Adjusted Hospital Costs Research Articles

Clinical and economic benefits associated with the use of powered and tissue-specific endoscopic staplers among the patients undergoing thoracoscopic lobectomy for lung cancer

Background: Thoracoscopic lobectomy for lung cancer is a complex procedure where endoscopic staplers play a critical role in transecting the lung parenchyme, vasculature, and bronchus. This retrospective study was performed to investigate the economic benefits of powered and tissue-specific endoscopic staplers such as gripping surface technology (GST) and powered vascular stapler (PVS) compared to standard staplers.Methods: Two hundred and seventy-five patients who received a thoracoscopic lobectomy between 2008 and 2016 were included. Group 1 (n = 117) consisted of patients who received the operation with manual endoscopic staplers, whereas Group 2 (n = 158) consisted of patients who received the operation with GST and PVS.Results: Patient demographics and clinical characteristics were comparable, except smoking history, pulmonary function, and pleural adhesion. All patients received the operation successfully without mortalities and broncho-pleural fistula. Operation time and blood loss were higher in Group 1. Pleurodesis was performed less in Group 2 than in Group 1 (18.0% vs 3.8%, p < 0.0001). Group 2 had statistically significant lower adjusted hospital costs (Korean Won, 14,610,162 ± 4,386,628 vs 12,876,111 ± 5,010,878, p < 0.0001), lower adjusted hemostasis related costs (198,996 ± 110,253 vs 175,291 ± 191,003, p = 0.0101); lower cartridge related adjusted costs (1,105,091 ± 489,838 vs 839,011 ± 307,894, p < 0.0001) compared to Group 1. As well, Group 2 showed ∼12% lower adjusted total hospital costs compared to Group 1. Multivariable analysis revealed that Group 1 was related to increased hospital costs.Conclusions: This study showed that thoracoscopic lobectomy with powered and tissue-specific endoscopic staplers were associated with better clinical outcomes and reduced adjusted hospital costs when compared in Korean real-world settings.

Acute Kidney Injury With Ventricular Assist Device Placement: National Estimates of Trends and Outcomes

Ventricular assist devices (VADs) are used for end-stage heart failure not amenable to medical therapy. Acute kidney injury (AKI) in this setting is common due to heart failure decompensation, surgical stress, and other factors. Little is known about national trends in AKI diagnosis and AKI requiring dialysis (AKI-D) and associated outcomes with VAD implantation. We investigated national estimates and trends for diagnosed AKI, AKI-D, and associated patient and resource utilization outcomes in hospitalizations in which implantable VADs were placed. Cohort study of 20% stratified sample of US hospitalizations. Patients who underwent implantable VAD placement in 2006 to2015. No AKI diagnosis, AKI without dialysis, AKI-D. In-hospital mortality, length of stay, estimated hospitalization costs. Multivariate logistic and linear regression using survey design methods to account for stratification, clustering, and weighting. An estimated 24,140 implantable VADs were placed, increasing from 853 in 2006 to 3,945 in 2015. AKI was diagnosed in 56.1% of hospitalizations and AKI-D occurred in 6.5%. AKI diagnosis increased from 44.0% in 2006 to 2007 to 61.7% in 2014 to 2015; AKI-D declined from 9.3% in 2006 to 2007 to 5.2% in 2014 to 2015. Mortality declined in all AKI categories but this varied by category: those with AKI-D had the smallest decline. Adjusted hospitalization costs were 19.1% higher in those with diagnosed AKI and 39.6% higher in those with AKI-D, compared to no AKI. Administrative data; timing of AKIwith respect to VAD implantation cannot be determined; limited pre-existing chronic kidney disease ascertainment; discharge weights not derived for subpopulation of interest. A decreasing proportion of patients undergoing VAD implantation experience AKI-D, but mortality among these patients remains high.AKI diagnosis with VAD implantation is increasing, possibly reflecting changes in AKI surveillance, awareness, and coding.

PMD33 ECONOMIC BENEFITS OF POWERED AND TISSUE-SPECIFIC ENDOSCOPIC STAPLERS IN THE PATIENTS UNDERGOING VIDEO-ASSISTED THORACIC PULMONARY RESECTION

Thoracoscopic pulmonary resections are complex procedures and endoscopic staplers play the critical roles in transecting the lung parenchyme, vasculature and bronchus. This retrospective study was performed to investigate the economic benefits of powered and tissue-specific endoscopic staplers (GST and PVS) compared to standard staplers. The 275 patients who received the thoracoscopic lobectomy between 2008 and 2016 were included. The group 1 (n=117) was defined the patients who received the operation with manual endoscopic staplers, whereas group 2 (n=158) was defined as patients who received the operation with GST and PVS. Patient demographics and clinical characteristics are comparable except the smoking history, pulmonary function and pleural adhesion. All patients received the operation successfully without mortalities and brocho-pleural fistula. The operation time and blood loss were higher in group 1. The pleurodesis was done less in group 2 than in group 1 (18.0% vs. 3.8%, p<0.0001). The group 2 had statistically significant lower adjusted hospital cost (KRW 14,610,162±4,386,628 vs. KRW 12,876,111±5,010,878, p<0.0001), lower adjusted hemostasis related cost (KRW 198,996±110,253 vs. KRW 175,291±191,003, p=0.0101); lower cartridge related adjusted cost (KRW 1,105,091±489,838 vs. KRW 839,011±307,894, p<0.0001) compared to the group 1. Compared to group 1, group 2 showed approximately 12% lower adjusted total hospital cost. Multivariate analysis revealed that group 1 was related to the increased hospital cost. This study showed that the thoracoscopic lobectomy with the powered and tissue-specific endoscopic staplers were associated with better clinical outcomes and reduced adjusted hospital costs compared in Korea real world setting.

