Analysis of the economic burden of docusate sodium at a United States tertiary care center.

OBJECTIVES: The primary objective was to determine the financial resources allocated to docusate at a representative U.S. tertiary care center. Secondary objectives included comparing docusate utilization between two tertiary care centers, and exploring alternative uses for the funds spent on docusate. METHODS: The study population included all patients 18 years and older admitted to University Hospital in Newark, New Jersey. Every scheduled docusate prescription for the study population between January 1st, 2015 and December 31st, 2019 was collected. The annual total cost associated with docusate use per year was calculated. The 2015 data from this study and a 2015 McGill University Health Centre study were compared. Also, alternative uses for the money utilized on docusate were assessed. RESULTS: Over the study period, 37,034 docusate prescriptions and 265,123 docusate doses were recorded. The average cost of prescribing docusate was $25,624.14 per year and $49.37 per hospital bed per year. A comparison between the 2015 data of University Hospital and McGill showed that McGill prescribed 107 doses and spent $10.09 more per hospital bed than University Hospital. Finally, alternative uses for the average yearly spending on docusate equated to 0.35 the salary of a nurse, 0.51 the salary of a secretary, 20.66 colonoscopies, 27.00 upper endoscopies, 186.71 mammograms, 1,399.37 doses of polyethylene glycol 3350, 3,826.57 doses of lactulose, or 4,583.80 doses of psyllium. CONCLUSION: A single average size tertiary care hospital spent about $25,000 yearly on docusate despite its lack of clinical effectiveness. While this amount is small compared to an overall hospital budget, when considering likely comparable docusate use at the U.S's 6,090 hospitals, the economic burden of docusate becomes significant. The funds currently being used on docusate could be redirected to alternative, more cost-effective purposes.

Cost-effectiveness analysis of an active 30-day surgical site infection surveillance at a tertiary hospital in Ghana: evidence from HAI-Ghana study.

OBJECTIVE: To assess the cost-effectiveness of an active 30-day surgical site infection (SSI) surveillance mechanism at a referral teaching hospital in Ghana using data from healthcare-associated infection Ghana (HAI-Ghana) study. DESIGN: Before and during intervention study using economic evaluation model to assess the cost-effectiveness of an active 30-day SSI surveillance at a teaching hospital. The intervention involves daily inspection of surgical wound area for 30-day postsurgery with quarterly feedback provided to surgeons. Discharged patients were followed up by phone call on postoperative days 3, 15 and 30 using a recommended surgical wound healing postdischarge questionnaire. SETTING: Korle-Bu Teaching Hospital (KBTH), Ghana. PARTICIPANTS: All prospective patients who underwent surgical procedures at the general surgical unit of the KBTH. MAIN OUTCOME MEASURES: The primary outcome measures were the avoidable SSI morbidity risk and the associated costs from patient and provider perspectives. We also reported three indicators of SSI severity, that is, length of hospital stay (LOS), number of outpatient visits and laboratory tests. The analysis was performed in STATA V.14 and Microsoft Excel. RESULTS: Before-intervention SSI risk was 13.9% (62/446) as opposed to during-intervention 8.4% (49/582), equivalent to a risk difference of 5.5% (95% CI 5.3 to 5.9). SSI mortality risk decreased by 33.3% during the intervention while SSI-attributable LOS decreased by 32.6%. Furthermore, the mean SSI-attributable patient direct and indirect medical cost declined by 12.1% during intervention while the hospital costs reduced by 19.1%. The intervention led to an estimated incremental cost-effectiveness ratio of US$4196 savings per SSI episode avoided. At a national scale, this could be equivalent to a US$60 162 248 cost advantage annually. CONCLUSION: The intervention is a simple, cost-effective, sustainable and adaptable strategy that may interest policymakers and health institutions interested in reducing SSI.

Sustainable Laboratory-Driven Method to Decrease Repeat, Same-Day WBC Differentials at a Tertiary Care Center.

