Billing Charges Research Articles

Affording unavoidable emergency surgical care - The lived experiences and payment coping strategies of households in Ibadan metropolis, Southwestern Nigeria.

BackgroundPre-payment and risk pooling schemes, central to the idea of universal health coverage, should protect households from catastrophic health expenditure and impoverishment; particularly when emergency care is required. Inadequate financial protection consequent on surgical emergencies occurs despite the existence of risk-pooling schemes. This study documented the experiences and coping strategies of slum and non-slum dwellers in a southwestern metropolis of Nigeria who had undergone emergency surgery.MethodsIn-depth interviews were conducted with 31 participants (13 slums dwellers, 18 non-slum dwellers) who had recently paid for emergency surgical care in Ibadan. Patients who had experienced catastrophic health expenditure from the use of emergency surgical care were identified and people who paid for the care were purposively selected for the interviews. Using an in-depth interview guide, information on the experiences and overall coping strategies during and after the hospitalization was collected. Data were analyzed inductively using the thematic approach.ResultsThe mean age of the 31 participants (consisting of 7 men and 24 women) was 31 ± 5.6years. Apathy to savings limited the preparation for unplanned healthcare needs. Choice of hospital was determined by word of mouth, perceptions of good quality or prompt care and availability of staff. Social networks were relied on widely as a coping mechanism before and during the admission. Patients that were unable to pay experienced poor and humiliating treatment (in severe cases, incarceration). Inability to afford care was exacerbated by double billing and extraneous charges. It was opined that health care should be more affordable for all and that the current National Health Insurance Scheme, that was operating sub-optimally, should be strengthened appropriately for all to benefit.ConclusionThe study highlights households’ poor attitude to health-related savings and pre-payment into a social solidarity fund to cover the costs of emergency surgical care. It also highlights the factors influencing costs of emergency surgical care and the role of social networks in mitigating the high costs of care. Improving financial protection from emergency surgical care would entail promoting a positive attitude to health-related savings, social solidarity and extending the benefits of social health insurance.

Cost-utility analysis comparing surgical and nonsurgical interventions in the treatment of erectile dysfunction

With recent innovative developments in microsurgery, novel, safe, and effective surgical options for erectile dysfunction (ED) are quickly emerging which may replace mainstay medical treatments. In an age where health care is increasingly focused on financial accountability and clinical outcomes, cost-utility analysis between nonsurgical treatment (pharmaceutical agents, mechanical devices, and shockwave therapy) and emerging surgical options will prove relevant and impactful to all physicians that treat patients with ED. The purpose of this study was to use the cost-utility analysis to compare the costs, outcomes, and overall quality of life conveyed to the patient by either nonsurgical or surgical treatments for ED. These results will help patients and physicians form more informed decisions when it comes to the treatment of men suffering from ED. The cost-utility analysis makes use of costs, probabilities, and utilities of health outcomes (referred to as health states) that are used to evaluate opposing interventions. Amazon Mechanical Turk© was used to derive utility scores for health states associated with surgical and nonsurgical interventions. In addition, a systematic review was performed to identify common complications of treatment and associated probabilities. All direct costs were derived from national Medicare facility reimbursement data and national hospital billing charges for fiscal year 2017, and indirect costs were accounted for by our utility estimates. Baseline analysis revealed an incremental cost-utility ratio of $(1428.00) in favor of surgical intervention. The cost of lifetime medical therapy was $15,488.28 greater than that of surgery even when adjusted for inflation. Furthermore, surgery provided patients with a quality-adjusted life-year gain of 10.77 years greater than medical treatment. Long-term costs and utility data should be taken into consideration when determining the best treatment options for a patient with ED. Surgical interventions for erectile dysfunctions represent a significant cost savings to society compared with nonsurgical treatment. Phosphodiesterase type-5 (PDE5) inhibitors offered the greatest cost with the least clinical benefit in the eyes of the patient. Level of evidence: Not ratable.

Impact of an integrated mother-preterm infant intervention on birth hospitalization charges

ObjectiveTo examine whether the H-HOPE (Hospital to Home: Optimizing the Preterm Infant’s Environment) intervention reduced birth hospitalization charges yielding net savings after adjusting for intervention costs.Study designOne hundred and twenty-one mother-preterm infant dyads randomized to H-HOPE or a control group had birth hospitalization data. Neonatal intensive care unit costs were based on billing charges. Linear regression, propensity scoring and regression analyses were used to describe charge differences.ResultsMean H-HOPE charges were $10,185 lower than controls (p = 0.012). Propensity score matching showed the largest savings of $14,656 (p = 0.003) for H-HOPE infants, and quantile regression showed a savings of $13,222 at the 75th percentile (p = 0.015) for H-HOPE infants. Cost savings increased as hospital charges increased. The mean intervention cost was $680 per infant.ConclusionsLower birth hospitalization charges and the net cost savings of H-HOPE infants support implementation of H-HOPE as the standard of care for preterm infants.