Cost analysis based on performance indicators during Healthcare Reform Plan in selected educational hospitals.

INTRODUCTION:Hospitals are the main axis of health-care reforms or national health plans; therefore, accurate recognition of hospital costs based on operational indexes to these plans is necessary. The impact of implementing national health plans on the performance of health systems is ambiguous and misleading; therefore, the aim of this study was to assess the impact of Healthcare Reform Plan (HRP) on the micro level (e.g., educational or university hospitals).METHODS:This study was a descriptive retrospective study that research variables are checked in 1 year before and mean of 3 years after implementation of HRP by self-administrated checklist in selected public-educational hospitals covered by the medical universities in Tehran. The final analysis of the data was performed using cost–performance ratio and independent t-test for comparing the variables’ changes before and after HRP.RESULTS:Unlike adjusted hospitalization costs, most operational indexes were not significant. The per capita cost adjusted of hospitalization in first and mean of 3 years after HRP increased 49.49% and 16.31%, respectively (P < 0.001), the adjusted cost per day was increased by 24.48% and 21.46% (P < 0.001), and adjusted cost per bed was increased 47.06% and 20.07% compared to before HRP (P < 0.001).CONCLUSION:Given the lack of alignment in adjusted cost changes in exchange for functional indicators, certainly, it cannot be argued that HRP had a favorable or undesirable effect on the hospitals.

Geographic variation in hospital costs, payments, and length of stay for opioid-related hospital visits in the USA.

PurposeDespite the rise in opioid-related hospitalizations, there has been little research regarding opioid-related healthcare utilization. The objective of this study was to estimate the mean adjusted hospital costs, payments, and length of stay (LOS) for opioid-related visits for the nation and each of the nine US census regions.MethodsAn observational study of retrospective claims data from the Vizient health system database was conducted. Eligible visits had a principal diagnosis of opioid use or dependence defined by ICD, ninth and tenth revision (ICD-9/10), and occurred between January 2014 and June 2017. Separate regression models for inpatient and outpatient visits were generated to estimate the adjusted costs, payments, and LOS for opioid-related visits.ResultsA total of 193,614 (32,713 inpatient and 160,901 outpatient) visits met the inclusion criteria. The overall adjusted mean cost, payment, and LOS for an inpatient opioid-related visit were $4,383 (range between regions: $2,894–$5,835), $6,689 (range between regions: $4,038–$9,001), and 4.35 days (range between regions: 3.8–5.7 days), respectively. The overall adjusted mean cost and payment for an outpatient opioid-related visit were $533 (range between regions: $395–$802) and $374 (range between regions: $187–$574), respectively. Opioid-related hospital costs, payments, and LOS varied across the US. Data on the regional variation and national averages are necessary for hospitals to benchmark their services and more effectively manage this population.ConclusionFuture research should examine intraregion utilization to understand the effect of prices and level of services.

Trends in use of echocardiography in hospitalized patients with syncope.

We sought to assess the trends in use, predictors of echocardiography, and its impact on in-hospital mortality in patients admitted with syncope using a large national database. Utilizing the Nationwide Inpatient Sample (NIS) database from 2001 to 2014, we identified adult patients (>18years) with a primary discharge diagnosis of syncope and use of echocardiogram was ascertained. A total of 3174619 patients with a primary discharge diagnosis of syncope were identified, of which 184167 (5.8%) underwent an echocardiogram. The rate of syncope hospitalization remained constant between 2001 and 2009 (1.1/1000 US population) but has since decreased steadily to about 0.5/1000 US population in 2014. After adjusting for patient and hospital characteristics, the rate of echocardiogram use increased significantly from 5.1% in 2001 to 6.8% in 2014 (2.7% relative increase per year [Ptrend =0.024]). Predictors of use were cardiac disorders, hypertension, diabetes, peripheral vascular disease, and renal failure. After adjusting for baseline risk, use of echocardiography was not associated with in-hospital mortality (OR=0.827, P=0.155), but was associated with a 14.6% increase in adjusted length of stay and a 22.6% increase in adjusted hospital cost compared to no echocardiography use (both P<0.001). The admission rates for syncope are decreasing and use of echocardiography in hospitalized patients with syncope is appropriately low. Given the lack of any favorable impact on mortality and the association with increased costs, there is a continued need to emphasize evidence-based use of echocardiography in patients presenting with syncope.