OBJECTIVES: A CBC with WBC differential is often ordered when a CBC alone would be sufficient for patient care. Performing unnecessary WBC differentials adds to costs in the laboratory. Our objective was to implement a laboratory middleware algorithm to cancel repeat, same-day WBC differentials to achieve lasting improvements in laboratory resource allocation. METHODS: Repeat same-day WBC differentials were first canceled only on intensive care unit samples; after a successful trial period, the algorithm was applied hospital-wide. We retrospectively reviewed CBC with differential orders from pre- and postimplementation periods to estimate the reduction in WBC differentials and potential cost savings. RESULTS: The algorithm led to a monthly WBC differential cancellation rate of 5.40% for a total of 10,195 canceled WBC differentials during the cumulative postimplementation period (September 25, 2019, to December 31, 2020). Nearly all (99.94%) differentials remained canceled. Most patients only had one WBC differential canceled (range, 1-38). Savings estimates showed savings of $0.99 CAD per canceled differential and 1,060 minutes (17.7 hours) of technologist time. CONCLUSIONS: A middleware algorithm to cancel repeat, same-day WBC differentials is a simple and sustainable way to achieve lasting improvements in laboratory utilization.

Three months in a high-volume tertiary orthopaedic trauma unit: What is a registrar worth?

BACKGROUND: South Africa has a high burden of traumatic injuries that is predominantly managed in the public healthcare system, despite the relative disparity in human resources between the public and private sectors. Because of budget and theatre time constraints, the trauma waiting list often exceeds 50 - 60 patients who need urgent and emergent surgery in high-volume orthopaedic trauma centres. This situation is exacerbated by other surgical disciplines using orthopaedic theatre time for life-threatening injuries because of lack of own theatre availability. One of the proposed solutions to this problem is outsourcing of some of the cases to private medical facilities. OBJECTIVES: To establish the volume of work done by an orthopaedic registrar during a 3-month trauma rotation, and to calculate the implant and theatre costs, as well as compare the salary of a registrar with the theoretical private surgeon fees for procedures performed by the registrar in the 3-month period. METHODS: In a retrospective study, the surgical logbook of a single registrar during a 3-month rotation, from 14 January to 14 April 2019, was reviewed. Surgeon fees were calculated for these procedures, according to current medical aid rates, without additional modifier codes being added. RESULTS: During the 3-month study period, a total of 157 surgical procedures was performed, ranging from total hip arthroplasty to debridement of septic hands. Surgeon fees amounted to ZAR186 565.10 per month ‒ double the gross salary of a registrar. Total implant costs amounted to ZAR1 272 667. Theatre costs were ZAR1 301 976 for the 3-month period. CONCLUSIONS: Although this analysis was conducted over a short period, it highlights the significant amount of trauma work done by a single individual at a high-volume tertiary orthopaedic trauma unit. With increasing budget constraints, pressure on theatre time and a growing population, cost-effective expansion of resources is needed. From this study, it appears that increasing capacity in the state sector could be cheaper than private outsourcing, although a more in-depth analysis needs to be conducted.

Assessment of hospitalization costs and its determinants in infants with clinical severe infection at a public tertiary hospital in Nepal.

Sepsis, an important and preventable cause of death in the newborn, is associated with high out of pocket hospitalization costs for the parents/guardians. The government of Nepal's Free Newborn Care (FNC) service that covers hospitalization costs has set a maximum limit of Nepalese rupees (NPR) 8000 i.e. USD 73.5, the basis of which is unclear. We aimed to estimate the costs of treatment in neonates and young infants fulfilling clinical criteria for sepsis, defined as clinical severe infection (CSI) to identify determinants of increased cost. This study assessed costs for treatment of 206 infants 3-59 days old, enrolled in a clinical trial, and admitted to the Kanti Children's Hospital in Nepal through June 2017 to December 2018. Total costs were derived as the sum of direct costs for bed charges, investigations, and medicines and indirect costs calculated by using work time loss of parents. We estimated treatment costs for CSI, the proportion exceeding NPR 8000 and performed multivariable linear regression to identify determinants of high cost. Of the 206 infants, 138 (67%) were neonates (3-28 days). The median (IQR) direct costs for treatment of CSI in neonates and young infants (29-59 days) were USD 111.7 (69.8-155.5) and 65.17 (43.4-98.5) respectively. The direct costs exceeded NPR 8000 (USD 73.5) in 69% of neonates with CSI. Age <29 days, moderate malnutrition, presence of any sign of critical illness and documented treatment failure were found to be important determinants of high costs for treatment of CSI. According to this study, the average treatment cost for a newborn with CSI in a public tertiary level hospital is substantial. The maximum limit offered for free newborn care in public hospitals needs to be revised for better acceptance and successful implementation of the FNC service to avert catastrophic health expenditures in developing countries like Nepal. Trial Registration: CTRI/2017/02/007966 (Registered on: 27/02/2017).

