Hospitalization costs of injury in elderly population in China: a quantile regression analysis.

BACKGROUND: Trauma in the elderly is gradually growing more prevalent as the aging population increases over time. The purpose of this study is to assess hospitalization costs of the elderly trauma population and analyze the association between those costs and the features of the elderly trauma population. METHODS: In a retrospective analysis, data on trauma patients over 65 who were admitted to the hospital for the first time due to trauma between January 2017 and March 2022 was collected from a tertiary comprehensive hospital in Baotou. We calculated and analyzed the hospitalization cost components. According to various therapeutic approaches, trauma patients were divided into two subgroups: non-surgical patients (1320 cases) and surgical patients (387 cases). Quantile regression was used to evaluate the relationship between trauma patients and hospitalization costs. RESULTS: This study comprised 1707 trauma patients in total. Mean total hospitalization costs per patient were ¥20,741. Patients with transportation accidents incurred the highest expenditures among those with external causes of trauma, with a mean hospitalization cost of ¥24,918, followed by patients with falls at ¥19,809 on average. Hospitalization costs were dominated by medicine costs (¥7,182 per capita). According to the quantile regression results, all trauma patients' hospitalization costs were considerably increased by length of stay, surgery, the injury severity score (16-24), multimorbidity, thorax injury, and blood transfusion. For non-surgical patients, length of stay, multimorbidity, and the injury severity score (16-24) were all substantially linked to higher hospitalization costs. For surgical patients, length of stay, injury severity score (16-24), and hip and thigh injuries were significantly associated with greater hospitalization costs. CONCLUSIONS: Using quantile regression to identify factors associated with hospitalization costs could be helpful for addressing the burden of injury in the elderly population. Policymakers may find these findings to be insightful in lowering hospitalization costs related to injury in the elderly population.

Association of Hospital Participation in Bundled Payments for Care Improvement Advanced With Medicare Spending and Hospital Incentive Payments.

Importance: Bundled Payments for Care Improvement Advanced (BPCI-A) is a Centers for Medicare & Medicaid Services (CMS) initiative that aims to produce financial savings by incentivizing decreases in clinical spending. Incentives consist of financial bonuses from CMS to hospitals or penalties paid by hospitals to CMS. Objective: To investigate the association of hospital participation in BPCI-A with spending, and to characterize hospitals receiving financial bonuses vs penalties. Design, Setting, and Participants: Difference-in-differences and cross-sectional analyses of 4 754 139 patient episodes using 2013-2019 US Medicare claims at 694 participating and 2852 nonparticipating hospitals merged with hospital and market characteristics. Exposures: BPCI-A model years 1 and 2 (October 1, 2018, through December 31, 2019). Main Outcomes and Measures: Hospitals' per-episode spending, CMS gross and net spending, and the incentive allocated to each hospital. Results: The study identified 694 participating hospitals. The analysis observed a -$175 change in mean per-episode spending (95% CI, -$378 to $28) and an aggregate spending change of -$75.1 million (95% CI, -$162.1 million to $12.0 million) across the 428 670 episodes in BPCI-A model years 1 and 2. However, CMS disbursed $354.3 million (95% CI, $212.0 million to $496.0 million) more in bonuses than it received in penalties. Hospital participation in BPCI-A was associated with a net loss to CMS of $279.2 million (95% CI, $135.0 million to $423.0 million). Hospitals in the lowest quartile of Medicaid days received a mean penalty of $0.41 million; (95% CI, $0.09 million to $0.72 million), while those in the highest quartile received a mean bonus of $1.57 million; (95% CI, $1.09 million to $2.08 million). Similar patterns were observed for hospitals across increasing quartiles of Disproportionate Share Hospital percentage and of patients from racial and ethnic minority groups. Conclusions and Relevance: Among US hospitals measured between 2013 and 2019, participation in BPCI-A was significantly associated with an increase in net CMS spending. Bonuses accrued disproportionately to hospitals providing care for marginalized communities.

Cost Differences Between Teaching and Nonteaching Hospitals for Older Adults Requiring Emergency General Surgery Procedures in the State of Maryland.

BACKGROUND: Older adults (OAs; ≥ 65 years) comprise a growing population in the United States and are anticipated to require an increasing number of emergency general surgery procedures (EGSPs). The aims of this study were to identify the frequency of EGSPs and compare cost of care in OAs managed at teaching hospitals (THs) vs nonteaching hospitals (NTHs). METHODS: A retrospective review of data from the Maryland Health Services Cost Review Commission database from 2009 to 2018 for OAs undergoing EGSPs was undertaken. Data collected included demographics, all patient-refined (APR)-severity of illness (SOI), APR-risk of mortality (ROM), Charlson Comorbidity Index (CCI), EGSPs (partial colectomy (PC), small bowel resection, cholecystectomy, operative management of peptic ulcers, lysis of adhesions, appendectomy, and laparotomy, categorized hospital charges, length of stay (LOS), and mortality. RESULTS: Of the 55,401 OAs undergoing EGSPs in this study, 28,575 (51.6%) were treated at THs and 26,826 (48.4%) at NTHs. OAs at THs presented with greater APR-ROM (major 25.6% vs 24.9%, extreme 22.6% vs 22.0%, P=.01), and CCI (3.1±3 vs 2.7±2.8, P<.001) compared to NTHs. Lysis of adhesions, cholecystectomy, and PC comprised the overall most common EGSPs. Older adults at THs incurred comparatively higher median hospital charges for every EGSP due to increased room charges and LOS. Mortality was higher at THs (6.13% vs 5.33%, P<.001). CONCLUSION: While acuity of illness appears similar, cost of undergoing EGSPs for OAs is higher in THs vs NTHs due to increased LOS. Future work is warranted to determine and mitigate factors that increase LOS at THs.