Proficiency-based training and credentialing can improve patient outcomes and decrease cost to a hospital system

BackgroundWhile proficiency-based robotic training has been shown to enhance skill acquisition, no studies have shown that training leads to improved outcomes or quality measures. MethodsBoard-certified general surgeons participated in an optional proficiency-based robotic training curriculum and outcomes from robotic hernia cases were analyzed. Multivariable analysis was performed for operative times to adjust for patient and surgical variables. ResultsSix out of 16 (38%) surgeons completed training and 210 robotic hernia cases were analyzed. Longer operative times were associated with bilateral repairs (observed-to-expected operative time ratio [OTR] = 1.41, p < 0.001) and incarceration (OTR = 1.24, p = 0.006), while female patients (OTR = 0.87, p = 0.001) and increasing chronologic case order (OTR = 0.94, p < 0.001) were associated with shorter operative times. Surgeons who completed robotic training achieved shorter OTRs than those who did not (p = 0.03). Comparing non-risk adjusted hospital costs, trainees had an average of $1207 in savings (20% reduction) per robotic hernia case. ConclusionsA structured proficiency-based robotics training curriculum is an effective way to reduce operative times and costs.

A Retrospective Cohort Study of the Management and Outcomes of Children Hospitalized with Stevens-Johnson Syndrome or Toxic Epidermal Necrolysis

Severe cutaneous adverse reactions are rare yet life-threatening conditions. The current management and outcomes of these conditions in US children are unclear. To characterize the current management and outcomes of Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) across US children's hospitals. We performed a retrospective cohort study of children younger than 18 years hospitalized with a primary diagnosis of SJS or TEN at 47 US freestanding children's hospitals. We compared treatment (intravenous immunoglobulin [IVIG], steroids, antibiotics, and others) and outcomes (length of stay [LOS], hospital mortality, readmission, recurrence, related complications, and adjusted hospital costs) across hospitals and by SJS versus TEN diagnoses. We identified 898 pediatric patients hospitalized with a primary diagnosis of SJS or TEN. Of these patients, 167(18.6%) were prescribed steroids only, 229 (25.5%) IVIG only, and 153 (17.04%) both IVIG and steroids. Median LOS was 8days (interquartile range, 5-13) with median hospital-adjusted costs of $16,265. Readmissions were common, with 88(9.9%) patients readmitted within 30 days of discharge and a recurrence rate of 2.7%. Overall hospital mortality in children was low at 0.56%. TEN was associated with higher mortality (3.23%) compared with SJS (0.13%). There was no association between the use of IVIG, systemic steroids, or IVIG and steroids during the first 2 days of hospitalization and decreased LOS or mechanical ventilation. Complex chronic conditions and TEN diagnoses were associated with increased LOS and increased odds of mechanical ventilation. Survival in children with SJS and TEN is significantly better than that observed in adults. However, there is variability in the management and outcomes in children diagnosed with these severe cutaneous reactions. Further studies are needed to determine the most effective treatment strategies given the extent of health care utilization and high rate of readmissions observed in this population.

Implementing a Thoracic Enhanced Recovery Program: Lessons Learned in the First Year

To minimize the stress of operations, improve the patient experience, reduce variability, and optimize resource utilization, we implemented a thoracic enhanced recovery after surgery (ERAS) protocol and evaluated progress after 1 year. Two protocols were developed: video-assisted thoracic surgery (ERAS-VATS) and thoracotomy (ERAS-T). Each incorporated preoperative patient education, carbohydrate loading, opioid-sparing analgesia, conservative fluid management, and early ambulation. Patient outcomes, length of stay, pain scores, opioid use, fluid administration, and cost for ERAS patients were compared with historic controls from the year before program initiation. Historic VATS (n= 162) were compared with 81 ERAS-VATS patients. Median postoperative morphine equivalents (86 versus 22 mg, p < 0.0001), total fluid balance (1279 versus 227 mL, p < 0.0001), and mean inflation adjusted hospital costs ($20,169 versus $14,870, p= 0.0003) all decreased significantly. Historic thoracotomy patients (n= 62) were compared with 58 ERAS-T patients. Median postoperative morphine equivalents (130 versus 54 mg, p<0.0001), total fluid balance (788 versus-489 mL, p= 0.012), length of stay (6.0 versus 4.0 days, p= 0.009), and mean inflation adjusted hospital costs ($41,950 versus $26,089, p < 0.00001) all decreased significantly. Implementation of thoracic ERAS is a dynamic process with potential to improve outcomes in thoracic surgical procedures. In the first year we shortened length of stay, decreased opioid usage, minimized fluid overload, and decreased hospital costs.

Hospital Variation in Neonatal Abstinence Syndrome Incidence, Treatment Modalities, Resource Use, and Costs Across Pediatric Hospitals in the United States, 2013 to 2016.

