Admission Charges Research Articles

A propensity score-matched cost-effectiveness analysis of magnetic resonance-guided laser interstitial thermal therapy versus craniotomy for brain tumor radiation necrosis.

Radiation necrosis is becoming an increasingly prevalent complication in patients with brain tumors given the growing utility of stereotactic radiosurgery in modern treatment paradigms. Magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) is a new minimally invasive modality that has exhibited an efficacy comparable to craniotomy in treating radiation necrosis. No studies to date have compared their cost-effectiveness despite the significant additional expenses associated with MRgLITT use. This study aimed to evaluate the cost-effectiveness of MRgLITT versus craniotomy in patients with comparable presentations of radiation necrosis. The National Inpatient Sample (NIS) was queried from 2011 to 2020 for patients with radiation necrosis and treated using craniotomy or MRgLITT. Admission charges and costs were inflation adjusted to 2020 $US. Surgical cohorts were propensity score-matched according to demographic, clinical, and admission characteristics. Multivariable linear and logistic regression analyses identified associations between type of intervention and outcomes. A semi-Markov model was created to simulate treatment with craniotomy versus MRgLITT. Cost, transition probabilities, and health state utilities were derived from the NIS, individual patient outcomes from multiple institutions, and prospectively collected quality-of-life data from a single institution and verified against other studies. Monte Carlo simulation and probabilistic sensitivity analysis were used to evaluate the cost-effectiveness between the two modalities. In the designated study period, 2869 patients had been admitted with brain tumor radiation necrosis and were managed with neurosurgical intervention. After propensity score matching, MRgLITT, relative to craniotomy, was independently associated with a shorter length of stay (LOS; β = -1.81, p = 0.002), lower odds of complications (OR 0.18, p = 0.033), and higher odds of home discharge (OR 3.05, p = 0.041), but there was no difference in total admission costs between the two modalities (β = $6229, p = 0.081). On Monte Carlo simulation, patients treated with MRgLITT had a lower probability of disease (radiation necrosis or tumor) recurrence (13.5% vs 22.0%, p < 0.001) but an equivalent mortality risk (22.8% vs 22.3%, p = 0.429) compared to the patients treated with craniotomy at the 1-year follow-up. Over a 4-year time horizon, MRgLITT had an incremental cost of -$25,685 and incremental effectiveness of 0.14 quality-adjusted life-year (QALY), resulting in an incremental cost-effectiveness ratio of -$183,464 per QALY relative to craniotomy. MRgLITT was a more cost-effective treatment strategy than craniotomy in the management of patients with brain tumor radiation necrosis. The cost-effectiveness of MRgLITT may be attributed to a shorter LOS, lower complication odds, and higher home discharge odds in the immediate postoperative period and a lower risk of disease recurrence over the long-term follow-up.

Electric Scooter-related Injuries Are Becoming More Frequent and Costly in Denver, CO.