Evidence-Based Access to Proton Therapy Does NOT Result in Overutilization: 3-Year Results of a State-Wide Employer-Based Insurance Coverage PILOT

Third party administrators often cite overutilization and cost as justifications for restrictive proton beam therapy (PBT) coverage policies. We collaborated with a state-wide self-funded employer, The University of Texas System (UTS), to implement a PBT coverage pilot ensuring appropriate access to care without increasing cost. This pilot conducts a value-based assessment of PBT through evaluation of utilization trends and comprehensive charge analysis of medical claims. UTS adopted our institution’s evidence-based treatment guidelines and inclusion criteria which expanded PBT coverage by 5 additional body sites: head and neck (HN), esophagus, breast, thoracic, and prostate (GU). Coverage also included patients on 1 of any 6 NCI/NIH randomized controlled trials. The pilot obtained IRB approval, with all patients enrolled on a prospective research trial. The majority of patients with UTS benefits treated with PBT during this time were approved via the pilot. Patient satisfaction (PROs), safety (grade 4-5 complications), treatment related toxicities, and total billed charges (cost of care) were pilot metrics. The primary endpoint was cost of care, including all claims 1 month pre-treatment, through the PBT course, up to 6 months post-treatment. PBT claims were compared with case-matched (by employer, site, indication, and stage) photon patients who were treated within the same enrollment period. Enrollment initiated April 2016, accruing 32 patients over 3 years, vs. predicted utilization of 120 patients (p<.01). The average pilot prior authorization time was <1 business day, vs. the historical pre-pilot average of 17 business days. Of the 32 pilot patients, 22 (9 HN, 8 GU, 3 breast, 2 thoracic) were treated with PBT with a median follow-up of 20.1 months. There were no Grade 4-5 toxicities. During this timeframe, 25 patients who met pilot eligibility were instead treated with photons. Out of these, 17 were case-matched to 17 PBT pilot patients with ≥6 month follow-up. Median number of fractions was 30 for both groups (p=.96). On analysis, employer costs with PBT were dramatically lower than estimated (initially expecting an increase for PBT), with average billed charges actually 4.4% lower for PBT (p=.84). Percentage of RT charges to total charges was 77% vs. 64% for PBT and photons (p=.09), respectively, with higher ancillary care utilization by the latter. This state-wide insurance coverage pilot demonstrates that appropriate access to PBT does not result in overutilization or increased employer cost. Objective evidence-based treatment guidelines and policies can ensure appropriate patient selection while reducing administrative burden. Collaboration among employers, payers, and providers can improve access to PBT without increasing cost.

Orthopedic Surgeons Have Inadequate Knowledge of the Cost of Trauma-Related Imaging Studies.

Radiographic imaging is integral to the diagnosis and treatment of orthopedic injuries. Previous studies have shown that orthopedists consistently underestimate the price of implants, but their knowledge of imaging charges is unknown. This study evaluated whether orthopedic residents and faculty could accurately estimate charges of imaging modalities at their respective institutions. A survey with 10 common imaging studies was sent to 8 academic level I trauma centers. Participants estimated the total charge of each imaging modality. This was compared with the actual charge at their institution. Seven centers produced 162 responders: 74 faculty and 88 residents. The differences between the estimated cost and the billing charge were calculated and broken down by training level and imaging modality. Overall, imaging charges were underestimated by 31% (P<.001), with 19.4% of estimates being within 20% of actual charges (95% confidence interval, 19.1-19.9). There was no difference between training levels (P=.69). There was greater than 1000% variation in charges between institutions. Orthopedists across training levels underestimate hospital charges associated with common imaging studies, and there is a large variation in charges between centers. Awareness of charges is important because charges affect clinical decision making and are relevant to practicing both cost-conscious and clinically sound medicine. [Orthopedics. 2019; 42(5):e454-e459.].