Comparative study between admission, orthopaedic surgery, and economic trends during Covid-19 and non-Covid-19 pandemic in an Italian tertiary hospital: a retrospective review.

BACKGROUND: The COVID-19 pandemic represents one of the most massive health emergencies in the last century and has caused millions of deaths worldwide and a massive economic and social burden. The aim of this study was to evaluate how the COVID-19 pandemic-during the Italian lockdown period between 8 March and 4 May 2020-influenced orthopaedic access for traumatic events to the Emergency Department (ER). METHODS: A retrospective review of the admission to the emergency room and the discharge of the trauma patients' records was performed during the period between 8 March and 4 May 2020 (block in Italy), compared to the same period of the previous year (2019). Patients accesses, admissions, days of hospitalisation, frequency, fracture site, number and type of surgery, the time between admission and surgery, days of hospitalisation, and treatment cost according to the diagnosis-related group were collected. Chi-Square and ANOVA test were used to compare the groups. RESULTS: No significant statistical difference was found for the number of emergency room visits and orthopaedic hospitalisations (p < 0.53) between the year 2019 (9.5%) and 2020 (10.81%). The total number of surgeries in 2019 was 119, while in 2020, this was just 48 (p < 0.48). A significant decrease in the mean cost of orthopaedic hospitalisations was detected in 2020 compared (261.431 euros, equal to - 52.07%) relative to the same period in 2019 (p = 0.005). Although all the surgical performances have suffered a major decline, the most frequent surgery in 2020 was intramedullary femoral nailing. CONCLUSION: We detected a decrease in traumatic occasions during the lockdown period, with a decrease in fractures in each district and a consequent decrease in the diagnosis-related group (DRG).

A single center experience with publicly funded clinical exome sequencing for neurodevelopmental disorders or multiple congenital anomalies.

Exome sequencing (ES) is an important diagnostic tool for individuals with neurodevelopmental disorders (NDD) and/or multiple congenital anomalies (MCA). However, the cost of ES limits the test's accessibility for many patients. We evaluated the yield of publicly funded clinical ES, performed at a tertiary center in Israel, over a 3-year period (2018-2020). Probands presented with (1) moderate-to-profound global developmental delay (GDD)/intellectual disability (ID); or (2) mild GDD/ID with epilepsy or congenital anomaly; and/or (3) MCA. Subjects with normal chromosomal microarray analysis who met inclusion criteria were included, totaling 280 consecutive cases. Trio ES (proband and parents) was the default option. In 252 cases (90.0%), indication of NDD was noted. Most probands were males (62.9%), and their mean age at ES submission was 9.3 years (range 1 month to 51 years). Molecular diagnosis was reached in 109 probands (38.9%), mainly due to de novo variants (91/109, 83.5%). Disease-causing variants were identified in 92 genes, 15 of which were implicated in more than a single case. Male sex, families with multiple-affected members and premature birth were significantly associated with lower ES yield (p < 0.05). Other factors, including MCA and coexistence of epilepsy, autism spectrum disorder, microcephaly or abnormal brain magnetic resonance imaging findings, were not associated with the yield. To conclude, our findings support the utility of clinical ES in a real-world setting, as part of a publicly funded genetic workup for individuals with GDD/ID and/or MCA.

Introducing day case thyroid lobectomy at a tertiary head and neck centre.