Electric scooters (e-scooters) have become a widely adopted form of transportation. Information regarding the timing, conditions, and context associated with increased frequency of e-scooter-related injuries could inform policy that may potentially reduce associated injuries and healthcare costs. However, this information is lacking, as most research to date has focused on the injury patterns sustained while using e-scooters rather than context. We sought to evaluate these factors in an urban setting and describe how these are evolving over time, as such information may help guide future safety initiatives. (1) How has the epidemiology of e-scooter-related injuries in Denver, CO, USA, changed over time? (2) What are the associated hospital charges to treat patients with these injuries? (3) What circumstances are associated with an increased frequency of e-scooter-related injuries and higher accompanying hospital charges? A retrospective study at a Level 1 trauma center in Denver, CO, USA, examined trends in e-scooter-related injuries from January 1, 2020, to November 1, 2023. Patients were identified by the key terms "e-scooter crash" or "scooter" within their emergency department/urgent care visit notes. Patient demographic and injury characteristics and hospital data (admission and hospital charges) were analyzed. Patients who sustained injuries from devices other than stand-up e-scooters or who did not have complete records available for analysis were excluded. The epidemiologic data on e-scooter-related injuries were quantified for each year within the study period, and descriptive analyses were performed to assess patient and injury characteristics, including age, gender, and fracture characteristics. Hospital charges were calculated using the mean annual sum of hospital charges associated with the treatment for e-scooter-related injuries. Circumstances influencing the frequency of injury and magnitude of hospital charges were assessed based on the timing of presentation to the emergency department or urgent care. We recognize that charge may have little or no direct relationship to true cost, but we believe that within one hospital system it represents a reasonable metric for comparative resource utilization. Injury frequency by time of the day and day of the week were compared using chi-square goodness-of-fit analyses. The value of hospital charges associated with e-scooter-related injuries was compared between patients presenting with alcohol intoxication and those who were not intoxicated. In all, 2424 patients were identified as having e-scooter-related injuries (58% [1405] men, 42% [1019] women, median (IQR) age 30 years [25 to 37 years]). The number of annual e-scooter-related injuries during the years 2020 to 2023 were 273 in 2020, 736 in 2021, 758 in 2022, and 657 in 2023 (only 10 months). From 2020 to 2023, the mean annual sum of hospital charges for treatment of e-scooter-related injuries was USD 10.4 million; USD 6.4 million in 2020, USD 11.5 million in 2021, USD 11.9 million in 2022, and USD 10.9 million in 2023 (only 10 months). Hospital charges associated with orthopaedic e-scooter-related injuries amounted to a mean annual sum of USD 3.6 million over the 4-year study period; USD 1.5 million in 2020, USD 3.9 million in 2021, USD 4.5 million in 2022, and USD 4.1 million in 2023 (only 10 months). Forty-five percent (1098) of all e-scooter-related injuries occurred between 7 PM and 3 AM, and 44% (1064) of them occurred over the weekend. The treatment of e-scooter-related injuries incurred higher hospital charges if injuries occurred during night hours (median [IQR] USD 10,459 [4779 to 16,423]) compared with early morning (USD 4973 [1178 to 11,671]) or daytime hours (USD 4871 [1059 to 11,673]; p < 0.001), or while patients were intoxicated (USD 13,404 [10,346 to 22,525]) compared with those who were not intoxicated (USD 6132 [2612 to 13,620]; p < 0.001). E-scooter-related injuries are increasing in frequency and occur most commonly during nighttime and weekend hours. Total hospital charges to treat these injuries are also increasing annually, with the highest charges observed during evening hours and in patients presenting with alcohol intoxication. These results may help inform e-scooter awareness initiatives and policy reform to place restrictions on e-scooter use during periods of highest injury frequency and healthcare charges. Further research related to the efficacy of implementing e-scooter restrictions is needed. Future observational studies evaluating time of injury compared with presentation for treatment could help to provide a more precise understanding of the epidemiology of these injuries. Level IV, prognostic study.

Using Machine Learning Models to Identify Factors Associated With 30-Day Readmissions After Posterior Cervical Fusions: A Longitudinal Cohort Study.

Readmission rates after posterior cervical fusion (PCF) significantly impact patients and healthcare, with complication rates at 15%-25% and up to 12% 90-day readmission rates. In this study, we aim to test whether machine learning (ML) models that capture interfactorial interactions outperform traditional logistic regression (LR) in identifying readmission-associated factors. The Optum Clinformatics Data Mart database was used to identify patients who underwent PCF between 2004-2017. To determine factors associated with 30-day readmissions, 5 ML models were generated and evaluated, including a multivariate LR (MLR) model. Then, the best-performing model, Gradient Boosting Machine (GBM), was compared to the LACE (Length patient stay in the hospital, Acuity of admission of patient in the hospital, Comorbidity, and Emergency visit) index regarding potential cost savings from algorithm implementation. This study included 4,130 patients, 874 of which were readmitted within 30 days. When analyzed and scaled, we found that patient discharge status, comorbidities, and number of procedure codes were factors that influenced MLR, while patient discharge status, billed admission charge, and length of stay influenced the GBM model. The GBM model significantly outperformed MLR in predicting unplanned readmissions (mean area under the receiver operating characteristic curve, 0.846 vs. 0.829; p < 0.001), while also projecting an average cost savings of 50% more than the LACE index. Five models (GBM, XGBoost [extreme gradient boosting], RF [random forest], LASSO [least absolute shrinkage and selection operator], and MLR) were evaluated, among which, the GBM model exhibited superior predictive performance, robustness, and accuracy. Factors associated with readmissions impact LR and GBM models differently, suggesting that these models can be used complementarily. When analyzing PCF procedures, the GBM model resulted in greater predictive performance and was associated with higher theoretical cost savings for readmissions associated with PCF complications.