The national incidence of neonatal abstinence syndrome (NAS) has increased with the opioid epidemic in the United States. The impact of pharmacologic treatment on hospital use is not well established. We examined the recent population of neonates with NAS admitted to pediatric hospitals, hospital variation in pharmacologic treatment, and the effect of treatment on resource use during neonatal hospitalization, including length of stay (LOS), readmission, and cost-of-living adjusted hospital costs. We included inpatients discharged between January 2013 and March 2016 from hospitals in the Pediatric Health Information System. We compared neonates with NAS to those without on demographic, socioeconomic, clinical characteristics and hospital resource use. We also compared neonates with NAS on these characteristics by pharmacologic treatment. This analysis included 136 762 neonatal encounters from 23 hospitals. Of these, 2% had a diagnosis of NAS. Compared with other neonates, neonates with NAS had a longer LOS (18.7 vs 2.9 days; P = .004). Average costs per admission were 10 times higher for neonates with NAS ($37 584 vs $3536; P = .003). Of neonates with NAS, 70% were treated pharmacologically with wide variation in hospital rates of pharmacotherapy (range: 13%-90%). Pharmacologically-treated neonates with NAS experienced a longer LOS (22.0 vs 10.9 days; P = .004) than other neonates with NAS. Total costs for pharmacologically-treated neonates with NAS were over 2 times higher ($44 720 vs $20 708; P = .002) than neonates with NAS treated without pharmacotherapy. Neonates with NAS, particularly those treated pharmacologically, have lengthier, more expensive hospital stays. Significant variation in pharmacologic treatment reflects opportunities for practice standardization and substantial reductions in resource use.

Spontaneous Pneumothorax in Children: National Management Strategies and Outcomes.

The timing of surgical intervention in the management of spontaneous pneumothorax remains controversial. The aim of this multicenter review was to compare management strategies and outcomes in children with spontaneous pneumothorax. We retrospectively reviewed patients 10-19 years old in the Pediatric Health Information System admitted for spontaneous pneumothorax from 2010 to 2014. Three treatment groups were identified based on initial hospital management-no intervention, initial chest tube placement, and operation; and outcomes were compared. A total of 1040 patients were included. The majority were male (82.1%) and White (71.1%). The mean age at first encounter was 15.7 ± 1.7 years. Initial treatment included no intervention in 336 (32.3%), chest tube in 497 (47.8%), and video-assisted thoracoscopic surgery (VATS) in 207 (19.9%). Ultimately, 417 (40.1%) patients underwent VATS during the initial admission and 559 (53.8%) during the initial admission or a subsequent encounter. Aggregate length of stay (LOS) was highest for those treated initially with chest tube alone (P < .001). For patients managed initially with chest tube, the probability of requiring surgery increased with each day of hospitalization. Initial operation was associated with a decreased risk of readmission (OR 0.67, 95% CI 0.50-0.90). Estimated adjusted hospital costs, aggregated across all encounters, were highest for chest tube alone (P < .001). Early VATS is associated with decreased hospital LOS, charges, and readmissions. For those managed initially with chest tube alone, the likelihood of requiring operation increases with each day hospitalized, and early conversion to operative management should be considered in patients with persistent pneumothorax or air leak.

Guideline Adherence and Hospital Costs in Pediatric Severe Traumatic Brain Injury*

Adherence to pediatric traumatic brain injury guidelines has been associated with improved survival and better functional outcome. However, the relationship between guideline adherence and hospitalization costs has not been examined. To evaluate the relationship between adherence to pediatric severe traumatic brain injury guidelines, measured by acute care clinical indicators, and the total costs of hospitalization associated with severe traumatic brain injury. Retrospective cohort study. Five regional pediatric trauma centers affiliated with academic medical centers. Demographic, injury, treatment, and charge data were included for pediatric patients (17 yr) with severe traumatic brain injury. Percent adherence to clinical indicators was determined for each patient. Cost-to-charge ratios were used to estimate ICU and total hospital costs for each patient. Generalized linear models evaluated the association between healthcare costs and adherence rate. Cost data for 235 patients were examined. Estimated mean adjusted hospital costs were $103,485 (95% CI, 98,553-108,416); adjusted ICU costs were $82,071 (95% CI, 78,559-85,582). No association was found between adherence to guidelines and total hospital or ICU costs, after adjusting for patient and injury characteristics. Adjusted regression model results provided cost ratio equal to 1.01 for hospital and ICU costs (95% CI, 0.99-1.03 and 0.99-1.02, respectively). Adherence to severe pediatric traumatic brain injury guidelines at these five leading pediatric trauma centers was not associated with increased hospitalization and ICU costs. Therefore, cost should not be a factor as institutions and providers strive to provide evidence-based guideline driven care of children with severe traumatic brain injury.

