and expenses.

Economic evaluation of passive monitoring technology for seniors.

BACKGROUND: Advances such as passive monitoring technology (PMT), which provides holistic supervision of chronically ill and elderly patients, enable and support improved monitoring and observation, thus empowering the growing population of older adults to live more independently while lowering health care expenses. AIMS: This study develops a conceptual model to estimate the potential savings associated with PMT. METHODS: We first develop a conceptual model to identify the main cost variables associated with independent living, focusing on three pathways: (1) PMT, (2) independent living supported by the current standard of care, and (3) facility-based care. We examined the impact on three outcomes [i.e., health care costs, institutional costs, and health-related quality of life (HRQoL)] along each of the three care pathways (i.e., PMT, independent living supported by the standard of care, and facility-based care) and developed a cost-benefit model to calculate the net costs and benefits associated with each care pathway. RESULTS: The cost-benefit model showed savings between approximately $425 per-member per-month (PMPM) for those using PMT compared to those on the standard of care pathway. Sensitivity analysis demonstrated that a 5% increase in nursing home utilization generates cost savings of more than 30% PMPM. DISCUSSION: The total projected cost savings for individuals on the PMT arm are projected to be more than $425 PMPM, with annual savings of $5069 per-person per-year, and over $5.1 million for a target population of 1000 individuals. CONCLUSIONS: The cost calculations in our cost-benefit simulation model clearly demonstrate the value of PMT and show the potential value to payers and integrated delivery systems in offering PMT to individuals who are likely to benefit the most from the services.

Economic evaluation of cardiac magnetic resonance with fast-SENC in the diagnosis and management of early heart failure.

INTRODUCTION: Heart failure (HF) is a major public health concern, prevalent in millions of people worldwide. The most widely-used HF diagnostic method, echocardiography, incurs a decreased diagnostic accuracy for heart failure disease progression when patients are asymptomatic compared to those who are symptomatic. The purpose of this study is to conduct a cost-effectiveness analysis of heart failure diagnosis comparing echocardiography to a novel myocardial strain assessment (Fast-SENC), which utilizes cardiac-tagged magnetic resonance imaging. METHODS: We develop two models, one from the perspective of payers and one from the perspective of purchasers (hospitals). The payer model is a cost-effectiveness model composed of a 1-year short-term model and a lifetime horizon model. The hospital/purchaser model is a cost impact model where expected costs are calculated by multiplying cost estimates of each subcomponent by the accompanying probability. RESULTS: The payer model shows lower healthcare costs for Fast-SENC in comparison to ECHO ($24,647 vs. $39,097) and a lifetime savings of 37% when utilizing Fast-SENC. Similarly, the hospital model revealed that the total cost per HF patient visit is $184 for ECHO and $209 for Fast-SENC, which results in hospital contribution margins of $81 and $115, respectively. CONCLUSIONS: Fast-SENC is associated with higher quality-adjusted life years and lower accumulated expected healthcare costs than echocardiogram patients. Fast-SENC also shows a significant short-term and lifetime cost-savings difference and a higher hospital contribution margin when compared to echocardiography. These results suggest that early discovery of heart failure with methods like Fast-SENC can be cost-effective when followed by the appropriate treatment.

Cost-impact of cardiac magnetic resonance imaging with Fast-SENC compared to SPECT in the diagnosis of coronary artery disease in the U.S.

AIMS: The purpose of this study is to assess the economic cost differences and the associated treatment resource changes between the developing coronary artery disease (CAD) diagnostic tool fast strain-encoded cardiac imaging (Fast-SENC) and the current commonly used stress test single-photon emission computed tomography (SPECT). MATERIALS AND METHODS: A "payer perspective" model was created first, consisting of long-term and short-term components that used a hypothetical cohort of patients of average age (60.8 years) presenting with chest pain and suspected CAD to assess cost-impact. A cost impact model was then built that assessed likely savings from a "hospital perspective" from substituting Fast-SENC for a portion of SPECTs assuming an average number of annual SPECT tests performed in US hospitals. RESULTS: In the payer model, using Fast-SENC followed by coronary angiography (CA) and percutaneous coronary intervention (PCI) treatment when necessary is less costly than the SPECT method when considering both direct and indirect costs of testing. Expected costs of the Fast-SENC were between $2,510 and $2,632 per correct diagnosis, while expected costs for the SPECT were between $3,157 and $4,078. Fast-SENC reduced false positives by 50% and false negatives by 86%, generating additional cost savings. The hospital model showed total costs per CAD patient visit of $825 for SPECT and $376 for Fast-SENC. LIMITATIONS: Limitations of this study are that clinical data are sourced from other published clinical trials on how CAD diagnostic strategies impact clinical outcome, and that necessary assumptions were made which impact health outcomes. CONCLUSION: The lower cost, higher sensitivity and specificity rates, and faster, less burdensome process for detecting CAD patients make Fast-SENC a more capable and economically beneficial stress test than SPECT. The payer model and hospital model demonstrate an alignment between payer and provider economics as Fast-SENC provides monetary savings for patients and resource benefits for hospitals.