Identification and assessment of a comprehensive set of structural factors associated with hospital costs in Switzerland.

Structural factors can influence hospital costs beyond case-mix differences. However, accepted measures on how to distinguish hospitals with regard to cost-related organizational and regional differences are lacking in Switzerland. Therefore, the objective of this study was to identify and assess a comprehensive set of hospital attributes in relation to average case-mix adjusted costs of hospitals. Using detailed hospital and patient-level data enriched with regional information, we derived a list of 23 cost predictors, examined how they are associated with costs, each other, and with different hospital types, and identified principal components within them. Our results showed that attributes describing size, complexity, and teaching-intensity of hospitals (number of beds, discharges, departments, and rate of residents) were positively related to costs and showed the largest values in university (i.e., academic teaching) and central general hospitals. Attributes related to rarity and financial risk of patient mix (ratio of rare DRGs, ratio of children, and expected loss potential based on DRG mix) were positively associated with costs and showed the largest values in children's and university hospitals. Attributes characterizing the provision of essential healthcare functions in the service area (ratio of emergency/ ambulance admissions, admissions during weekends/ nights, and admissions from nursing homes) were positively related to costs and showed the largest values in central and regional general hospitals. Regional attributes describing the location of hospitals in large agglomerations (in contrast to smaller agglomerations and rural areas) were positively associated with costs and showed the largest values in university hospitals. Furthermore, the four principal components identified within the hospital attributes fully explained the observed cost variations across different hospital types. These uncovered relationships may serve as a foundation for objectifying discussions about cost-related heterogeneity in Swiss hospitals and support policymakers to include structural characteristics into cost benchmarking and hospital reimbursement.

Effect of influenza vaccination on the outcomes of hospitalization for kidney disease in a geriatric population: A propensity-score matched study.

BACKGROUND AND AIMS: The effects of influenza vaccination (IV) on the outcomes of patients with kidney disease (KD) are not completely understood. We aimed to evaluate and compare the outcomes during admission of KD between elderly patients who did or did not receive an IV within the previous 12 months. METHODS: We used health insurance research data in Taiwan and conducted a population-based cohort study that included 22,590 older people aged ≥ 65 years who were hospitalized for KD in 2008-2013. We performed propensity score matching (case-control ratio 1:1) to select 4386 eligible IV recipients and 4386 nonrecipient controls for comparison. The adjusted odds ratios (ORs) with 95% confidence intervals (CIs) of IV associated with complications and mortality during KD admission were calculated using multivariable logistic regression analyses. RESULTS: During hospitalization for KD, IV was significantly associated with lower risks of 30-day in-hospital mortality (OR 0.56, 95% CI 0.39-0.82), septicemia (OR 0.77, 95% CI 0.68-0.87), and intensive care (OR 0.85, 95% CI 0.75-0.96). Additionally, IV recipients had a shorter length of hospital stay and lower medical expenditure than nonrecipients. Subgroup analyses further showed that the association of IV with reduced adverse events was confined to patients aged ≥ 75 years. CONCLUSIONS: Previous IV was associated with reduced risks of complications and mortality and in elderly patients hospitalized for KD. We raised the possibility and suggested the need to promote IV for this susceptible population of patients with KD.

Pediatric Traumatic Injury Emergency Department Visits and Management in US Children's Hospitals From 2010 to 2019.

STUDY OBJECTIVE: To examine trends in trauma-related pediatric emergency department (ED) visits and management in US children's hospitals over 10 years. METHODS: This is a retrospective, descriptive study of the Pediatric Health Information Systems database, including encounters from 33 US children's hospitals. We included patients aged 0 to 19 years with traumatic injuries from 2010 to 2019 identified using International Classification of Diseases-9 and -10 codes. The primary outcome was prevalence of trauma-related ED visits. The secondary outcomes included ED disposition, advanced imaging use, and trauma care costs. We examined trends over time with Poisson regression models, reporting incidence rate ratios (IRRs) with 95% confidence intervals (CIs). We compared demographic groups with rate differences with 95% CIs. RESULTS: Trauma-related visits accounted for 367,072 ED visits (16.3%) in 2010 and 479,458 ED visits (18.1%) in 2019 (IRR 1.022, 95% CI 1.018 to 1.026). From 2010 to 2019, 54.6% of children with traumatic injuries belonged to White race and 23.9% had Hispanic ethnicity. Institutional hospitalization rates (range 3.8% to 14.9%) decreased over time (IRR 0.986, 95% CI 0.977 to 0.994). Hospitalizations from 2010 to 2019 were higher in White children (8.9%) than in children of other races (6.4%) (rate difference 2.56, 95% CI 2.51 to 2.61). Magnetic resonance imaging for brain (IRR 1.05, 95% CI 1.04 to 1.07) and cervical spine (IRR 1.03, 95% CI 1.02 to 1.05) evaluation increased. The total trauma care costs were $6.7 billion, with median costs decreasing over time. CONCLUSION: During the study period, pediatric ED visits for traumatic injuries increased, whereas hospitalizations decreased. Some advanced imaging use increased; however, median trauma costs decreased over time.