Financial toxicity among patients undergoing resectional surgery for inflammatory bowel disease in the United States.

Financial toxicity describes the financial burden and distress that patients experience due to medical treatment. Financial toxicity has yet to be characterized among patients with inflammatory bowel disease (IBD) undergoing surgical management of their disease. This study investigated the risk of financial toxicity associated with undergoing surgery for IBD. This study used a retrospective analysis using the National Inpatient Sample from 2015 to 2019. Adult patients who underwent IBD-related surgery were identified using the International Classification of Diseases (10th Revision) diagnostic and procedure codes and stratified into privately insured and uninsured groups. The primary outcome was risk of financial toxicity, defined as hospital admission charges that constituted 40% or more of patient's post-subsistence income. Secondary outcomes included total hospital admission cost and predictors of financial toxicity. The analytical cohort consisted of 6412 privately insured and 3694 uninsured patients. Overall median hospital charges were $21 628 (interquartile range $14 758-$35 386). Risk of financial toxicity was 86.5% among uninsured patients and 0% among insured patients. Predictors of financial toxicity included emergency admission, being in the lowest residential income quartile and having ulcerative colitis (compared to Crohn's disease). Additional predictors were being of Black race or male sex. Financial toxicity is a serious consequence of IBD-related surgery among uninsured patients. Given the pervasive nature of this consequence, future steps to support uninsured patients receiving surgery, in particular emergency surgery, related to their IBD are needed to protect this group from financial risk.

A novel scale for triage assessment of frailty in the emergency department (ED-FraS): a prospective videotaped study

BackgroundRapid recognition of frailty in older patients in the ED is an important first step toward better geriatric care in the ED. We aimed to develop and validate a novel frailty assessment scale at ED triage, the Emergency Department Frailty Scale (ED-FraS).MethodsWe conducted a prospective cohort study enrolling adult patients aged 65 years or older who visited the ED at an academic medical center. The entire triage process was recorded, and triage data were collected, including the Taiwan Triage and Acuity Scale (TTAS). Five physician raters provided ED-FraS levels after reviewing videos. A modified TTAS (mTTAS) incorporating ED-FraS was also created. The primary outcome was hospital admission following the ED visit, and secondary outcomes included the ED length of stay (EDLOS) and total ED visit charges.ResultsA total of 256 patients were included. Twenty-seven percent of the patients were frail according to the ED-FraS. The majority of ED-FraS was level 2 (57%), while the majority of TTAS was level 3 (81%). There was a weak agreement between the ED-FraS and TTAS (kappa coefficient of 0.02). The hospital admission rate and charge were highest at ED-FraS level 5 (severely frail), whereas the EDLOS was longest at level 4 (moderately frail). The area under the Receiver Operating Characteristic curve (AUROC) in predicting hospital admission for the TTAS, ED-FraS, and mTTAS were 0.57, 0.62, and 0.63, respectively. The ED-FraS explained more variation in EDLOS (R2 = 0.096) compared with the other two methods.ConclusionsThe ED-Fras tool is a simple and valid screening tool for identifying frail older adults in the ED. It also can complement and enhance ED triage systems. Further research is needed to test its real-time use at ED triage internationally.

Budget ratcheting in museums

PurposeThis study focuses on ratcheting and budget behavior in nonprofit museums. Specifically, the authors examine how performance compared with the budget affects future revenue budgets, and how this differs from the extant literature focused on for-profit organizations. The study focuses specifically on the relationship between museums and their sources of public funding and how this affects how museums prepare budgets.Design/methodology/approachBased on four years of data covering 97 state-subsidized Danish museums, the authors analyze budget ratcheting using least absolute deviation (LAD) estimations in the form of median regressions.FindingsThe authors find that when actual revenue from admission charges is below the budget, the decrease in the following year's budget is greater than the increase in the following year's budget when actual revenue from admission charges is above the budget (i.e. the authors find asymmetrical ratcheting).Research limitations/implicationsThe findings are based on a specific setting (Danish museums), and the results may not be generalizable to other settings.Practical implicationsThis study provides insights into the museum sector and other sectors with similar characteristics and contributes to understanding the differences between museums and for-profit organizations when it comes to budgeting. As private-sector management practices are gaining ground in the museum sector, it is important to learn more about budgeting-related issues in this sector.Originality/valueThe asymmetrical ratcheting the authors find is the opposite of ratcheting typically found in for-profit organizations. The authors attribute the results to the incentive conflict between museums and their public funding sources. The authors point to the museums' dependence on public funding as an explanation for the results and, thereby, extend the knowledge on ratcheting to organizations with different characteristics than traditional, for-profit organizations.