Abstract WP315: Acute Myocardial Infarction Associated With Worse Outcomes in Acute Cerebrovascular Disease

Introduction/Hypothesis: We examined the prevalence and outcomes of patients admitted with acute cerebrovascular disease (ACVD) and concomitant acute myocardial infarction (AMI). Methods: We utilized the Healthcare Cost and Utilization Project Nationwide Inpatient Sample database (1998-2009) and identified 1,760,415 adult ACVD patients among 92,848,710 patients enrolled. Using SAS 6.4 and applying SPSS 22 the outcome variables mortality, length of hospital stay (LOS), hospital costs &gt;$20,000, and disposition (home or any care facility) were selected and logistic regression analyses was performed adjusting for the covariates hypertension, diabetes mellitus, age, race, sex, number of comorbidities, and care complexity (numbers of inpatient procedures) among all ACVD with and without AMI. Results: Mean age was 71 years (SD 15) with 76% &gt;65 years old; 54% female gender; 55% Whites, 11% Blacks, and 6% Hispanics. Among all ACVD, 66% had HTN, 28% DM, AMI 4.1%, LOS was 7.6 days (SD 9.8), in-patient mortality 12%; disposition home 42% and facility 44%, and mean hospital costs $36,010 (SD $63,331). After covariate adjustment, ACVD patients with AMI compared to those without AMI had a mortality of 30% vs 12% (P&lt;0.000); LOS ≥7 days 53% vs 30% (P&lt;0.000), facility discharge 68% vs 51% (P&lt;0.000), and adjusted hospital costs 71% vs 44% (P&lt;0.000). Conclusions: Acute myocardial infarction occurred in 4.1% of patients with acute cerebrovascular disease. It was associated with significantly increased risks of in-patient mortality, length of hospital stay, facility disposition and hospital costs. Considering the poor outcomes of ACVD patients with AMI may indicate more aggressive strategies for early recognition and reduction of myocardial injury.

Impact of postoperative complications on hospital costs following the Norwood operation.

Introduction Patients undergoing the Norwood operation consume considerable healthcare resources; however, detailed information regarding factors impacting hospitalisation costs is lacking. We evaluated the association of postoperative complications with hospital costs. In the present study, we utilised a unique data set consisting of prospectively collected clinical data from the Pediatric Heart Network Single Ventricle Reconstruction trial linked at the patient level with cost data for 10 hospitals participating in the Children's Hospital Association Case Mix database during the trial period. The relationship between complications and cost was modelled using linear regression, accounting for the skewed distribution of cost, adjusting for within-centre clustering and baseline patient characteristics. A total of 334 eligible Norwood records (97.5%) were matched between data sets. Overall, 82% suffered from at least one complication (median 2; with a range from 0 to 33). Those with complications had longer postoperative length of stay (25 versus 12 days, p<0.001), more total ventilator days (7 versus 5 days, p<0.001), and higher in-hospital mortality (17.6 versus 3.4%, p<0.006). Mean adjusted hospital cost in those with a complication was $190,689 (95% CI $111,344-$326,577) versus $120,584 (95% CI $69,246-$209,983) in those without complications (p=0.002). Costs increased with the number of complications (1-2 complications=$132,800 versus 3-4 complications=$182,353 versus ⩾5 complications=$309,372 [p<0.001]). This merged data set of clinical trial and cost data demonstrated that postoperative complications are common following the Norwood operation and are associated with worse clinical outcomes and higher costs. Efforts to reduce complications in this population may lead to improved outcomes and cost savings.

Hospital Cost Associated with Veno-Occlusive Disease (VOD) in Patients with Hematopoietic Stem Cell Transplant (HSCT)