Utility Dependency Reduction by Multi-Agent Participation in Smart Grid

The Electric vehicle has a battery to store electric energy in the form of chemical energy as the energy stored in invertor’s batteries. These sources are used as a self-supporting energy source at the time of outage of electricity due to a fault, equipment’s failure and other not working conditions if they have stored energy. In this paper, a multi-agent system is consisting of microgrid agent, home agent, control distribution agent, and supply source. The supply source agents include those agents who control the storage; it also called as energy storage agents which are controlled by house agents. If the utility is not providing the demand energy to the consumers due to fault or some other reasons in this case stored energy in batteries and other resources like a solar panel, small wind plant of the microgrid and provide the energy within the microgrid and outside the microgrid. In this paper main focus is given on the Priority index, cost optimization, and load optimization algorithms. By doing this it helps in providing the energy during the outage at the lower cost and dependency on the main grid may be reduced. It also boosts the principle of bidirectional flow of power which make consumer as a supplier also. This will reduce the electric bill charges and increases the reliability of supply electricity.

Is There Value in Radiology Reads for Pediatric Supracondylar Fractures in the Outpatient Clinic?

Increased health care costs have driven assessment of value of common practices. The Joint Commission mandates the dual interpretation of musculoskeletal radiographs by radiologists and orthopedic surgeons in hospital-based clinic settings. However, the value of this practice has come under question. The purpose of this study was to investigate whether radiologist interpretations change orthopedists' management during follow-up of pediatric supracondylar humerus fractures. A retrospective review was performed of pediatric elbow fractures at a single institution from January 2012 to December 2015. Patients with supracondylar humerus fractures and at least one clinic follow-up were included. For each radiograph, the orthopedic surgeon and radiologist interpretations were reviewed and a determination was made as to whether the radiologist interpretation affected management of the patient. In films with disagreement of displacement, Baumann angle and posterior displacement based on Gartland classification with Wilkins and Leitch modifications were measured. Timing of final radiologist and orthopedic interpretations were also assessed. Finally, billing charges of radiologist interpretations were assessed. There were 441 pediatric supracondylar humerus fracture patients included in this study. All 441 patients had at least 1 clinic follow-up, 397 patients had at least 2 clinic follow-ups, and 123 patients had at least 3 clinic follow-ups, with a total of 716 elbow radiographs obtained. There were 17 cases (2.4%) where orthopedics and radiologist final interpretations disagreed regarding fracture displacement. In no cases did radiologist interpretations change orthopedic management. Radiographs that orthopedics interpreted as displaced were more likely to be posteriorly displaced (80.0% vs. 0.0%; P=0.002). However there was no difference in Baumann angle (P=0.125). Of the 716 films included, 28 radiologist interpretations were performed the day after the clinic visit (4%). Excluding these cases, there was an average of 57±3 minutes between radiograph acquisition and final interpretation. There were 352 cases where final orthopedic note filing time was documented, and 32% of these notes were finalized prior to the final radiologist interpretations. The total charges of radiologist interpretations was $18,772. The results of this study suggest that dual-interpretation of radiographs obtained in the follow-up clinic setting does not add value in management of pediatric supracondylar humerus fractures. Level IV-case series.