Costs of Joint Replacement in Osteoarthritis: A Study Using the National Joint Registry and Clinical Practice Research Datalink Data Sets.

OBJECTIVE: To estimate the costs of primary hip and knee replacement in individuals with osteoarthritis up to 2 years postsurgery, compare costs before and after the surgery, and identify predictors of hospital costs. METHODS: Patients age ≥18 years with primary planned hip or knee replacements and osteoarthritis in England between 2008 and 2016 were identified from the National Joint Registry and linked with Hospital Episode Statistics data containing inpatient episodes. Primary care data linked with hospital outpatient records were also used to identify patients age ≥18 years with primary hip or knee replacements between 2008 and 2016. All health care resource use was valued using 2016/2017 costs, and nonparametric censoring methods were used to estimate total 1-year and 2-year costs. RESULTS: We identified 854,866 individuals undergoing hip or knee replacement. The mean censor-adjusted 1-year hospitalization costs for hip and knee replacement were £7,827 (95% confidence interval [95% CI] 7,813, 7,842) and £7,805 (95% CI 7,790, 7,818), respectively. Complications and revisions were associated with up to a 3-fold increase in 1-year hospitalization costs. The censor-adjusted 2-year costs were £9,258 (95% CI 9,233, 9,280) and £9,452 (95% CI 9,430, 9,475) for hip and knee replacement, respectively. Adding primary and outpatient care, the mean total hip and knee replacement 2-year costs were £11,987 and £12,578, respectively. CONCLUSION: There are significant costs following joint replacement. Revisions and complications accounted for considerable costs and there is a significant incentive to identify best approaches to reduce these.

Volume of frail patients predicts outcome in frail patients after cardiac surgery.

OBJECTIVE: Recent data from major noncardiac surgery suggest that outcomes in frail patients are better predicted by a hospital's volume of frail patients specifically, rather than overall surgical volume. We sought to evaluate this "frailty volume-frailty outcome relationship" in patients undergoing cardiac surgery. METHODS: We studied 72,818 frail patients undergoing coronary artery bypass grafting or valve replacement surgery from 2010 to 2014 using the Nationwide Readmissions Database. Frailty was defined using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnoses indicator. Multilevel logistic regression was used to assess the independent effect of frailty volume by quartile on mortality, surgical complications, failure to rescue, nonhome discharge, 30-day readmissions, length of stay, and hospital costs in frail patients. RESULTS: In comparing the highest volume quartiles with the lowest, both overall cardiac surgical volume and volume for frail patients were significantly associated with shorter length of stay and reduced costs. However, frailty volume was also independently associated with significantly reduced in-hospital mortality (odds ratio, 0.79; 95% confidence interval, 0.67-0.94; P = .006) and failure to rescue (odds ratio, 0.83; 95% confidence interval, 0.70-0.98; P = .03), whereas no such association was seen between overall volume and either mortality (odds ratio, 0.94; 95% confidence interval, 0.74-1.10; P = .43) or failure to rescue (odds ratio, 0.98; 95% confidence interval, 0.83-1.17; P = .85). Neither frailty volume nor overall volume showed any significant relationship with the rate of 30-day readmissions. CONCLUSIONS: In frail patients undergoing cardiac surgery, surgical volume of frail patients was a significant independent of predictor of in-hospital mortality and failure to rescue, whereas overall surgical volume was not. Thus, the "frailty volume-outcome relationship" superseded the traditional "volume-outcome relationship" in frail patients with cardiac disease.

Procedural and 12-month in-hospital costs of primary infra-popliteal bypass surgery, infrapopliteal best endovascular treatment, and major lower limb amputation for chronic limb threatening ischemia.