Introduction: VOD (also known as Sinusoidal Obstruction Syndrome) is a potentially life threatening complication of hematopoietic stem-cell transplantation (HSCT). Severe VOD (sVOD), defined as VOD with evidence of multi-organ dysfunction (MOD), leads to high morbidity and mortality in HSCT patients. This study assessed healthcare utilization and costs associated with VOD in patients undergoing HSCT.Methods: A retrospective cohort study was conducted using the Premier research database and had a starting population of all patients with inpatient HSCT between January 1, 2009 and May 31, 2014. The VOD cohort ("all-VOD") included those who also had at least one discharge diagnosis indicating liver injury or at least two diagnoses for VOD symptoms, such as hyperbilirubinemia and/or hepatomegaly, during the study period. sVOD patients were identified using diagnoses for multi-organ dysfunction and were a subset of the VOD cohort. The non-VOD cohort was all patients from the starting cohort who did not have evidence of VOD. Primary outcomes were total hospitalization costs, hospital length of stay (LOS), and inpatient mortality. Secondary outcomes were intensive care unit (ICU) costs, ICU LOS, 30-day all-cause readmission rates and associated costs. Unadjusted descriptive analysis included Chi-squared or Wilcoxon Rank Sum tests for comparisons between cohorts, with non-VOD as the reference group. Multivariable analysis estimated the association between VOD status and primary outcomes, adjusting for differences in demographic, hospital, and clinical characteristics. Generalized linear models (GLM) were applied for total costs and LOS, and logistic regression was used for inpatient mortality. Recycled prediction was used to calculate the adjusted outcomes by VOD status.Results: A total of 5,418 patients had inpatient HSCT during the study period. The study included 291 all-VOD patients (134 sVOD and 157 non-severe VOD), in addition to 5,127 patients without evidence of VOD. Unadjusted descriptive analysis found that the all-VOD cohort had higher hospital costs (Median: $119,594, IQR: $59,793-$220,461) and longer LOS (Median: 28 days, IQR: 20-41) than the non-VOD cohort (Median cost: $62,747, IQR: $40,590-$120,974, p<0.001; Median LOS: 21 days, IQR: 16-27; p <0.001). The sVOD sub-cohort had much higher costs and LOS (Median cost: $198,436, IQR: $102,027-$406,683, p<0.001; Median LOS: 37.5 days, IQR: 27-66; p<0.001). Inpatient mortality rates in the all-VOD and sVOD groups were significantly higher than the non-VOD group (non-VOD: 3.0% vs VOD: 18.6%, p<0.001; sVOD: 39.6%, p<0.001). In multivariable regressions, the adjusted hospital costs for non-severe VOD was $8,988 higher than the non-VOD group (p=0.037), and sVOD was $41,703 higher than the non-VOD group (p<0.001). The adjusted hospital LOS for non-severe VOD was 0.90 days longer than the non-VOD group (p=0.023) and for the sVOD group was 7.02 days longer than the non-VOD group (p<0.001). The sVOD group had significantly higher inpatient mortality (10.6%) compared with non-VOD group (3.4%, Adjusted Odds Ratio=5.88, p<0.001), although the mortality difference between non-severe VOD and non-VOD groups was not significant.Discussion: This analysis is subject to limitations of administrative data. Since there is no diagnostic code for VOD, we used clinical judgment to sort through the codes most likely to be related to VOD/sVOD. Notably, the 40% mortality in the sVOD group is considerably lower than the approximately 80% mortality reported in the literature. One important reason for this difference is that our analysis measured mortality during initial HSCT hospitalization, while the higher rates in the literature are based on 100-day mortality. Additionally, our algorithm may have yielded less severe disease compared to the literature.Conclusions: VOD and sVOD were associated with increased healthcare utilization and costs compared with the HSCT patients without VOD. sVOD patients also had almost 6 times higher odds of inpatient mortality compared with patients without VOD. [Display omitted] [Display omitted] DisclosuresDvorak:Jazz Pharmaceuticals: Consultancy. Nejadnik:Jazz Pharmaceuticals: Employment, Equity Ownership. Cao:Premier Research Services: Employment; Jazz Pharmaceuticals: Other: Premier Research Services received funding from Jazz Pharmaceuticals for data access, study design, and analysis. Lipkin:Premier Research Services: Employment; Jazz Pharmaceuticals: Other: Premier Research Services received funding from Jazz Pharmaceuticals for data access, study design, and analysis. Robinson:Premier Research Services: Employment; Jazz Pharmaceuticals: Other: Premier Research Services received funding from Jazz Pharmaceuticals for data access, study design, and analysis. Villa:Jazz Pharmaceuticals: Employment, Equity Ownership.

Impact of antibiotic prophylaxis for intrathecal baclofen pump surgery in pediatric patients.

OBJECT This study explored antibiotic prophylaxis (AP) in pediatric patients undergoing intrathecal baclofen pump (ITBP) surgery and factors associated with perioperative AP compliance with clinical guidelines. METHODS Data were obtained from the Pediatric Health Information System. The study cohort comprised patients who underwent ITBP surgery within 3 days of admission, between July 1, 2004, and March 31, 2014, with a minimum prior screening period and follow-up of 180 days. Exclusion criteria were prior infection, antibiotic use within 30 days of admission, and/or missing financial data. Chi-square tests and multivariate logistic regressions were used to determine factors associated with compliance with AP guidelines in ITBP surgeries. RESULTS A total of 1,534 patients met the inclusion criteria; 91.5% received AP and 37.6% received dual coverage or more. Overall bundled compliance comprised 2 components: 1) perioperative antibiotic administration and 2) < 24-hour postoperative antibiotic course. The most frequently used antibiotics in surgery were cefazolin (n = 873, 62.2%) and vancomycin (n = 351, 25%). Documented bundled AP compliance rates were 70.2%, 62.0%, 66.0%, and 55.2% in West, South, Midwest, and Northeast regions of the US, respectively. Compared with surgeries in the Northeast, procedures carried out in the West (OR 2.0, 95% C11.4-2.9, p < 0.001), Midwest (OR 1.6, 95% C11.1-2.3, p = 0.007), and South (OR 1.5, 95% C11.1-2.0, p = 0.021) were more likely to have documented AP compliance. Black (OR 0.74, 95% CI 0.55-1.00, p = 0.05) and Hispanic (OR 0.63, 95% CI 0.47-0.86, p = 0.004) patients were less likely to have documented AP compliance in ITBP surgeries than white patients. There were no significant differences in compliance rate by age, sex, type of insurance, and diagnosis. AP process measures were associated with shorter length of stay, lower hospitalization costs, and lower 6-month rates of surgical infection/complication. One of the 2 noncompliance subgroups, missed preoperative antibiotic administration, was correlated with a significantly higher 6-month surgical complication/infection rate (27.03%) compared with bundled compliance (20.00%, p = 0.021). For the other subgroup, prolonged antibiotic use > 24 hours postoperatively, the rate was insignificantly higher (22.00%, p = 0.368). Thus, of direct relevance to practicing clinicians, missed preoperative antibiotics was associated with 48% higher risk of adverse complication/infection outcome in a 6-month time frame. Adjusted hospitalization costs associated with baclofen pump surgery differed significantly (p < 0.001) with respect to perioperative antibiotic practices: 22.83, 29.10, 37.66 (× 1000 USD) for bundled compliance, missed preoperative antibiotics, and prolonged antibiotic administration, respectively. CONCLUSIONS Significant variation in ITBP antibiotic prophylaxis was found. Documented AP compliance was associated with higher value of care, showing favorable clinical and financial outcomes. Of most impact to clinical outcome, missed preoperative antibiotics was significantly associated with higher risk of 6-month surgical complication/infection. Prolonged antibiotic use was associated with significantly higher hospital costs compared with those with overall bundled antibiotic compliance. Future research is warranted to examine factors associated with practice variation and how AP compliance is associated with outcomes and quality, aiming for improving delivery of care to pediatric patients undergoing ITBP procedures.