Growth factor use in patients with breast cancer treated with docetaxel, carboplatin, trastuzumab, and pertuzumab (TCHP) regimen: Cost implications in a safety-net system.

10 Background: Growth factor (G-CSF) support has been shown to reduce the incidence of neutropenic complications after chemotherapy; however, it can be associated with a significant increase in cost of care. Here, we reviewed G-CSF use in breast cancer patients receiving docetaxel, carboplatin, trastuzumab, and pertuzumab (TCHP) regimen at a safety-net system. Methods: Parkland Health is the safety-net system that provides care to primarily uninsured/underinsured patients in Dallas County, Texas. The majority of patients treated at Parkland belong to racial and ethnic minorities. We reviewed electronic medical records of patients with HER-2 positive breast cancer who were treated with TCHP between 01/01/2017 and 12/31/2022 at Parkland. Data on patient demographics, treatment history, laboratory values, and treatment related complications were collected. Results: A total of 171 consecutive patients underwent neoadjuvant/adjuvant treatment with TCHP for HER-2 positive breast cancer. Forty-one patients (24.0%) received G-CSF for primary prophylaxis, as per discretion of treating physician. In the 130 patients (76.0%) who did not receive primary prophylaxis, G-CSF was added later in 41 patients (32.5%). Febrile neutropenia (FN), neutropenic treatment delays, and infections not meeting FN criteria accounted for the majority of cases where G-CSF was added later in the course of treatment. Overall, 529 cycles of TCHP were administered without G-CSF vs. 372 cycles with G-CSF. Without primary prophylaxis, 18.5% (24/130) of the patients developed FN vs 2.4% (1/41) for those who received primary prophylaxis, p=0.011. FN was a complication in 4.5% (24/529) of chemotherapy cycles without G-CSF vs. 1.1% (4/372) of cycles administered with G-CSF, p=0.003. In patients treated without G-CSF, the majority of FN episodes (71%) occurred within the first 3 cycles. FN resulted in a total of 150 days (median 5 days) of hospital stay resulting in $1.2 million (M) in charges (median $36,000 per admission). Universal G-CSF use in our patient population could have prevented 21 episodes of febrile neutropenia with an estimated saving of $1.05 M (hospital admission charges), at an extra cost of $1.8M (based on the pegfilgrastim Medicare average sales price (ASP) from 2017-2022). However, based on the 2023 Medicare ASP, by substituting pegfilgrastim for biosimilars, the estimated cost would have been $603,000. Conclusions: Our study did not show an FN rate &gt;20% to warrant routine addition of G-CSF for primary prophylaxis as recommended by the NCCN. During the study period, the cost of G-CSF was prohibitive for its universal use. However, the recent introduction of G-CSF biosimilars has significantly reduced the cost burden and justifies routine G-CSF prophylaxis as a cost saving measure.

Predictors of re-admission after COVID-19 hospitalizations in patients with underlying gastrointestinal malignancy.