Impact of a Novel Insulin Management Service on Non-insulin Pharmaceutical Expenses.

BACKGROUND: Studies have shown that improvements in glycemic control are associated with avoidance or delayed onset of diabetes complications, improvements in health-related quality of life, and reductions in diabetes-related health care costs. Clinical practice guidelines recommend maintaining a hemoglobin A1c (HbA1c) level less than 7%, but among type 2 diabetes patients using insulin, two-thirds have HbA1c above 7% and one-third have HbA1c above 9%. OBJECTIVES: This study examined the use of insulin management services to enable patients to optimize insulin dosing to achieve HbA1c targets and subsequently reduce health care costs. Cost savings may be achieved through reduced complications and hospitalizations, as well as reduced outpatient, physician, and clinic costs. This study quantified the reduction in pharmaceutical expenses related to the use of an enhanced insulin management service to improve glycemic control. METHODS: Two hundred seventeen insulin-reliant patients were enrolled in the d-Nav® Insulin Guidance Service through a participating insurance group. A prospective cost analysis was conducted using data from enrolled patients who completed the first 90 days of follow up. RESULTS: Of the 192 patients who completed the 90-day study period, 54 (28.13%) were prescribed one or more expensive medications at baseline, but 45 (83.33%) of those patients were eligible for medication discontinuation after 90 days. At baseline, the annual cost of expensive medications per patient was $7564 (CI: $5191-$9938) and $1483 (CI: -$1463-$4429) at 90 days (p<0.001). Direct savings from medication elimination was estimated to be $145 per patient per month (PPPM) or $1736 per patient per year (PPPY) for all patients and $514 PPPM/$6172 PPPY for the target group. Patients that completed the 90-day period significantly reduced HbA1c levels from 9.37% (CI:7.72%-11.03%) at baseline to 7.71% (CI: 6.70%-8.73%) (p<0.001). A total of 170 (88.54%) patients had improved HbA1c at 90 days. CONCLUSIONS: Use of the insulin guidance service achieved improved glycemic control by optimizing insulin dosing, which enabled most patients using the service to reduce or eliminate the use of expensive diabetes medications. Further study is needed to assess the impact of optimized insulin dosing on other diabetes-related health care costs in a usual practice setting.

Outcomes of Surgeries Performed in Physician Offices Compared With Ambulatory Surgery Centers and Hospital Outpatient Departments in Florida.

BACKGROUND: The proportion of outpatient surgeries performed in physician offices has been increasing over time, raising concern about the impact on outcomes. OBJECTIVE: To use a private insurance claims database to compare 7-day and 30-day hospitalization rates following relatively complex outpatient surgical procedures across physician offices, freestanding ambulatory surgery centers (ASCs), and hospital outpatient departments (HOPDs). METHODS: A multivariable logistic regression model was used to compare the risk-adjusted probability of hospitalization among patients after any of the 88 study outpatient procedures at physician offices, ASCs, and HOPDs over 2008-2012 in Florida. RESULTS: Risk-adjusted hospitalization rates were higher following procedures performed in physician offices compared with ASCs for all procedures grouped together, for most procedures grouped by type, and for many individual procedures. CONCLUSIONS: Hospitalizations following surgery were more likely for procedures performed in physician offices compared with ASCs, which highlights the need for ongoing research on the safety and efficacy of office-based surgery.

Assessing the impact of state "opt-out" policy on access to and costs of surgeries and other procedures requiring anesthesia services.

In 2001, the U.S. government released a rule that allowed states to "opt-out" of the federal requirement that a physician supervise the administration of anesthesia by a nurse anesthetist. To date, 17 states have opted out. The majority of the opt-out states cited increased access to anesthesia care as the primary rationale for their decision. In this study, we assess the impact of state opt-out policy on access to and costs of surgeries and other procedures requiring anesthesia services. Our null hypothesis is that opt-out rule adoption had little or no effect on surgery access or costs. We estimate an inpatient model of surgeries and costs and an outpatient model of surgeries. Each model uses data from multiple years of U.S. inpatient hospital discharges and outpatient surgeries. For inpatient cost models, the coefficient of the opt-out variable was consistently positive and also statistically significant in most model specifications. In terms of access to inpatient surgical care, the opt-out rules did not increase or decrease access in opt-out states. The results for the outpatient access models are less consistent, with some model specifications indicating a reduction in access associated with opt-out status, while other model specifications suggesting no discernable change in access. Given the sensitivity of model findings to changes in model specification, the results do not provide support for the belief that opt-out policy improves access to outpatient surgical care, and may even reduce access to outpatient surgical care (among freestanding facilities).