THE RISE AND FALL OF DGEMRIC EVALUATION IN THE ADOLESCENT HIP

BACKGROUND: Delayed Gadolinium Enhanced Magnetic Resonance Imaging of Cartilage (dGEMRIC) was first introduced in 1996 by Bashir et al. as a method of indirectly evaluating glycosaminoglycan (GAG) changes in cartilage microstructure. Following publications originating from the Boston Children’s research group describing the association of early joint failure following periacetabular osteotomy (PAO) in patients with diminished preoperative cartilage T1 relaxation values, the interest in this imaging technique spread. dGEMRIC imaging was introduced into our clinical practice in 2013 with enrollment of both pediatric and adult patients. However, since the program’s apex in 2015, a marked decline in referral of adolescent patients for preoperative dGEMRIC imaging has occurred. Using data acquired during a quality analysis of the dGEMRIC program, this project was designed to investigate the utility of the dGEMRIC exam in our adolescent imaging cohort from 2013-2015 and to identify potential factors leading to decreased utilization from 2015-2018. METHODS: IRB approval was obtained for a HIPAA-compliant, retrospective cohort study which included all patients referred for dGEMRIC from May 2013- June 2015. 108 patients/112 exams/122 hips were identified. The study was designed in 4 parts including a. Blinded quantitative imaging review x 2 performed by 4 radiologists, b. Surgical review with 2 year post-operative follow-up completed July 2017, c. Patient phone interview, and d. Financial billing and reimbursement analysis. Subsequently, dGEMRIC utilization data from July 2015-May 2018 was compiled for comparative analysis of adolescent referral patterns. RESULTS: Of the 108 patients included in the comprehensive retrospective analysis, 56 were &lt; 19 years of age with 43% of the adolescent patients participating in sports at time of presentation. 4 patients were excluded as the dGEMRIC data was either incomplete or could not be reprocessed. 61 hips were evaluated in the remaining 52 patients. The following summary data was compiled during the 4 part analysis. From the radiologist review: Siemens MapIt® T1 measurement software performed well at both 1.5 T and 3 T with good to excellent within rater ICC (0.79-0.92) but the between rater agreement was lacking particularly at 3.0 T (0.45) compared to 1.5 T (0.77) (p&lt;0.05). Variability between sequential T1 measurements performed by the same radiologist at 2 different time points existed averaging 36-41 ms at 1.5 T and 76-84 ms at 3 T. From the surgical perspective: 17 hips in 16 patients were determined to have abnormally low T1 relaxation values when reprocessed by the 4 radiologists. 1 patient’s T1 values differed significantly after blinded review compared to the original interpretation. Of the 16 abnormal patients, 5 were referred for total hip arthroplasty. 7 patients underwent surgical intervention (2 PAO, 3 arthroscopic debridement/rim trim/chondroplasty/labral repair, 2 femoral/acetabular osteotomy). 1 patient was referred to rheumatology and 3 were lost to follow-up. After 2 year follow-up, all surgical patients reported decreased pain and improved function compared to presentation. From the patient perspective: 62 of the original 108 patients were contacted by phone with 60 (56%) participating in the phone survey. Patients described the dGEMRIC exam as a difficult procedure. The total time expenditure for the dGEMRIC exam averaged 3.5 hours in hospital with an average time in magnet of 107 minutes. 40% of patients reported significant pain with the pre-imaging exercise and 33% reported significant pain while in the MRI. Of 49 respondents who had undergone previous hip injections, 28 (57%) stated the dGEMRIC exam was as or more difficult than the injection. However, 50/57 (88%) stated they would undergo dGEMRIC again if the surgeon felt the information would be of added value in decision making. From the financial review, a lack of standardization of CPT codes billed was discovered resulting in discrepant billed charges varying by a factor &gt;10 ($2300-$24,000). Following completion of the quality analysis and review of the results with the referring orthopedists, only 17 dGEMRIC exams have been performed in the adolescent age group in the subsequent 36 months. CONCLUSIONS: While the dGEMRIC exam holds promise as a prognosticating tool to guide surgical planning, in the adolescent practice environment, our historical data reveals that even when faced with abnormal T1 relaxation values, surgeons may opt to proceed with hip sparing surgical procedures simply because of the young age of the patient. From the radiologist’s perspective, dGEMRIC reporting is clouded by measurement variability. Inherent variability in the numbers reported brings to question the wisdom of using absolute T1 numeric thresholds to prognosticate joint failure risk. From the patient’s perspective, this imaging test comes with significant cost measured by time, pain, and financial burden. For all these reasons, utilization of this imaging study should be limited to the select few adolescent patients in whom documentation of an abnormal cartilage T1 value alone could substantially impact the surgical plan.

Interruptible Power Estimation and Auxiliary Service Allocation Using Contract Theory and Dynamic Game for Demand Response in Aggregator Business Model

The traditional power market only considers the cost for electricity users, the willingness-to-pay, and the priority of electricity consumption. From the perspective of the electricity industry, only stable power supply, generator equipment set expansion, new power plant construction, and the strengthening of the transmission grid can meet the requirements of electricity users. In recent years, the distributed generation (DG) and energy storage system capacity in microgrid have gradually increased, effectively reducing and suppressing the demand from traditional power sources. In addition, incentive or contractual strategies, such as time-of-use and real-time pricing, can also encourage electricity users to change their electricity consumption behaviors. If the DGs can be integrated into generation aggregators in cooperation with demand response (DR) and efficient load direct/indirect) controls, it can meet the users' demands in auxiliary service (AS) market, as well as achieve a win-win mode for the electricity industry and electricity users. Hence, this study proposes the contract theory (CT) to estimate the interruptible power of the user group (DR aggregator) for DR during peak periods. Then, according to the user group's DR, the dynamic game model (DGM) is used to effectively allocate AS power under the consideration of the DG resource risk situation. In the aggregator business market, experimental results will show that the proposed methods can suppress the use of traditional power sources, effectively activate the proportion of schedulable DG, increase system flexibility, and increase billing charges.