e16327 Background: COVID-19 infections have been known to cause worse outcomes in patients with underlying co-morbid conditions. Currently, there is limited data regarding re-admissions in such patients after COVID-19 infection. So, we pursued to assess the rates, predictors, and causes of re-admission after COVID-19 infection in patients who had underlying gastrointestinal malignancy. Methods: The National Readmission Database for 2020 was analyzed to identify patients with COVID-19 hospitalizations who also had a co-diagnosis of GI malignancy. Data for re-admission was gathered, at 30 and 90 days after initial hospitalization. Multivariate logistic and linear regression analysis was used accordingly to adjust for possible confounders. Results: For 30 days: A total of 2,726 COVID-19 hospitalizations had a co-diagnosis of GI malignancy. The mean LOS (length of stay) for index admission was 8.7 days. The mean TOTCHG (total hospital charge) for index admission was $85,747. Within 30 days from discharge, 462 (21%) were re-admitted. The in-hospital mortality in re-admissions (18.4%) was quite similar to that for index hospitalization (18.5%). Positive predictors of re-admission include shorter length of stay during initial hospitalization (&lt;3 days), anemia, renal insufficiency/chronic kidney disease, and atherosclerosis of the aorta. Females had a lower chance of re-admission compared to males. Among the top causes of re-admission were ongoing COVID-19 infection (27%), sepsis (16.3%), acute kidney injury (2.4%), and metabolic encephalopathy (1.2%). For 90 days: A total of 1,782 COVID-19 hospitalizations had a co-diagnosis of GI malignancy. The mean LOS (length of stay) for index admission was 9.2 days. The mean TOTCHG (total hospital charge) for index admission was $90,908. Within 90 days from discharge, 411 (29%) were re-admitted. The in-hospital mortality in readmissions (14%) was lower than that for index hospitalization (20.3%). Predictors of re-admissions include secured insurance, anemia, renal insufficiency/chronic kidney disease, and cerebrovascular accidents. Top causes of re-admission were ongoing COVID-19 infection (18.5%), aspiration pneumonitis (2.9%), pneumonia (2.3%), and acute kidney injury (1.4%). Conclusions: Infections were the leading cause of re-admission, which is an important factor to consider when managing patients with GI malignancies due to sub-optimal immunity. Among these patients, those with concomitant anemia and chronic kidney disease were more prone to being re-admitted. Patients with GI malignancies also tended to have a higher length of stay, leading to higher charges, more exposure to nosocomial infections, and delays in cancer treatment leading to worse cancer outcomes. Pre-mature discharges, without medical optimization, can also potentially predispose to higher rates of re-admissions.

Clinical and economic outcomes associated with intravenous albumin fluid use in the intensive care unit: a retrospective cohort study

ABSTRACT Objectives This study was undertaken to evaluate the prescribing practice of albumin in the intensive care unit (ICU) and to compare the clinical and economic outcomes associated with intravenous (IV) albumin compared to crystalloids in the ICU. Methods This was a retrospective cohort study of ICU adult patients admitted to King Abdullah University Hospital during 2018–2019. Patient demographics, clinical characteristics, and admission charges were retrieved from medical records and billing system. Survival analysis, multivariable regression models, and propensity score matching estimator were performed to evaluate the impact of IV resuscitation fluid types on the clinical and economic outcomes. Results Albumin administration in the ICU was associated with significantly lower hazards of ICU death (HR = 0.57; P value <0.001), but without improving overall death probability compared to crystalloids. Albumin was associated with significant prolongation in the ICU length of stay (5.86 days; P value <0.001). Only 88 patients (24.3%) were prescribed albumin for Food and Drug Administration (FDA)-approved indications. Admission charges were significantly higher for patients treated with albumin (p value <0.001). Conclusions IV Albumin use in the ICU was not associated with significant improvement in clinical outcomes, but with a remarkable increase in economic burden. The majority of patients received albumin for non-FDA-approved indications.

Hypothyroidism as an Independent Predictor of 30-day Readmission in Head and Neck Cancer Patients.

To define the role of hypothyroidism and other risk factors for unplanned readmissions after surgery for head and neck cancer. Retrospective cohort study. The Nationwide Readmission Database (NRD) was used to identify patients who underwent surgery for mucosal head and neck cancer (oral cavity, oropharynx, larynx, and hypopharynx) between 2010 and 2017. Univariate and multivariate logistic regression were performed to determine patient, tumor, and hospital related risk factors for 30-day readmission. Readmitted patients were stratified by preoperative diagnosis of hypothyroidism to compare readmission characteristics. For the 131,013 patients who met inclusion criteria, the readmission rate was 15.9%. Overall, 11.91% of patients had a preoperative diagnosis of hypothyroidism. After controlling for other variables, patients with a preoperative diagnosis of hypothyroidism had 12.2% higher odds of readmission compared to those without hypothyroidism (OR: 1.12, 1.03-1.22, p = 0.008). Patients with hypothyroidism had different reasons for readmission, including higher rates of wound dehiscence, fistula, infection, and electrolyte imbalance. Among readmitted patients, the length of stay for index admission (mean 10.5 days vs. 9.2 days, p < 0.001), readmission (mean 7.0 vs. 6.6 days, p = 0.05), and total hospital charge were higher for hypothyroid patients ($137,742 vs. $119,831, p < 0.001). Hypothyroidism is an independent risk factor for 30-day readmission following head and neck cancer resection. Furthermore, hypothyroid patients are more likely to be readmitted for wound complications, infection, and electrolyte imbalance. Targeted interventions should be considered for hypothyroid patients to decrease readmission rates and associated patient morbidity, potentially leading to earlier initiation of adjuvant treatment. 3 Laryngoscope, 133:2988-2998, 2023.