OBJECTIVE: Chronic limb-threatening ischemia (CLTI) is a growing global problem due to the widespread use of tobacco and increasing prevalence of diabetes. Although the financial consequences are considerable, few studies have compared the relative cost-effectiveness of different CLTI management strategies. The Bypass vs Angioplasty in Severe Ischaemia of the Leg (BASIL)-2 trial is randomizing patients with CLTI to primary infrapopliteal (IP) vein bypass surgery (BS) or best endovascular treatment (BET) and includes a comprehensive within-trial cost-utility analysis. The aim of this study is to compare over a 12-month time horizon, the costs of primary IP BS, IP best endovascular treatment (BET), and major limb major amputation (MLLA) to inform the BASIL-2 cost-utility analysis. METHODS: We compared procedural human resource (HR) costs and total in-hospital costs for the index admission, and over the following 12-months, in 60 consecutive patients undergoing primary IP BS (n = 20), IP BET (n = 20), or MLLA (10 transfemoral and 10 transtibial) for CLTI within the BASIL prospective cohort study. RESULTS: Procedural HR costs were greatest for BS (BS £2551; 95% confidence interval [CI], £1934-£2807 vs MLLA £1130; 95% CI, £1046-£1297 vs BET £329; 95% CI, £242-£390; P < .001, Kruskal-Wallis) due to longer procedure duration and greater staff requirement. With regard to the index admission, MLLA was the most expensive due to longer hospital stay (MLLA £13,320; 95% CI, £8986-£18,616 vs BS £8714; 95% CI, £6097-£11,973 vs BET £4813; 95% CI, £3529-£6097; P < .001, Kruskal-Wallis). The total cost of the index admission and in-hospital care over the following 12 months remained least for BET (MLLA £26,327; 95% CI, £17,653-£30,458 vs BS £20,401; 95% CI, £12,071-£23,926 vs BET £12,298; 95% CI, £6961-£15,439; P < .001, Kruskal-Wallis). CONCLUSIONS: Over a 12-month time horizon, MLLA and IP BS are more expensive than IP BET in terms of procedural HR costs and total in-hospital costs. These economic data, together with quality of life data from BASIL-2, will inform the calculation of incremental cost-effectiveness ratios for different CLTI management strategies within the BASIL-2 cost-utility analysis.

Gastos com internações por condições sensíveis à atenção primária: estudo ecológico / Gastos con internaciones por condiciones sensibles en la atención primaria: estudio ecológico / Expenses with hospitalizations by sensitive conditions to the primary care: an ecological study

Resumo Objetivo Analisar os gastos com Internações por Condições Sensíveis à Atenção Primária no Estado de Minas Gerais. Métodos Estudo ecológico e retrospectivo das internações dos anos de 2014 e 2019, com dados do Sistema de Informação Hospitalar analisados por meio de estatística descritiva e teste pareado de Wilcoxon. Resultados Observou-se redução de valores gastos (-9,88%), em internações eletivas (-1,77%) e de urgência (-10,54%), nos sexos masculino e feminino e em todas as faixas etárias; com diferença significativa de valores gastos nas faixas etárias de 5 a 14 anos (p=0,005) e de 15 a 49 anos (p<0,001). Os maiores valores absolutos se deram nos grupos Angina, Insuficiência Cardíaca e Doenças Cerebrovasculares; as principais reduções ocorreram nas Doenças inflamatórias de órgãos pélvicos, Gastroenterites infecciosas e Asma. Conclusão A análise por grupos e caráter de internação das condições sensíveis possibilita a identificação de frequência e custos elevados e/ou desproporcionais, mostrando condições de maior risco e atuação dos serviços de cuidados primários em saúde no momento oportuno à demanda da população.

Resumen Objetivo Analizar los gastos con Internaciones por Condiciones Sensibles en la Atención Primaria en el Estado de Minas Gerais. Métodos Estudio ecológico y retrospectivo de las internaciones en los años de 2014 y de 2019, con datos del Sistema de Información Hospitalaria analizados por medio de estadística descriptiva y pruebas pareadas de Wilcoxon. Resultados Se observó una reducción en los montos gastados (-9,88 %), en internaciones electivas (-1,77 %) y de urgencia (-10,54 %), en los sexos masculino y femenino y en todos los grupos de edad; con una diferencia significativa en los montos gastados en los grupos de edad de los 5 a los 14 años (p=0,005) y de los 15 a los 49 años (p<0,001). Los mayores valores absolutos se dieron en los grupos Angina, Insuficiencia Cardíaca y Enfermedades Cerebrovasculares; las principales reducciones se dieron en las Enfermedades inflamatorias de órganos pélvicos, Gastroenteritis infecciosas y Asma. Conclusión El análisis por grupos y tipo de internación de las condiciones sensibles posibilita la identificación de frecuencia y elevados costos o desproporcionales, mostrando condiciones de mayor riesgo y actuación de los servicios de cuidados primarios en salud en el momento oportuno a la demanda de la población.

Abstract Objective To analyse the expenses with hospitalizations by Sensitive Conditions to the Primary Care at the Minas Gerais State. Methods Ecological and retrospective study of the hospitalizations from 2014 to 2019, with data from the Hospital Information System, analysed through descriptive statistics and Wilcoxon paired test. Results We observed a decrease in the expense values (-9.88%), in electives hospitalizations (-1.77%) and urgency hospitalizations (-10.54%), in male and female sexes, and all group ages; with significant expense values difference in the age groups from 5 to 14 years old (p=0.005), and from 15 to 49 (p<0.001). We found the absolute higher values in the Angina, Cardiac insufficiency, and Cerebrovascular diseases groups; the main decreases occurred in Pelvic organs inflammatory diseases, Infectious gastroenteritis, and Asthma. Conclusion The analysis by groups and hospitalization character of the sensitive conditions allows the identification of frequency and elevated and/or disproportionate expenses, highlighting conditions of greater risk and action of the primary care services in health in the appropriate moment to the population demand.

Concordance of Disclosed Hospital Prices With Total Reimbursements for Hospital-Based Care Among Commercially Insured Patients in the US.