The feasibility and promise of mobile technology with community health worker reinforcement to reduce rural preterm birth

(1) Assess feasibility of a smartphone platform intervention combined with Community Health Worker (CHW) reinforcement in rural pregnant women; (2) Obtain data on the promise of the intervention on birth outcomes, patient activation, and medical care adherence; and (3) Explore financial implications of the intervention using return on investment (ROI). A total of 98 rural pregnant women were enrolled and assigned to intervention or control groups in this two-group experimental design. The intervention group received usual prenatal care plus a smartphone preloaded with a tailored prenatal platform with automated texting, chat function, and hyperlinks and weekly contact from the CHW. The control group received usual prenatal care and printed educational materials. Demographics, health risk data, interaction with platform, medical records, hospital billing charges, Client Satisfaction Questionnaire-8, satisfaction comments, and the Patient Activation Measure. A total of 77 women completed the study. The intervention was well-received, showed promise for improving birth outcomes, patient activation, and medical care adherence. Financial analysis showed a positive ROI under two scenarios. Despite several practical issues, the study appears feasible. The intervention shows promise for extending prenatal care and improving birth outcomes in rural communities. Further research is needed with a larger and more at-risk population to appreciate the impact of the intervention.

Safety, Efficacy, and Cost-Analysis of Percutaneous Endoscopic Gastrostomy and Ventriculoperitoneal Shunt Placement in a Simultaneous Surgery

Limited historical data suggest that concomitant placement of both a ventriculoperitoneal (VP) shunt and percutaneous endoscopic gastrostomy (PEG) tube is associated with an increased risk of complications, including VP shunt infections. Here we compare the outcomes and cost difference between 2 groups of patients, one in which a VP shunt and PEG tube were placed in the same operation and the other in which separate operations were performed. A total of 10 patients underwent simultaneous placement of a VP shunt and PEG tube. This group was compared with a group of 18 patients that underwent separate placements. Hospital billing charges were used to compare the total cost of the procedures in the 2 groups. Eight of the 10 patients presented with aneurysmal subarachnoid hemorrhage. The average length of stay was 25 ± 2 days for the simultaneous procedure group and 43 ± 7 days for the separate procedures group. The average duration of follow-up was 12 ± 3 months after simultaneous placement. No patient in the simultaneous surgery group had signs of infection or shunt malfunction at last follow-up. The overall complication rate was significantly lower in the simultaneous surgery group. A cost analysis demonstrated significant cost savings by completing both procedures in the same surgical procedure. Simultaneous placement of a PEG tube and VP shunt is safe, efficacious, and cost-effective. Thus, in patients requiring both a VP shunt and PEG tube, placement of both devices in a single surgical procedure should be considered.

3:27 PM Abstract No. 114 Nationwide trends in pediatric percutaneous kidney and liver biopsies: is there a value proposition for interventional radiologists who can safely perform these procedures as outpatients?

To investigate trends, costs, relative safety, and potential savings of inpatient versus outpatient percutaneous kidney and liver biopsies in the pediatric population. Data on admission type and cost (using billed charges as a cost-surrogate) from all percutaneous kidney and liver biopsies performed from 2008-2015 was collected using the Pediatric Health Information System (PHIS), a comparative database of patient encounters from 44 US Children’s Hospitals. Regression analysis was performed to evaluate the annual trend in the biopsy patients admitted as inpatients vs outpatients. Costs were compared using the Tukey-Kramer Method (significance: p < 0.05). To assess safety of outpatient biopsies performed by interventional radiology (IR), data was collected on all percutaneous kidney and liver biopsies performed at a single, large tertiary care children’s hospital (“Hospital A”) from 2014-2017, using complications requiring escalation in care (SIR Classifications B-F) as a surrogate for safety. 7,835 kidney and 9,984 liver biopsies were performed by all specialties at all PHIS hospitals. Regression analysis showed a significant annual decline in percentage of kidney (-0.6%, p = 0.008) and liver (-3.0%, p = 0.01) biopsies. Notably, > 15% and >10% of kidney and liver biopsies were still performed as inpatients as of 2015, respectively. Costs were significantly (p < 0.0001) higher for inpatient biopsies (mean: $65,872 + $201,572 for kidney, mean: $173,331+ $505,177 for liver) vs outpatients (mean: $13,410 + $7,385 kidney, mean: $10,338+ $7,273 liver). 223 kidney biopsies and 441 liver biopsies were performed on outpatients from 2014-17 by IR at Hospital A. Percutaneous kidney biopsy complication rate = 1.3% (1 SIR class C, 2 SIR class D). Percutaneous liver biopsy complication rate = 0.2% (1 SIR Class C). A substantial percentage of pediatric patients are still admitted as inpatients for postprocedure monitoring following percutaneous kidney and liver biopsies. Our study shows that these procedures can be done safely by IRs as outpatients, offering substantial potential cost savings for healthcare systems.