Incidence, predictors, clinical outcomes, and economic burden of recurrent acute kidney injury: a retrospective cohort study

Objective This study aimed to assess the incidence, predictors, mortality, and economic outcomes of recurrent Acute kidney injury (AKI) in Jordan. Methods This was a retrospective cohort study that included adult patients who were admitted with AKI to university hospitals in the country from 2010–2019. Recurrent episodes of AKI, laboratory data, baseline medication list, and death dates were retrieved from patient’s medical records. The incidence rate of recurrent AKI was estimated. Predictors of recurrent AKI and mortality during the five years post-discharge was evaluated. Total admission charges were described and evaluated in total and by service provided. Results Among 1162 AKI patients, 57 patients (4.9%) died during the index admission (first admission during the study period), and among the survivors, 220 patients were re-hospitalized with a recurrent AKI during five years of follow-up. Patients with higher discharge serum creatinine level (SCr) at index admission had higher odds of AKI recurrence (OR = 1.001). Patients who were on respiratory, antineoplastic, or anticoagulant medications were also more susceptible to recurrence; ORs were 1.69, 2.77, and 4.16, respectively. Patients who were elderly, with recurrent AKI episodes, or with a more extended hospital stay at index admission were more likely to die during the five years post discharge. The median charge of recurrent admissions was higher than the median charge of the index admissions; 1519.17 JOD ($2142.7) versus 1362.85 JOD ($1922.2), respectively. Conclusions Recurrent AKI is associated with increased mortality and health expenditures. Higher discharge SCr levels at index admission, and chronic comorbidities are associated with a higher likelihood of AKI recurrence.

Analysis of the Epidemiological Trends on Inpatient Diverticulosis Admissions in the US: A Longitudinal Analysis From 1997-2018.

Background Diverticulosis of the colon is characterized by outpouchings of mucosa and serosa through the muscular layer of the large intestinal wall. It is classically associated with increasing age with older individuals having a higher prevalence and greater density of diverticula secondary to its progressive disease nature. Also, diverticular disease is associated with dietary habits, low fiber intake in western society as well as obesity. The aim of this study was to investigate the epidemiological trends associated with diverticular disease in the United States in a 21-year interval from 1997 to 2018. Methods Using the Nationwide Inpatient Sample, all hospitalizations between 1997 and 2018 were analyzed. We examined annual data for hospitalization rate, the average length of stay (LOS), mean age and interval age groups, and hospital charges for inpatient admissions for diverticular disease (diverticulitis and diverticulosis). Results Between 1997 and 2018, the number of hospitalizations for patients with a primary discharge diagnosis of diverticular disease (diverticulosis and diverticulitis) increased 32% from 220,896 to 293,530 with 89.7 discharges per 100,000 persons in 2018 versus 81.0 discharges per 100,000 persons in 1997. Overall, the average age of patients decreased from 67.55 ± 0.15 years in 1997 to 64.59 ±0.08 in 2018, [t-value (t) 12.56, degrees of freedom (df) 514424, 95% confidence interval (CI) 2.497-3.423, P<0.0001]. On further evaluation, the mean average age in males decreased from 63.16±0.21 years in 1997 to 61.31±0.12 years in 2018,(t 8.16, df 217981, 95% CI 1.404-2.295 P<0.0001), while in females it decreased from 70.53±0.14 years to 67.15±0.10 years, (t 20.13, df 296422, 95% CI 3.050-3.709 P<0.0001), in the same interval time. While evaluating different subgroups of age in this time interval, the prevalence rate of diverticular disease diagnosis per 100,000 persons increased in the interval age between 18-44 years from 20.1 to 29.8, [relative risk (RR) 0.848, CI95% 0.834-0.863, P< 0.0001) and 45-64 years from 107.1 to 125.3, (RR 0.761, CI 95% 0.754-0.769P<0.0001) while it decreased in the interval age between 65-84 years from 357.6 to 259.7, (RR 1.211, CI 95% 1.206-1.226, P<0.0001) as well as > 85 years from 746.2 to 523.6, (RR 1.130, CI 95% 1.112-1.147, P<0.0001) The length of stay (LOS) mean average in days decreased from 5.8 ± 0.04 days in 1997 to 4.4±0.021 days in 2018, (t 33.08 df 514424, 95%CI 1.316-1.483, P< 0.0001). Hospital Inpatient National Statistics data over hospital mean charges, available from the period between 1997 to 2015, shows that the mean hospital charges in US dollars increased over 100%, from $19,735.17 in 1997 to $39,575 in 2015 (P<0.001) even after adjusting values to 2015 inflation. Conclusion There is an overall trend of decreased mean age of patients admitted with diverticular disease in the US over the past 21 years with a respective significant increased rate of disease in younger age groups. We postulate that these changes may be associated with poor dietary habits and obesity epidemics worsened in the last two decades in the US. In addition, despite the decreased length of stay over the same time period, the mean hospital charges more than double likely reflecting the increased access to expensive diagnostic methods such as computed tomography and colonoscopies.