Importance: To improve health care price transparency and promote cost-conscious selection of health care organizations and practitioners, the Centers for Medicare & Medicaid Services (CMS) required that hospitals share payer-specific negotiated prices for selected shoppable health services by January 2021. While this regulation improves price transparency, it is unclear whether disclosed prices reflect total costs of care, since many hospital-based services are delivered and billed separately by independent practitioners or other health care entities. Objective: To assess the extent to which prices disclosed under the new hospital price transparency regulation are correlated with total costs of care among commercially insured individuals. Design, Setting, and Participants: This cross-sectional study used a large database of commercial claims from 2018 to analyze encounters at US hospitals for shoppable health care services for which price disclosure is required by CMS. Data were analyzed from November 2020 to February 2021. Exposures: Whether the service was billed by the hospital or another entity. Main Outcomes and Measures: Outcomes of interest were the percentage of encounters with at least 1 service billed by an entity other than the hospital providing care, number of billing entities, amounts billed by nonhospital entities, and the correlation between hospital and nonhospital reimbursements. Results: The study analyzed 4 545 809 encounters for shoppable care. Independent health care entities were involved in 7.6% (95% CI, 6.7% to 8.4%) to 42.4% (95% CI, 39.1% to 45.6%) of evaluation and management encounters, 15.9% (95% CI, 15.8% to 16%) to 22.2% (95% CI, 22% to 22.4%) of laboratory and pathology services, 64.9% (95% CI, 64.2% to 65.7%) to 87.2% (95% CI, 87.1% to 87.3%) of radiology services, and more than 80% of most medicine and surgery services. The median (IQR) reimbursement of independent practitioners ranged from $61 ($52-$102) to $412 ($331-$466) for evaluation and management, $5 ($4-$6) to $7 ($4-$12) for laboratory and pathology, $26 ($20-$32) to $210 ($170-$268) for radiology, and $47 ($21-$103) to $9545 ($7750-$18 277) for medicine and surgery. The reimbursement for services billed by the hospital was not strongly correlated with the reimbursement of independent clinicians, ranging from r = -0.11 (95% CI, -0.69 to 0.56) to r = 0.53 (95% CI, 0.13 to 0.78). Conclusions and Relevance: This cross-sectional study found that independent practitioners were frequently involved in the delivery of shoppable hospital-based care, and their reimbursement may have represented a substantial portion of total costs of care. These findings suggest that disclosed hospital reimbursement was usually not correlated with total cost of care, limiting the potential benefits of the hospital price transparency rule for improving consumer decision-making.

Association of Multiple Hospital Affiliations With Clinician Service Use, Breadth of Procedures, and Costs.

Importance: Little is known about whether a clinician having multiple hospital affiliations (ie, 1 clinician working across multiple teams and organizations) is associated with clinician practice style and cost. The measurement of this association requires adjusting for selection into multihospital affiliations based on both observable and unobservable clinician characteristics. Objective: To evaluate the association of multiple hospital affiliations with clinician service use, breadth of procedures used, and costs. Design, Setting, and Participants: This cohort study used Medicare Part B data from 2016 through 2017 in a fixed-effects panel data design to compare service use, procedure breadth, and costs between clinicians with multiple affiliations (treatment group) and clinicians with a single affiliation (control group), with adjustment for volume, patients, and clinician characteristics. The study also controlled for unobserved (time-invariant) clinician characteristics using individual clinician fixed effects. Clinicians with Medicare claims, a reported National Provider Identifier, and affiliation data within Medicare Physician Compare were included for a total sample of 1 073 252 observations (633 552 unique clinicians) for medical services and 358 669 observations (210 260 unique clinicians) for drug prescribing. Statistical analyses were performed from February 1 to October 15, 2021. Main Outcomes and Measures: Service use is the total number of medical (or drug) services that clinicians render to their Medicare beneficiaries within a given year, procedure breadth is the total number of unique Healthcare Common Procedure Coding System codes that are associated with clinicians' medical (or drug) services within a given year, and costs represent the total standardized amount paid by Medicare for the medical (or drug) services. Additional measures were multiple-hospital affiliations, Accountable Care Organization affiliation, and controls across clinician and patient characteristics. Results: The medical service sample consisted of 633 552 clinicians (248 359 women [39.2%]; mean [SD] of 19.6 [12.5] years of experience), and the drug service sample consisted of 210 260 clinicians (74 875 women [35.6%]; mean [SD] of 21.6 [12.3] years of experience). For medical services, clinicians with multiple practice affiliations used a mean 8.2% (95% CI, 7.5%-8.9%; P < .001) more medical services per patient, drew on a mean 5.4% (95% CI, 5.1%-5.7%; P < .001) wider set of procedures within their medical care, and incurred a mean 8.6% (95% CI, 7.9%-9.2%; P < .001) more in medical costs. Pertaining to drug services, clinicians with multiple practice affiliations used a mean 2.9% (95% CI, 1.9%-3.9%; P < .001) more drug services per patient, drew on a mean 1.0% (95% CI, 0.5%-1.4%; P < .001) wider set of procedures within their medical care, and incurred a mean 2.7% (95% CI, 1.6%-3.7%; P < .001) more in drug costs. Significant results were also found across extensive and intensive margins of hospital affiliation, and supplemental analysis further indicated heterogenous treatment associations across clinician specialties. Conclusions and Relevance: This cohort study found that a clinician having multihospital affiliations was associated with greater service use, procedure breadth, and costs across both medical and drug services. These findings suggest that clinician affiliations ought to be considered as part of health care delivery design and potential cost-containment strategies.