BACKGROUND: Thyroid lobectomy is considered to be a safe day case procedure by the British Association of Day Surgery. However, currently only 5.5% of thyroid surgeries in the UK are undertaken as day cases. We determine if and how thyroid lobectomy with same-day discharge could safely be introduced in our centre. METHODS: We analysed all thyroid lobectomy surgeries performed between April 2015 and May 2019. Exclusion criteria included completion surgery, revision surgery, additional procedures and disseminated disease. Outcomes were benchmarked against surgeon-reported complications from the British Association of Endocrine and Thyroid Surgery's 5th National Audit. Additionally, we reviewed the number of patients who met day case criteria currently in use at our hospital to determine accessibility to the service. RESULTS: In total, 259 thyroid lobectomy surgeries were undertaken and of these 173 met the inclusion criteria. There was no mortality, return to theatre for evacuation of postoperative haematoma or readmission. There was one postoperative haematoma which was drained at the bedside. Some 47 of the 173 (27.2%) patients met day case criteria currently in use at our centre. CONCLUSIONS: Day case surgery provides a cost-effective solution to rising bed pressures and a coherent protocol can optimise patient safety and experience.

A virtual multi-disciplinary meeting is a cost-effective method of triaging referrals to a regional musculoskeletal oncology service.

BACKGROUND AND AIMS: In 2010, a virtual sarcoma referral model was implemented, which aims to provide a centralised multidisciplinary team (MDT) to provide rapid advice, avoiding unnecessary appointments and providing a streamlined service. The aim of this study is to examine the feasibility of this screening tool in reducing the service burden and expediting patient journey. METHODS AND RESULTS: All referrals made to a single tertiary referral sarcoma unit from January 2010 to December 2018 were extracted from a prospective database. Only 26.0% events discussed required review directly. 30.3% were discharged back to referrer. 16.5% required further investigations. 22.5% required a biopsy prior to review. There was a reduction in the rate of patients reviewed at the sarcoma clinic, and a higher discharge rate from the MDT in 2018 versus 2010 (p < 0.001). This gives a potential cost saving of 670,700 GBP over the 9 year period. CONCLUSION: An MDT meeting which triages referrals is cost-effective at reducing unnecessary referrals. This can limit unnecessary exposure of patients who may have an underlying diagnosis of cancer to a high-risk environment, and reduces burden on services as it copes with increasing demands during the COVID-19 pandemic.

Gynecologic oncology treatment modifications or delays in response to the COVID-19 pandemic in a publicly funded versus privately funded North American tertiary cancer center.

OBJECTIVE: To compare gynecologic oncology surgical treatment modifications and delays during the first wave of the COVID-19 pandemic between a publicly funded Canadian versus a privately funded American cancer center. METHODS: This is a retrospective cohort study of all planned gynecologic oncology surgeries at University Health Network (UHN) in Toronto, Canada and Brigham and Women's Hospital (BWH) in Boston, USA, between March 22,020 and July 302,020. Surgical treatment delays and modifications at both centers were compared to standard recommendations. Multivariable logistic regression was performed to adjust for confounders. RESULTS: A total of 450 surgical gynecologic oncology patients were included; 215 at UHN and 235 at BWH. There was a significant difference in median time from decision-to-treat to treatment (23 vs 15 days, p < 0.01) between UHN and BWH and a significant difference in treatment delays (32.56% vs 18.29%; p < 0.01) and modifications (8.37% vs 0.85%; p < 0.01), respectively. On multivariable analysis adjusting for age, race, treatment site and surgical priority status, treatment at UHN was an independent predictor of treatment modification (OR = 9.43,95% CI 1.81-49.05, p < 0.01). Treatment delays were higher at UHN (OR = 1.96,95% CI 1.14-3.36 p = 0.03) and for uterine disease (OR = 2.43, 95% CI 1.11-5.33, p = 0.03). CONCLUSION: During the first wave of COVID-19 pandemic, gynecologic oncology patients treated at a publicly funded Canadian center were 9.43 times more likely to have a surgical treatment modification and 1.96 times more likely to have a surgical delay compared to an equal volume privately funded center in the United States.

Provider cost of treating oral potentially malignant disorders and oral cancer in Malaysian public hospitals.