Economic evaluation of procalcitonin-guided antibiotic therapy in acute respiratory infections: a Chinese hospital system perspective.

BACKGROUND: Cost-impact models have indicated that in the USA, the use of antibiotic stewardship protocols based on procalcitonin (PCT) levels for patients with suspected acute respiratory tract infection results in cost savings. Our objective was to assess the cost impact of adopting PCT testing among patients with acute respiratory infections (ARI) from the perspective of a typical hospital system in urban China. METHODS: To conduct an economic evaluation of PCT testing versus usual care we built a cost-impact model based on a previously published patient-level meta-analysis data of randomized trials including Chinese sites. The data were adapted to the China setting by applying the results to mean lengths of stay, costs, and practice patterns typically found in China. We estimated the annual ARI visit rate for the typical hospital system (assumed to be 1650 beds) and ARI diagnosis. RESULTS: In the inpatient setting, the costs of PCT-guided care compared to usual care for a cohort of 16,405 confirmed ARI patients was almost 1.1 million Chinese yuan (CNY), compared to almost 1.8 million CNY for usual care, resulting in net savings of 721,563 CNY to a typical urban Chinese hospital system for 2015. In the ICU and outpatient settings, savings were 250,699 CNY and 2.4 million CNY, respectively. The overall annual net savings of PCT-guided care was nearly 3.4 million CNY. CONCLUSIONS: Substantial savings are associated with PCT protocols of ARI across common China hospital treatment settings mainly by direct reduction in unnecessary antibiotic utilization.

Cost impact of unexpected disposition after orthopedic ambulatory surgery associated with category of anesthesia provider.

STUDY OBJECTIVE: To provide estimates of the costs and health outcomes implications of the excess risk of unexpected disposition for nurse anesthetist (NA) procedures. DESIGN: A projection model was used to apply estimates of costs and health outcomes associated with the excess risk of unexpected disposition for NAs reported in a recent study. SETTING: Ambulatory and inpatient surgery. PATIENTS: Base-case model parameters were based on estimates taken from peer-reviewed publications when available, or from other sources including data for all hospital stays in the United States in 2013 from the Healthcare Cost and Utilization Project Web site. The impact of parameter uncertainty was assessed using 1-way and 2-way sensitivity analyses. INTERVENTIONS: Not applicable. MEASUREMENTS: Major complication rates, relative risks of complications, anesthesia costs, costs of complications, and cost-effectiveness ratios. MAIN RESULTS: In the base-case model, there were on average 2.3 fewer unexpected dispositions for physician anesthesiologists compared with NAs. Overall, anesthesia-related costs (including the cost of managing unexpected dispositions) were estimated to be about $31 higher per procedure for physician anesthesiologists compared with NAs. Alternative model scenarios in the sensitivity analysis produced estimates of smaller additional costs associated with physician anesthesia administration, to the point of cost savings in some scenarios. CONCLUSIONS: Provision of anesthesia for ambulatory knee and shoulder procedures by physician anesthesiologists results in better health outcomes, at a reasonable additional cost, compared with procedures with NA-administered anesthesia, at least when using updated cost-effectiveness willingness-to-pay benchmarks.

In-office magnetic resonance imaging (MRI) equipment ownership and MRI volume among medicare patients in orthopedic practices.

BACKGROUND: Concerns have been raised about physician ownership of onsite advanced imaging equipment as allowed under Stark laws by the in-office ancillary service exception (IOASE). METHODS: A web-based survey of orthopedic practices in the United States was used to assign a first date of onsite MRI capacity acquisition (if any) to specific orthopedic practices. Medicare claims data for 2006-2010 was obtained for providers in orthopedic practices acquiring onsite MRI capacity and in matched orthopedic practices without an onsite MRI over the same period of time. Multivariate regression was used to estimate the change in provider Medicare MRI volume one year before and one year after the onsite MRI acquisition year for providers in MRI practices compared to providers in propensity-score matched non-MRI practices. RESULTS: In all of the MRI volume change models estimated, the association between onsite MRI acquisition and the change in provider Medicare MRI volume (one-year post-onsite-MRI-acquisition less one year pre-acquisition) was consistently small and not statistically significant. This lack of association was robust to changes in model specification in terms of types of MRI exams considered, specific covariates included in the multivariate model, or the process used to confirm individual provider affiliation with study practices in study years. CONCLUSIONS: Our analysis of Medicare claims data provides no empirical support for the proposition that acquisition of onsite MRI capacity within an orthopedic surgery practice induces an increase in the rate of MRI use for Medicare patients among practice providers, relative to physicians in practices without MRI capacity over the same time period.