Effect of a Multiorgan Focused Clinical Ultrasonography on Length of Stay in Patients Admitted With a Cardiopulmonary Diagnosis: A Randomized Clinical Trial.

Importance: There are accumulating data about the utility of diagnostic multiorgan focused clinical ultrasonography (FCU) in the assessment of patients admitted with cardiopulmonary symptoms. Objective: To determine whether adding multiorgan FCU to the initial clinical evaluation of patients admitted with cardiopulmonary symptoms reduces hospital length of stay, hospital readmissions, and in-hospital costs. Design, Setting, and Participants: This is a prospective, parallel-group, superiority, randomized clinical trial with a 1:1 allocation ratio. The study was conducted at The Royal Melbourne Hospital, a tertiary public hospital located in Melbourne, Victoria, Australia. Adults aged 18 years or older admitted to the internal medicine ward with a cardiopulmonary diagnosis were enrolled between September 2018 and December 2019 and were followed up until hospital discharge. Data analysis was performed from August 2020 to January 2021. Interventions: The intervention involved an internal medicine physician-performed heart, lung, and 2-point vein compression FCU in addition to standard clinical evaluation. Main Outcomes and Measures: The primary outcome was the difference in the mean length of hospital stay, defined as the number of hours from admission to the internal medicine ward to hospital discharge. A difference of 24 hours was defined as clinically important. Secondary outcomes included hospital readmissions at 30 days and hospital care costs. Results: A total of 250 participants were enrolled and 2 were excluded, leaving 248 participants (mean [SD] age, 80.1 [11.0] years; 121 women [48.7%]) in the final analysis. There were 124 patients in the intervention group and 124 patients in the control group. The most common initial diagnoses were acute decompensated heart failure (113 patients [45.5%]), pneumonia (45 patients [18.1%]), and exacerbated chronic pulmonary disease (32 patients [12.9%]). The length of hospital stay was 113.4 hours (95% CI, 91.7-135.1 hours) in the FCU group and 125.3 hours (95% CI, 101.7-148.8 hours) in the control group (P = .53). The 30-day readmission rate was not different between groups (FCU vs control, 20 of 124 patients [16.1%] vs 15 of 124 patients [12.0%]), nor were total in-hospital costs (FCU vs control, A$7831.1 [95% CI, A$5586.1-A$10 076.1] vs A$7895.7 [95% CI, A$6385.9-A$9.405.5]). Conclusions and Relevance: In this randomized clinical trial, adult patients admitted to an internal medicine ward with a cardiopulmonary diagnosis, who underwent multiorgan FCU of the heart, lungs, and lower extremities veins during their initial clinical assessment, did not have a shorter hospital length of stay by more than 24 hours, compared with patients who received standard care. Trial Registration: Australian New Zealand Clinical Trials Registry Identifier: ACTRN12618001442291.

Trends in Hospital Costs and Levels of Services Provided for Children With Bronchiolitis Treated in Children's Hospitals.

Importance: Increasing hospital costs for bronchiolitis have been associated with increasing patient complexity and mechanical ventilation. However, the associations of illness severity and diagnostic coding practices with bronchiolitis hospitalization costs have not been examined. Objective: To investigate the association of patient complexity, illness severity, and diagnostic coding practices with bronchiolitis hospitalization costs. Design, Setting, and Participants: This retrospective cross-sectional study included 385 883 infants aged 24 months or younger who were hospitalized with bronchiolitis at 39 hospitals in the Pediatric Health Information System database from January 1, 2010, to December 31, 2019. Exposure: Hospitalization for bronchiolitis. Main Outcomes and Measures: Inflation-adjusted standardized unit cost (expressed in dollar units) per hospitalization over time. A nested subgroup analysis was performed to further examine factors associated with changes in cost. Results: A total of 385 883 bronchiolitis hospitalizations were studied; the patients had a mean (SD) age of 7.5 (6.4) months and included 227 309 of 385 883 boys (58.9%) and 253 870 of 385 883 publicly insured patients (65.8%). Among patients hospitalized with bronchiolitis, the median standardized unit cost per hospitalization increased significantly during the study period (from $5636 [95% CI, $5558-$5714] in 2010 to $6973 [95% CI, $6915-$7030] in 2019; P < .001 for trend). Similar increases in cost were observed among subgroups of patients without a complex chronic condition and without the need for mechanical ventilation. However, costs for patients without a complex chronic condition or mechanical ventilation, who received care outside the intensive care unit did not change in an economically significant manner (from $4803 [95% CI, $4752-$4853] in 2010 to $4853 [95% CI, $4811-$4895] in 2019; P < .001 for trend), suggesting that intensive care unit use was a primary factor associated with cost increases. Substantial changes in coding practices were observed. Among patients hospitalized with bronchiolitis, 1.2% (95% CI, 1.1%-1.3%) were assigned an APR-DRG (All Patient Refined Diagnosis Related Group) for respiratory failure in 2010, which increased to 21.6% (95% CI, 21.2%-21.9%) in 2019 (P < .001 for trend). Increased costs and coding intensity were not accompanied by objective evidence of worsening illness severity. Conclusions and Relevance: This cross-sectional study suggests that hospitalized children with bronchiolitis are receiving costlier and more intensive care without objective evidence of increasing severity of illness. Changes in coding practices may complicate efforts to study trends in the use of health care resources using administrative data.