Orthognathic Surgical Outcomes in Patients With and Without Craniofacial Anomalies

The objective of this study is to examine hospitalization outcomes after orthognathic surgery.This study tests the hypothesis that patients with craniofacial anomalies have higher billed hospital charges, longer lengths of stay, and increased odds of development of infectious complications when compared with patients without craniofacial anomalies. The Nationwide Inpatient Sample for the years 2012 and 2013 was used. All patients who underwent an orthognathic surgical procedure were selected. The primary independent variable of interest was presence of a congenital cleft and/or craniofacial anomaly.The outcome variables were the occurrence of complications, billed hospital charges, and length of stay. Multivariable logistic and linear regression models were used to examine the effect of the presence of craniofacial anomalies on outcomes. During the study period, a total of 16,515 patients underwent an orthognathic surgical procedure in the United States. Of these patients, 2,760 had a cleft and/or craniofacial anomaly. An infectious complication occurred in 7.4% of those with a craniofacial anomaly (compared with 0.6% of those without a craniofacial anomaly). The mean billed hospital charges in those with a craniofacial anomaly was $139,317 (compared with $56,189 in those without a craniofacial anomaly). The mean length of stay in the hospital in patients with a craniofacial anomaly was 8.8days (compared with 1.8days in those without a craniofacial anomaly). These differences in outcomes between patients with and patients without craniofacial anomalies were significant after we adjusted for patient- and hospital-level confounders. Patients with a craniofacial anomaly are at higher risk of development of infectious complications, have higher hospital charges, and stay in the hospital for a longer duration after orthognathic surgery when compared with those without a craniofacial anomaly.

Measuring public understanding on Tenaga Nasional Berhad (TNB) electricity bills using ordered probit model

In 2016, Tenaga Nasional Berhad (TNB) had introduced an upgrade in its Billing and Customer Relationship Management (BCRM) as part of its long-term initiative to provide its customers with greater access to billing information. This includes information on real and suggested power consumption by the customers and further details in their billing charges. This information is useful to help TNB customers to gain better understanding on their electricity usage patterns and items involved in their billing charges. Up to date, there are not many studies done to measure public understanding on current electricity bills and whether this understanding could contribute towards positive impacts. The purpose of this paper is to measure public understanding on current TNB electricity bills and whether their satisfaction towards energy-related services, electricity utility services, and their awareness on the amount of electricity consumed by various appliances and equipment in their home could improve this understanding on the electricity bills. Both qualitative and quantitative research methods are used to achieve these objectives. A total of 160 respondents from local universities in Malaysia participated in a survey used to collect relevant information. Using Ordered Probit model, this paper finds respondents that are highly satisfied with the electricity utility services tend to understand their electricity bills better. The electric utility services include management of electricity bills and the information obtained from utility or non-utility supplier to help consumers manage their energy usage or bills. Based on the results, this paper concludes that the probability to understand the components in the monthly electricity bill increases as respondents are more satisfied with their electric utility services and are more capable to value the energy-related services.

Comparative Cost of Surgical and Nonsurgical Treatment of Acute Achilles Tendon Rupture