Oral cancer has been recognized as a significant challenge to healthcare. In Malaysia, numerous patients frequently present with later stages of cancers to the highly subsidized public healthcare facilities. Such a trend contributes to a substantial social and economic burden. This study aims to determine the cost of treating oral potentially malignant disorders (OPMD) and oral cancer from a public healthcare provider's perspective. Medical records from two tertiary public hospitals were systematically abstracted to identify events and resources consumed retrospectively from August 2019 to January 2020. The cost accrued was used to estimate annual initial and maintenance costs via two different methods- inverse probability weighting (IPW) and unweighted average. A total of 86 OPMD and 148 oral cancer cases were included. The initial phase mean unadjusted cost was USD 2,861 (SD = 2,548) in OPMD and USD 38,762 (SD = 12,770) for the treatment of cancer. Further annual estimate of initial phase cost based on IPW method for OPMD, early and late-stage cancer was USD 3,561 (SD = 4,154), USD 32,530 (SD = 12,658) and USD 44,304 (SD = 16,240) respectively. Overall cost of late-stage cancer was significantly higher than early-stage by USD 11,740; 95% CI [6,853 to 16,695]; p< 0.001. Higher surgical care and personnel cost predominantly contributed to the larger expenditure. In contrast, no significant difference was identified between both cancer stages in the maintenance phase, USD 700; 95% CI [-1,142 to 2,541]; p = 0.457. A crude comparison of IPW estimate with unweighted average displayed a significant difference in the initial phase, with the latter being continuously higher across all groups. IPW method was shown to be able to use data more efficiently by adjusting cost according to survival and follow-up. While cost is not a primary consideration in treatment recommendations, our analysis demonstrates the potential economic benefit of investing in preventive medicine and early detection.

Research on the economic loss of hospital-acquired pneumonia caused by Klebsiella pneumonia base on propensity score matching.

BACKGROUND: Hospital-acquired pneumonia (HAP) caused by Klebsiella pneumonia (KP) is a common nosocomial infection (NI). However, the reports on the economic burden of hospital-acquired pneumonia caused by Klebsiella pneumonia (KP-HAP) were scarce. The study aims to study the direct economic loss caused by KP-HAP with the method of propensity score matching (PSM) to provide a basis for the cost accounting of NI and provide references for the formulation of infection control measures. METHODS: A retrospective investigation was conducted on the hospitalization information of all patients discharged from a tertiary group hospital in Shenzhen, Guangdong province, China, from June 2016 to August 2019. According to the inclusion and exclusion criteria, patients were divided into the HAP group and noninfection group, the extended-spectrum beta-lactamases (ESBLs) positive KP infection group, and the ESBLs-negative KP infection group. After the baselines of each group were balanced with the PSM, length of stay (LOS) and hospital cost of each group were compared. RESULTS: After the PSM, there were no differences in the baselines of each group. Compared with the noninfection group, the median LOS in the KP-HAP group increased by 15 days (2.14 times), and the median hospital costs increased by 7329 yuan (0.89 times). Compared with the ESBLs-negative KP-HAP group, the median LOS in the ESBLs-positive KP-HAP group increased by 7.5 days (0.39 times), and the median hospital costs increased by 22,424 yuan (1.90 times). CONCLUSION: KP-HAP prolonged LOS and increased hospital costs, and HAP caused by ESBLs-positive KP had more economic losses than ESBLs-negative, which deserves our attention and should be controlled by practical measures.

Care Fragmentation and Mortality in Readmission after Surgery for Hepatopancreatobiliary and Gastric Cancer: A Patient-Level and Hospital-Level Analysis of the Healthcare Cost and Utilization Project Administrative Database.

BACKGROUND: Hepatopancreatobiliary (HPB) and gastric oncologic operations are frequently performed at referral centers. Postoperatively, many patients experience care fragmentation, including readmission to "outside hospitals" (OSH), which is associated with increased mortality. Little is known about patient-level and hospital-level variables associated with this mortality difference. STUDY DESIGN: Patients undergoing HPB or gastric oncologic surgery were identified from select states within the Healthcare Cost and Utilization Project database (2006-2014). Follow-up was 90 days after discharge. Analyses used Kruskal-Wallis test, Youden index, and multilevel modeling at the hospital level. RESULTS: There were 7,536 patients readmitted within 90 days of HPB or gastric oncologic surgery to 636 hospitals; 28% of readmissions (n = 2,123) were to an OSH, where 90-day readmission mortality was significantly higher: 8.0% vs 5.4% (p < 0.01). Patients readmitted to an OSH lived farther from the index surgical hospital (median 24 miles vs 10 miles; p < 0.01) and were readmitted later (median 25 days after discharge vs 12; p < 0.01). These variables were not associated with readmission mortality. Surgical complications managed at an OSH were associated with greater readmission mortality: 8.4% vs 5.7% (p < 0.01). Hospitals with <100 annual HPB and gastric operations for benign or malignant indications had higher readmission mortality (6.4% vs 4.7%, p = 0.01), although this was not significant after risk-adjustment (p = 0.226). CONCLUSIONS: For readmissions after HPB and gastric oncologic surgery, travel distance and timing are major determinants of care fragmentation. However, these variables are not associated with mortality, nor is annual hospital surgical volume after risk-adjustment. This information could be used to determine safe sites of care for readmissions after HPB and gastric surgery. Further analysis is needed to explore the relationship between complications, the site of care, and readmission mortality.