Health Costs and Outcomes Associated with Medicare Part D Prescription Drug Cost-Sharing in Beneficiaries on Dialysis.

High out-of-pocket costs for prescription medications have been associated with poor patient outcomes. A previous study found that the Part D coverage gap was significantly associated with decreases in adherence and persistence for medications frequently used in patients undergoing dialysis. It is not known what effect the decreased use of prescription drugs associated with the coverage gap had on utilization and spending for other medical care. To determine the relationship between the Part D prescription drug cost-sharing structure and health and economic outcomes in Medicare beneficiaries on dialysis. A retrospective analysis using data from the United States Renal Data System (2006-2008) was conducted for Medicare-eligible patients receiving dialysis. Patients were grouped in 1 of 4 cohorts based on low-income subsidy (LIS) receipt and benefit phase in 2007: Cohort 1 (non-LIS and did not reach the coverage gap); Cohort 2 (non-LIS and reached the coverage gap); Cohort 3 (non-LIS and reached catastrophic coverage after the gap); and Cohort 4 (received an LIS, and none of the LIS patients reached the coverage gap). Outcomes included medical care utilization, direct medical costs, and mortality. A total of 11,732 subjects met the inclusion criteria. Patients in Cohorts 1, 2, and 3 had $3,222 lower, $2,457 lower, and $1,182 higher adjusted pharmacy costs (P less than 0.001), but their adjusted hospitalization costs were $1,499 (P = 0.09), $2,287 (P = 0.01), and $2,959 (P = 0.01) higher, respectively, compared with Cohort 4 (LIS). In the propensity score-matched cohorts, patients who reached the coverage gap (Cohort 2) had higher rates of hospitalization (relative risk [RR] = 1.02, 95% CI = 0.94-1.10), outpatient visits (RR = 1.16, 95% CI = 1.08-1.25), and other visits (RR = 1.17, 95% CI = 1.03-1.32) compared with those who had an LIS (Cohort 4). Patients in Cohort 3 had a higher rate of outpatient visits compared with those in Cohort 4 (RR = 1.14, 95% CI = 1.03-1.25). There were no differences in medical care utilization between patients in Cohort 1 and Cohort 4. Compared with patients in Cohort 4 (LIS), patients in Cohort 2 (those who reached the coverage gap) had 9% higher hospitalization costs (RR = 1.09, 95% CI = 1.01-1.18) and 6% higher outpatient costs (RR = 1.06, 95% CI = 0.97-1.17), respectively. During the 1-year follow-up period, patients in Cohort 2 had a 20% (HR = 1.20, 95% CI = 1.05-1.37) and a 22% (HR = 1.22, 95% CI = 1.01-1.47) increased risk of all-cause and cardiovascular-related mortality compared with those in Cohort 4, respectively. Our findings suggest that reaching the Part D coverage gap was associated with unfavorable clinical and economic outcomes in patients undergoing dialysis.