Category: Sports, Practice Management Introduction/Purpose: Treatment of acute achilles tendon rupture (AATR) is controversial. Prospective clinical trials have demonstrated similar functional and quality of life outcomes following surgical repair and nonoperative care when a functional rehabilitation protocol is utilized. Meta-analysis would suggest that the apparent benefit of surgical treatment is an earlier return to function at the cost of an increased risk for surgical wound morbidity. The goal of this investigation was to perform a cost analysis of patients in a single orthopaedic clinic comparing operative and nonoperative treatment of acute achilles tendon rupture. Methods: After receiving IRB approval, patients whom were treated for acute Achilles tendon ruptures were retrospectively selected. A total of 13 adult patients with AATR, 6 non-operative and 7 operative, were identified in the period between June 1st 2014 and January 1st 2016. All patients participated in the same functional rehabilitation protocol. All patients had 1 year follow- up. Results: Operative treatment resulted in 3.7 times higher cost of total care compared to nonoperative treartment ($25,239 vs $6,785). Surgeon charges were 3.3 times higher in the operative group as well. ($4,543 vs $1,395). During the total length of treatment, patients in the operative group had an average of 7.4 physician visits and produced 11.9 surgeon relative value units (RVUs) while the non-operative group had 9.2 visits (p=0.0431) and produced 9.68 surgeon RVUs (p=0.102). Conclusion: Operative treatment of AATR had 3.7 times higher per patient treatment cost, 3.3 times higher billed surgeon charges, and slightly fewer physician visits, but with no statistically significant difference in the number of physician RVUs produced. This study questions the cost-effectiveness of operative treatment for AATR given previous long-term studies demonstrating equivalent 1-year patient outcomes.

Characteristics, length of stay, and hospital bills associated with severe odontogenic infections in Houston, TX

BackgroundThere were 2 main purposes of this retrospective chart review study. The first was to describe the demographic, social, and financial characteristics of patients with severe odontogenic infections. The second was to assess the relationships among several demographic, social, and treatment variables and length of stay (LOS) in the hospital and hospital bill (charges). MethodsThe authors conducted a retrospective chart review for patients admitted to the hospital and taken to the operating room for treatment of severe odontogenic infections at 3 hospitals in Houston, TX (Ben Taub, Memorial Hermann Hospital, and Lyndon B. Johnson) from January 2010 through January 2015. ResultsThe authors included data from severe odontogenic infections in 298 patients (55% male; mean age, 38.9 years) in this study. In this population, 45% required admission to the intensive care unit, and the mean LOS was 5.5 days. Most patients (66.6%) were uninsured. The average cost of hospitalization for this patient population was $13,058, and the average hospital bill was $48,351. At multivariable analysis, age (P = .011), preadmission antibiotic use (P = .012), diabetes mellitus (P = .004), and higher odontogenic infection severity score (P < .001) were associated with increased LOS. Higher odontogenic infection severity score, diabetes mellitus, and an American Society of Anesthesiologists score of 3 or more were associated with an increased charge of hospitalization. ConclusionsSevere odontogenic infections were associated with substantial morbidity and cost in this largely unsponsored patient population. The authors identified variables associated with increased LOS and charge of hospitalization. Practical ImplicationsClinicians should consider these findings in their decision-making processes and prioritize early treatment of odontogenic infections potentially to decrease the number of patients admitted to the hospital, LOS, and overall costs of treatment for these infections.

Impact of a Fellowship-Trained Minimally Invasive Gynecologic Surgeon on Patient Outcomes.

Background and Objectives:As the performance of minimally invasive hysterectomy has increased in the United States, the need to apply outcomes measures has also increased. This study was conducted to determine the impact of a fellowship-trained minimally invasive gynecologic surgery (MIGS) specialist on patient outcomes after laparoscopic hysterectomy (LH) in a gynecology department.Methods:This is a retrospective review of 218 patients who underwent a laparoscopic hysterectomy for benign indications at a suburban academic-affiliated tertiary care hospital with a broad patient base from 2010 to 2014.Results:A total of 218 women underwent conventional laparoscopic hysterectomy by 10 members of a gynecology department: 96 women (44%) by a MIGS specialist and 122 women (56%) by a group of general gynecologists. Operative time was less (119 vs 148 min; P < .001), and patients were more likely to be discharged on the same day (90.6% vs 66.4%; P < .001) for the MIGS specialist compared to other surgeons. More patients of the MIGS specialist had undergone prior laparotomies (42.7% vs 17.2%; P = < .001) and had a greater uterine weight (392 vs 224 g; P < .001). Although the difference was not statistically significant, conversion to laparotomy (0 vs 2 cases; P = .505) and postoperative infection (6 vs 16 cases; P = .095) were lower for the MIGS specialist. Total billing charges were also lower for the MIGS specialist ($9,920 vs $11,406; P < .001).Conclusion:A fellowship-trained MIGS specialist performed laparoscopic hysterectomy in less time on more difficult surgical patients, with a shorter length of stay and lower costs, and no difference in complications compared to other providers in a gynecology department.