A Surgeon Badge or Text Message Sign-in Intervention Improves Operating Room Start Efficiency.

BACKGROUND: Operating room (OR) efficiency, often measured by first case on-time start (FCOTS) percentage, is an important driver of perioperative team morale and the financial success of a hospital. MATERIALS AND METHODS: In this quasi-experimental study of elective surgical procedures at a single tertiary academic hospital, an intervention requiring attending surgeon attestation of availability via SMS text message or identification badge swipe was implemented. Key measures of OR efficiency were compared before and after the change. RESULTS: FCOTS percentage increased from 61.6% to 66.9% after the intervention (P = 0.01). After adjusting for patient and procedural characteristics, postintervention period remained associated with an increased odds of an on-time start (odds ratio 1.29, P = 0.01). Additionally, procedural start times from the pre- to postintervention period were significantly improved (-0.08 min/day, P = 0.009). CONCLUSIONS: Implementation of an attending surgeon text or badge sign-in process was associated with improved FCOTS percentage and earlier procedure start times.

The Impact of Socioeconomic Risk Factors on the Survival Outcomes of Patients With Newly Diagnosed Multiple Myeloma: A Cross-analysis of a Population-based Registry and a Tertiary Care Center.

BACKGROUND: Multiple myeloma (MM) is a heterogeneous clonal plasma cell disorder leading to differences in clinical outcomes such as overall survival (OS) among patients. We hypothesized that with expensive, novel therapeutic agents and paradigm shifts to maintain continuous therapy and improvement in OS, patients with MM are subject to the pressures of financial toxicity and the need for social support, which may be of prognostic importance. MATERIALS AND METHODS: In this study, we examined the records of 122,458 patients from the National Cancer Database (NCDB) to determine the significance of socioeconomic factors such as estimated annual household income and education level, which were based on the patient's ZIP Code and the United States Census Bureau's 5-year report from 2008 to 2012. These socioeconomic factors, in addition to marital status, were then assessed individually and as a cumulative socioeconomic score for prognostic significance in a cohort of 2543 patients treated at a tertiary care center utilizing known biologic risk factors, such as cytogenetic risk, International Staging System classification, and serum lactate dehydrogenase levels. RESULTS: Only marital status and estimated annual household income at diagnosis negatively impacted OS in a univariate analysis, but not in the context of a multivariable analysis incorporating known biologic risk factors. CONCLUSION: Future analyses in other academic and non-academic centers located in urban and rural regions are required to understand the socioeconomic drivers of OS disparity among patients with MM observed nationally.

Influence of Geographic Access on Surgical Center Readmissions After Index Congenital Heart Surgery.

OBJECTIVE: To assess the impact of geographic access to surgical center on readmission risk and burden in children after congenital heart surgery. STUDY DESIGN: Children <6 years old at discharge after congenital heart surgery (Risk Adjustment for Congenital Heart Surgery-1 score 2-6) were identified using Pediatric Health Information System data (46 hospitals, 2004-2015). Residential distance from the surgery center, calculated using ZIP code centroids, was categorized as <15, 15-29, 30-59, 60-119, and ≥120 miles. Rurality was defined using rural-urban commuting area codes. Geographic risk factors for unplanned readmissions to the surgical center and associated burden (total hospital length of stay [LOS], costs, and complications) were analyzed using multivariable regression. RESULTS: Among 59 696 eligible children, 19 355 (32%) had ≥1 unplanned readmission. The median LOS was 9 days (IQR 22) across the entire cohort. In those readmitted, median total costs were $31 559 (IQR $90 176). Distance from the center was inversely related but rurality was positively related to readmission risk. Among those readmitted, increased distance was associated with longer LOS, more complications, and greater costs. Compared with urban patients, highly rural patients were more likely to have an unplanned readmission but had fewer average readmission days. CONCLUSIONS: Geographic measures of access differentially affect readmission to the surgery center. Increased distance from the center was associated with fewer unplanned readmissions but more complications. Among those readmitted, the most isolated patients had the greatest readmission costs. Understanding the contribution of geographic access will aid in developing strategies to improve care delivery to this population.