Definitive surgical femur fracture fixation in Northern Tanzania: implications of cost, payment method and payment status.

INTRODUCTION: Kilimanjaro Christian Medical Centre (KCMC) covers major orthopaedic trauma for a catchment population of 12.5 million people in northern Tanzania. Femur fractures, the most common traumatic orthopaedic injury at KCMC (39%), require open reduction and internal fixation (ORIF) for definitive treatment. It is unclear whether payment affects care. This study sought to explore associations of payment method with episodes of care for femur fracture ORIFs at KCMC. METHODS: we performed a retrospective review of orthopaedic records between February 2018 and July 2018. Patients with femur fracture ORIF were eligible; patients without charts were excluded. Ethical clearance was obtained from the KCMC ethics committee. Statistical analysis utilized descriptive statistics, Chi-squared and Fisher's exact Tests, and Student´s t-tests where appropriate. RESULTS: of 76 included patients, 17% (n=13) were insured, 83% (n=63) paid out-of-pocket, 11% (n=8) had unpaid balance, and 89% (n=68) fully paid. Average patient charge ($417) was 42% of per capita GDP ($998). Uninsured patients had higher bills ($429 vs $356; p=0.27) and were significantly more likely to pay an advance payment (95.2% vs 7.7%; p<0.001). Inpatient care was equivalent regardless of payment. Unpaid patients were less likely to receive follow-up (76.5% vs. 25%; p=0.006) and waited longer from injury to admission (31.5 vs 13.3 days; p<0.001), from admission to surgery (30.1 vs 11.1 days; p<0.001), and from surgery to discharge (18.4 vs 7.1 days; p<0.001). CONCLUSION: equal standard of care is provided to all patients. However, future efforts may decrease disparities in advance payment, timeliness, and follow-up.

Assessment of Costs and Care Quality Associated With Major Surgical Procedures After Implementation of Maryland's Capitated Budget Model.

Importance: In 2014, Maryland implemented the all-payer model, a distinct hospital funding policy that applied caps on annual hospital expenditures and mandated reductions in avoidable complications. Expansion of this model to other states is currently being considered; therefore, it is important to evaluate whether Maryland's all-payer model is achieving the desired goals among surgical patients, who are an at-risk population for most potentially preventable complications. Objective: To examine the association between the implementation of Maryland's all-payer model and the incidence of avoidable complications and resource use among adult surgical patients. Design, Setting, and Participants: This comparative effectiveness study used hospital discharge records from the Healthcare Cost and Utilization Project state inpatient databases to conduct a difference-in-differences analysis comparing the incidence of avoidable complications and the intensity of health resource use before and after implementation of the all-payer model in Maryland. The analytical sample included 2 983 411 adult patients who received coronary artery bypass grafting (CABG), carotid endarterectomy (CEA), spinal fusion, hip or knee arthroplasty, hysterectomy, or cesarean delivery between January 1, 2008, and December 31, 2016, at acute care hospitals in Maryland (intervention state) and New York, New Jersey, and Rhode Island (control states). Data analysis was conducted from July 2019 to July 2021. Exposures: All-payer model. Main Outcomes and Measures: Complications (infectious, cardiovascular, respiratory, kidney, coagulation, and wound) and health resource use (ie, hospital charges). Results: Of 2 983 411 total patients in the analytical sample, 525 262 patients were from Maryland and 2 458 149 were from control states. Across Maryland and the control states, there were statistically significant but not clinically relevant differences in the preintervention period with regard to patient age (mean [SD], 49.7 [19.0] years vs 48.9 [19.3] years, respectively; P < .001), sex (22.7% male vs 21.4% male; P < .001), and race (0.3% vs 0.4% American Indian, 2.8% vs 4.5% Asian or Pacific Islander, 25.9% vs 12.7% Black, 4.7% vs 11.9% Hispanic, and 63.5% vs 63.4% White; P < .001). After implementation of the all-payer model in Maryland, significantly lower rates of avoidable complications were found among patients who underwent CABG (-11.3%; 95% CI, -13.8% to -8.7%; P < .001), CEA (-1.6%; 95% CI, -2.9% to -0.3%; P = .02), hip arthroplasty (-0.8%; 95% CI, -1.0% to -0.5%; P < .001), knee arthroplasty (-0.4%; 95% CI, -0.7% to -0.1%; P = .01), and cesarean delivery (-1.0%; 95% CI, -1.3% to -0.7%; P < .001). In addition, there were significantly lower increases in index hospital costs in Maryland among patients who underwent CABG (-$6236; 95% CI, -$7320 to -$5151; P < .001), CEA (-$730; 95% CI, -$1367 to -$94; P = .03), spinal fusion (-$3253; 95% CI, -$3879 to -$2627; P < .001), hip arthroplasty (-$328; 95% CI, -$634 to -$21; P = .04), knee arthroplasty (-$415; 95% CI, -$643 to -$187; P < .001), cesarean delivery (-$300; 95% CI, -$380 to -$220; P < .001), and hysterectomy (-$745; 95% CI, -$974 to -$517; P < .001). Significant changes in patient mix consistent with a younger population (eg, a shift toward private/commercial insurance for orthopedic procedures, such as spinal fusion [4.3%; 95% CI, 3.4%-5.2%; P < .001] and knee arthroplasty [1.6%; 95% CI, 1.0%-2.3%; P < .001]) and a lower comorbidity burden across surgical procedures (eg, CABG: -0.7% [95% CI, -0.1% to -0.5%; P < .001]; hip arthroplasty: -3.0% [95% CI, -3.6% to -2.3%; P < .001]) were also observed. Conclusions and Relevance: In this study, patients who underwent common surgical procedures had significantly fewer avoidable complications and lower hospital costs, as measured against the rate of increase throughout the study, after implementation of the all-payer model in Maryland. These findings may be associated with changes in the patient mix.