Can progression of odontogenic infections to cervical necrotizing soft tissue infections be predicted?

The progression of odontogenic infections to necrotizing soft tissue infections (NSTIs) is unknown. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score is used to predict risk of NSTI. This study aimed to (1) estimate the frequency at which odontogenic infections progress to NSTIs, (2) measure the value of LRINEC in predicting progression to NSTI, and (3) estimate the charges associated with managing NSTIs. This retrospective cohort study enrolled all subjects admitted for the management of odontogenic infections from 2001 to 2013. The primary predictor was the LRINEC score. The primary outcome was NSTI. The secondary outcome was billing charges. Descriptive and bivariate statistical analyses were performed, with significance set at a P-value of <0.05. Of 479 odontogenic infections, (1.0%) progressed to NSTI. The mean LRINEC for NSTI was 5.8 and for odontogenic infection was 3.4 (P=0.043). LRINEC parameters for the prediction of NSTIs had 60% sensitivity, 68.4% specificity, 20% positive predictive value, and 92.9% negative predictive value. The mean charge for NSTI was $319,337 and for odontogenic infections was $19,291 (P=0.051). One percent of odontogenic infections progressed to NSTIs. The LRINEC score was not able to identify all NSTIs. NSTIs are 16 times more costly.

Reducing Inpatient Length of Stay Using a Multicollaborative Protocol for Management of Non-Intensive Care Unit Asthmatics.

Maximizing clinical efficiency through the reduction in inpatient length of stay (LOS) using standardized protocols has been a major objective among hospital administrators, most notably in the context of recent healthcare reimbursement changes at statewide levels. The objective of our project was to determine whether a synchronous change in an inpatient asthma protocol that relied on a respiratory therapist (RT)-driven bronchodilator weaning algorithm and bronchodilator therapy given through a metered dose inhaler (MDI) plus valved holding chamber (VHC) could impact clinical and financial outcomes. A pre-post study assessed patients aged 2-21 years of age admitted with a primary diagnosis of status asthmaticus. The effect of the protocol was measured from October 2014 to July 2015. Outcome variables included patient demographics, hospital LOS, all-patient refined diagnosis-related groups (APR-DRGs), and inpatient charges. Outcomes were compared between the preimplementation and postimplementation time periods. Statistical significance was measured using Wilcoxon signed-rank test and bootstrap logistic regression models. Protocol patients (n = 110) had a similar demographic and clinical profile compared with the matched population from the previous nonprotocol fiscal year (n = 150). Use of the protocol resulted in a significantly reduced LOS that maintained significance after adjusting for APR-DRGs weight (P < 0.05). The protocol did not alter the total hospital billing charges. A nonstatistically significant reduction in 30-day readmission rates was observed among those administered the protocol. An RT-led weaning protocol using a quantitative scoring system and MDI+VHC for bronchodilator administration resulted in a significantly reduced LOS.

A prospective randomized cost billing comparison of local fasciocutaneous perforator versus free Gracilis flap reconstruction for lower limb in a developing economy

Distal half leg complex wounds are usually a formidable problem that necessitates either local or free flap coverage. The aim of this study was to compare cost billing charges in free Gracilis flap (fGF) and local fasciocutaneous perforator flap (lFPF) in reconstructing complex soft tissue leg and foot defects. Thirty consecutive adult (>15-year-old) patients with soft tissue defects in the leg and/or foot requiring tissue coverage with a flap in the period between 2012 and 2015 were randomly assigned (block randomization) to either an fGF or lFPF procedure. The outcome measures addressed were total billed charges costs, perioperative billed charges cost, partial or complete flap loss, length of hospital stay, inpatient postsurgical care duration, complications, operating time and number of operative scrub staff. One patient suffered from complete flap loss in each group. Reconstruction with lFPF showed total lower billed charges costs by 62% (2509 USD) (p<0.001) and perioperative billed charges cost by 54% (779 USD) (p<0.001), and shorter total hospital stay (36.5 days; p<0.001), inpatient postsurgical care duration (6.4 days; p<0.001), operating time (4.3h; p<0.001) and fewer scrub staff (2.2 persons; p<0.001). These results suggest that neither flap is totally superior to the other; the choice should instead be based on the outcome sought and logistics. lFPF requires lower billed charges cost and resource use and saves operative time and personnel and reduces length of hospital stay. Our approach changed towards using perforator flaps in medium-sized defects, keeping the free flap option for larger defects.