Financial analysis of revision knee surgery at a tertiary referral centre as classified according to the Revision Knee Complexity Classification (RKCC).

BACKGROUND: Revision total knee arthroplasty (rTKA) can be complex, with greater costs to the treating hospital than primary TKA. A rTKA regional network has been proposed in England. The aim of this work was to accurately quantify current costs and reimbursement for the rTKA service and to assess whether costs are proportional to case complexity at a tertiary referral centre within the National Health Service (NHS). METHODS: A review of all rTKA performed at our institution over two consecutive financial years (2017-2019) was performed. Cases were classified according to the Revision Knee Complexity Classification (RKCC) and by mode of failure; "infected" and "non-infected". Financial data was acquired through Patient-Level Information and Costing System (PLICS). The primary outcome was the financial difference between tariff and cost per episode. Comparisons between groups were analysed using analysis of variance and two-tailed unpaired t-test as appropriate. RESULTS: 159 patients underwent 188 rTKA procedures. Length of stay and cost significantly increased between complexity groups (p < 0.0001) and for infected revisions (p < 0.0001). All groups sustained a mean deficit but this significantly increased with revision complexity (from £1,903 to £5,269 per case) and for infected revisions. The total deficit to the Trust for the two-year rTKA service was £667,091. CONCLUSIONS: The current level of NHS reimbursement are inadequate for centres that offer rTKA and should be more closely aligned to case complexity. An increase in the most complex rTKA at major revision centres will undoubtedly place an even greater strain on the finances of these units.

Financial implications of coronavirus disease 2019 on a tertiary academic vascular surgery practice.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has had an unprecedented impact on the healthcare system in the United States. The redistribution of resources and suspension of elective procedures and other services has resulted in financial stress across all service lines. The financial effects on the practice of vascular surgery have not yet been quantified. We hypothesized that vascular surgery divisions have experienced losses affecting the hospital and professional sides that will not be recoupable without significant productivity increases. METHODS: Administrative claims data for clinical services performed by the vascular surgery division at a tertiary medical center for March and April 2019 and for March and April 2020 were analyzed. These claims were separated into two categories: hospital claims (inpatient and outpatient) and professional claims (professional reimbursement for all services provided). Medicare reimbursement methods were used to assign financial value: diagnosis-related group for inpatient services, ambulatory payment classification for outpatient services, and the Medicare physician fee schedule for professional reimbursement and work relative value units (wRVUs). Reimbursements and productivity (wRVUs) were compared between the two periods. A financial model was created to determine the increase in future productivity over baseline required to mitigate the losses incurred during the pandemic. RESULTS: A total of 11,317 vascular surgery claims were reviewed. Hospital reimbursement during the pandemic decreased from $4,982,114 to $2,649,521 (-47%) overall (inpatient, from $3,505,775 to $2,128,133 [-39%]; outpatient, from $1,476,339 to $521,388 [-65%]) and professional reimbursement decreased from $933,897 to $430,967 (-54%) compared with the same period in 2019. Professional productivity as measured by wRVUs sustained a similar decline from 10,478 wRVUs to 5386 wRVUs (-51%). Modeling sensitivity analyses demonstrated that if a vascular division were able to increase inpatient and outpatient revenue to greater than prepandemic levels by 10%, 5%, or 3%, it would take 9, 19, or 31 months, respectively, for the hospital to recover their pandemic-associated losses. Similarly, professional reimbursement recovery would require 11, 20, or 36 months with corresponding increases in productivity. CONCLUSIONS: The COVID-19 pandemic has had profound and lasting effects on the world in terms of lives lost and financial hardships. The financial effects on vascular surgery divisions has resulted in losses ranging from 39% to 65% compared with the prepandemic period in the previous year. Because the complete mitigation of losses is not feasible in the short term, alternative and novel strategies are needed to financially sustain the vascular division and hospital during a prolonged recovery period.