Trends in Hospital Lawsuits Filed Against Patients for Unpaid Bills Following Published Research About This Activity.

Importance: Suing patients and garnishing their wages for unpaid medical bills can be a predatory form of financial activity that may be inconsistent with the mission of a hospital. Many hospitals in the state of Virginia were discovered to be suing patients for unpaid medical bills, as first presented in a 2019 research article that launched 2.5 months of media attention on hospital billing practices and a grassroots public demand for hospitals to stop the practice. Objective: To evaluate the association of a research publication and subsequent media coverage with the number of hospital lawsuits filed against patients for unpaid medical bills. Design, Setting, and Participants: This cross-sectional study of Virginia hospitals that sued patients for unpaid medical bills used an interrupted time series analysis. Data on hospitals suing patients for unpaid medical bills were collected during a preintervention period (June 25, 2018, to June 24, 2019), an intervention period (June 25, 2019, to September 10, 2019), and a postintervention period (September 11, 2019, to September 10, 2020). Exposures: Publication of a research article and subsequent media coverage. Main Outcomes and Measures: The total number of warrant in debt and wage garnishment lawsuits filed by Virginia hospitals and the frequency of those lawsuits filed before, during, and after the intervention period on a weekly basis. Results: A total of 50 387 lawsuits, filed by 67 Virginia hospitals, were included; 33 204 (65.9%) were warrant in debt lawsuits, and 17 183 (34.1%) were wage garnishment lawsuits. From the preintervention period to the postintervention period, there was a 59% decrease in the number of lawsuits filed (from 30 760 lawsuits to 12 510 lawsuits), a 55% decrease in the number of warrant in debt cases filed (from 19 329 to 8651), a 66% decrease in the number of wage garnishments filed (from 11 431 to 3859), and a 64% decrease in the dollar amount pursued in court (from $38 700 209 to $13 960 300). During the study period, 11 hospitals banned the practice of suing patients for unpaid medical bills. The interrupted time series analysis showed a significant decrease of 5% (incidence rate ratio, 0.95; 95% CI, 0.94-0.96) in the total weekly number of lawsuits in the postintervention period. Conclusions and Relevance: The findings of this study suggest that research leading to public awareness can shift hospital billing practices.

Methods for estimating the cost of treat-and-release emergency department visits.

OBJECTIVE: To evaluate and compare approaches to estimating the service delivery cost of emergency department (ED) visits from total charge data only. DATA SOURCES: The 2013-2017 Healthcare Cost and Utilization Project's (HCUP) State Emergency Department Databases (SEDD) and the Centers for Medicare and Medicaid Services Healthcare Cost Report Information System (HCRIS) public use files. STUDY DESIGN: Compare a baseline approach (requiring cost-center-level charge detail) and four alternative methods (relying on total charges only) for estimating ED visit costs. Estimation errors are calculated after applying each method to a sample of ED visits, treating estimates from the baseline approach as the "true" cost. Performance metrics are calculated at the visit and hospital levels. DATA COLLECTION/EXTRACTION METHODS: The charges, revenue center codes, and patient/hospital characteristics were extracted from the SEDD. Detailed costs and charges were extracted from HCRIS public use files. PRINCIPAL FINDINGS: Baseline ("true") ED visit costs increased from $383 to $420 per visit between 2013 and 2017. Three methods performed comparatively well estimating mean cost per visit. The method using an overall cost-to-charge ratio (CCR) for all ancillary cost centers without regression adjustment (ANC-CCR) performed the worst, overestimating "true" costs by $63-$113 per visit. The other three methods, which used CCRs computed from selected cost centers, exhibited much smaller bias, with two of the methods yielding estimates within $2 of the "true" cost in 2017. Compared with ANC-CCR, the other three methods had more compact estimation error distributions. The estimated mean visit costs from all four methods have relatively small statistical variance, with 95% confidence intervals for mean cost in a hospital with 25,000 ED visits ranging between $4 and $7. CONCLUSIONS: When cost-center-level charge detail for ED visits is unavailable, alternative methods relying on total ED charges can estimate ED service costs for patient and hospital segments.