Epidemiology and socioeconomic features of appendicitis in Taiwan: a 12-year population-based study

IntroductionThis paper presents an epidemiologic study of appendicitis in Taiwan over a twelve-year period. An analysis of the incidence in the low-income population (LIP) is included to explore the effects of lower socioeconomic status on appendicitis.MethodsWe analyzed the epidemiological features of appendicitis in Taiwan using data from the National Health Insurance Research Database (NHIRD) from 2000 to 2011. All cases diagnosed as appendicitis were enrolled.ResultsThe overall incidences of appendicitis, primary appendectomy, and perforated appendicitis were 107.76, 101.58, and 27.20 per 100,000 per year, respectively. The highest incidence of appendicitis was found in persons aged 15 to 29 years; males had higher rates of appendicitis than females at all ages except for 70 years and older. Appendicitis rates were 11.76 % higher in the summer than in the winter months. A multilevel analysis with hierarchical linear modeling (HLM) revealed that male patients, younger patients (aged ≤14 years), and elderly patients (aged ≥60 years) had a higher risk of perforated appendicitis; among adults, the incidence increased with age. Moreover, the risk of perforation was higher in patients with one or more comorbidities. LIP patients comprised 1.25 % of the total number of patients with appendicitis from 2000 to 2011. The overall incidence of appendicitis was 34.99 % higher in the LIP than in the normal population (NP), and the incidence of perforated appendicitis was 40.40 % higher in the LIP than in the NP. After multivariate adjustment, the adjusted hospital costs and length of hospital stay (LOS) for the LIP patients were higher than those for the NP patients.ConclusionsAppendicitis and appendectomy in Taiwan had similar overall incidences, seasonality patterns, and declining trends compared to numerous previous studies. Compared to NP patients, LIP patients had a higher risk of appendicitis, longer LOS and higher hospital costs as a result of appendectomy.

Ulcerative colitis-associated hospitalization costs: a population-based study.

Hospitalization costs for ulcerative colitis (UC) following the introduction of infliximab have not been evaluated. To study predictors of costs for UC patients who were hospitalized for a flare or colectomy. Population-based surveillance identified adults (≥18 years of age) admitted to hospital for UC flare or colectomy between 2001 and 2009 in the Calgary Health Zone (Alberta). Medical charts were reviewed and patients stratified into three admission types: responsive to inpatient medical therapy (n=307); emergent colectomy (n=227); and elective colectomy (n=208). The annual median cost with interquartile range (IQR) was calculated. Linear regression determined the effect of admission type on hospital charges after adjusting for age, sex, smoking, comorbidities, disease extent, medication use (eg, infliximab) and year. The adjusted cost increase was presented as the percent increase with 95% CIs. Joinpoint analysis assessed for an inflection point in hospital cost after the introduction of infliximab. Median hospitalization cost for UC flare, emergent colectomy and elective colectomy, respectively, were: $5,499 (IQR $3,374 to $8,904), $23,698 (IQR $17,981 to $32,385) and $14,316 (IQR $11,932 to $18,331). Adjusted hospitalization costs increased approximately 6.0% annually (95% CI 4.5% to 7.5%). Adjusted costs were higher for patients who underwent an elective colectomy (percent increase cost 179.8% [95% CI 151.6% to 211.1%]) or an emergent colectomy (percent increase cost 211.1% [95% CI 183.2% to 241.6%]) than medically responsive patients. Infliximab in hospital was an independent predictor of increased costs (percent increase cost 69.5% [95% CI 49.2% to 92.5%]). No inflection points were identified. Hospitalization costs for UC increased due to colectomy and infliximab.

Abstract 17406: Association of Post-operative Complications with Clinical Outcomes and Hospital Costs following the Norwood Operation

Introduction: Patients undergoing the Norwood operation consume considerable healthcare resources. However, data are limited regarding factors impacting hospitalization costs for these patients. We evaluated the association of post-operative complications with hospital costs. Methods: We utilized a unique dataset consisting of prospectively collected clinical outcomes and complications data from the Pediatric Heart Network Single Ventricle Reconstruction trial linked at the patient level with cost data for hospitals (n=10) participating in the Children’s Hospital Association administrative databases during the trial period. Probabilistic matching of indirect identifiers was used to link records. Cost-to-charge ratios were used to estimate costs, which were adjusted for regional differences and inflation. The relationship between complications and cost was modeled using linear regression, accounting for the skewed distribution of cost, and adjusting for within-center clustering and patient characteristics. Results: A total of 334 eligible Norwood records (95%) were matched between datasets. Overall, 82% suffered at least one complication (median 2; range 0-33). The most common complications associated with increased hospital costs included: cardiopulmonary resuscitation (22%), arrhythmia (22%), sepsis (15%), and extracorporeal membrane oxygenation (11%). Those with complications had longer post-operative length of stay (25d vs. 12d, p&lt;0.0001), more total ventilator days (7d vs. 5d, p&lt;0.0001), and higher in-hospital mortality (17.6% vs. 3.4%, p&lt;0.01). Adjusted hospital costs in those with a complication were $113,505 (95% CI $99,326 - $129,707) vs. $71,453 (95% CI $59,200 - $86,243) in those without a complication, p=0.0001, and costs increased with the number of complications (1-2 complications = $117,137 vs. 3-4 complications = $155,500 [p&lt;0.01] vs. ≥5 complications $266,386 [p&lt; 0.0001]). Conclusions: This unique dataset of merged clinical trial and cost data demonstrated that postoperative complications are common following the Norwood operation and are associated with worse clinical outcomes and higher costs. Efforts to reduce complications in this population may lead to both improved outcomes and cost savings.