Patterns, price and predictors of successful empiric antibiotic therapy in a real-world setting.

WHAT IS KNOWN AND OBJECTIVE: Prompt and appropriate empiric antibiotic therapy (EAT) remains the cornerstone of successful outcomes, while the majority of blood cultures do not identify pathogen. We aimed to report patterns of EAT and its impact on outcomes and associated medical costs, while exploring predictors of its success in a real-world setting. METHODS: We retrospectively utilized the prospective registry of the medical unit of a tertiary university hospital, including patients admitted with diagnosis of infection between 1st May 2016 and 1st May 2018. Costs of hospitalization and unit of antibiotic regimen were retrieved from a database regarding Greek hospitals containing hospitalization-cost data for each ICD-10 code and the national formulary, respectively. RESULTS: A total of 489 patients were included in this study. Mean age was 61.3 years, 53% were males, while intra-abdominal infections predominated (55%). The most commonly administered EAT included quinolones (48%), followed by piperacillin/tazobactam (18%), or other regimens alone or in combination. EAT was successful in 67% and failed in 33% of cases. Fourteen patients died of the infection before EAT was switched, while among 55 patients that EAT had to be modified, mortality was 22%. Presence of urinary tract infection and use of quinolones, least predicted for failure of EAT [OR:0.15 (0.07-0.35), p < 0.0001, OR:0.53 (0.32-0.90), p = 0.019, respectively], in contrast to presence of sepsis [OR:3.11 (1.79-5.40), p < 0.0001]. Patients with failure had longer length of stay [7(5-11) versus 4 (3-6) days], higher antibiotic [201.9 (97.8-471.8) vs 104.6 (60.2-187.7) euros] and hospitalization costs [1409.3 (945.4-2311.6) vs 759.4 (516.5-1036.5) euros] (p < 0.0001). DISCUSSION: We observed significantly increased antibiotic-related, healthcare-related costs and length of stay in patients with failure of EAT. Moreover, in our cohort, absence of sepsis, presence of urinary tract infection and use of quinolones better predicted for success of EAT. WHAT IS NEW AND CONCLUSIONS: Appropriate selection of EAT is crucial to ensure better outcomes and minimize costs.

Comorbid Dysphagia and Malnutrition in Elderly Hospitalized Patients.

OBJECTIVE/HYPOTHESIS: Elderly individuals account for one-third of all hospitalizations. The goal of this study was to evaluate the prevalence of dysphagia in elderly patients admitted to a tertiary care center. It also sought to investigate how dysphagia is identified, how it covaries with malnutrition and other conditions, and how it impacts hospital stay. STUDY DESIGN: Case Series. METHODS: A retrospective chart review was performed. All patients >65 years admitted to a tertiary care center in January and February 2016 were included. Patients with primary psychiatric diagnoses and patients with upper aerodigestive tract malignancy or surgery were excluded. RESULTS: A total of 655 patients were identified. Mean age was 76.6 years. Twenty-four percent (155 patients) had dysphagia while 43% (282 patients) had malnutrition. Thirteen percent (84 patients) had both dysphagia and malnutrition. Fifty percent of patients who had malnutrition were seen by speech language pathology (SLP). One hundred percent of malnourished patients that saw SLP were identified as having dysphagia. Three hundred and eighty-two patients (58%) were seen by the dietician but not by SLP. Multiple logistic regression indicated that the presence of dysphagia was positively associated with age, presence of malnutrition, admission to either cardiology or neurology service as compared to medicine service, and history of stroke. CONCLUSIONS: One-quarter of elderly patients admitted to our tertiary care center had dysphagia. Dysphagia, especially when linked with malnutrition, has poorer outcomes and increased healthcare costs. Our data suggests a possible disconnect between malnutrition diagnosis and dysphagia identification. This is an important area of intervention that has the potential to improve the treatment and outcomes of these patients. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:2441-2447, 2021.