Evaluating Inpatient Hospital Charges Associated With Trauma Service Patients Participating in an Accountable Care Organization.

The Medicare Accountable Care Organization (ACO) Program has created a vehicle for providers who practice cost containment and exceed quality for the Medicare population. The success of ACO's nationwide have been well documented. However, there is little research evaluating if there is a cost saving benefit in trauma care with respect to participating in an ACO. Thus, the primary objective of this study was to evaluate inpatient hospital charges associated with trauma service utilization of patients participating in the ACO compared to non-ACO patients. This case-control retrospective study includes a comparison of inpatients charges of ACO patients (cases) and general trauma patients (controls) presenting to our trauma center in Staten Island, New York from January 1st, 2019 to December 31st, 2021. A 1:1 matching of case to control was performed based on age, sex, race, and injury severity score. Statistical analysis was performed with IBM SPSS, with P < .05 as significant. A total of 80 patients were included in the ACO cohort and 80 matched in the General Trauma cohort. Patient demographics were similar. Comorbidities were similar with the exception of a higher in incidence of hypertension (75.0% vs 47.5%, P < .001) and cardiac disease (35.0% vs 17.5%, P = .012) in the ACO cohort. Both the ACO and general trauma cohort had similar Injury Severity Scores, number of visits and lenght of stay. Both charge total ($76 148.93 vs $70 916.82, P = .630) receipt total ($15 080.26 vs $14 180, P = .662) charges were similar between ACO and General Trauma patients. In spite of increased incidence of hypertension and cardiac disease in ACO trauma patients, mean Injury Severity Score, number of visits, length of hospital stay, ICU admission rate and charge total was similar compared to general trauma patients presenting to our Level 1 Adult Trauma Center.

Comparing patient comorbidity between hospital outpatient department and ambulatory surgery center for arthroscopic surgery

Ambulatory Surgery Centers (ASCs) and Hospital Outpatient Departments (HOPDs) report similar perioperative outcomes for orthopedic surgeries in healthy patients. Patient comorbidity may be an important deciding factor to choose between HOPD and ASC for arthroscopic surgeries that are often painful and need a general anesthetic, with the assumption that sicker patients are being done at HOPD with more resources. However, it is unclear if HOPD patients are truly sicker. Using New York State Ambulatory Surgery Dataset (2010–2015), in patients undergoing shoulder/knee arthroscopies, we assessed for differences in patient comorbidity calculated as Elixhauser Comorbidity Index (ECI) and trend in ECI over time, between HOPDs and ASCs. We also assessed for differences in duration of stay, unplanned hospital admission, 90-day readmissions, and total and regional anesthesia (RA) charges between HOPDs and ASCs. A higher proportion of patients in ASCs were healthy (ECI 0) (97.9% versus 78.4% of patients in HOPDs). Only 1.21% of patients in ASCs had a high ECI score (≥5) versus 11.9% of patients in HOPDs (p<0.001). The proportion of sicker patients in HOPDs increased from 2010 to 2015 and declined for ASCs. The duration of stay was longer and unplanned hospital admissions lower for HOPDs. 90-day readmissions were similar between HOPDs and ASCs. Total and RA charges were higher in HOPDs.

Trends in Inpatient Immunotherapy for Lymphoma: The Impact of CAR T-Cell Therapy

BACKGROUND Lymphoma is a malignancy of the lymphatic system that arises from clonal proliferation of B-cells, T-cells, or natural killer cells. It is one of the most common malignancies in adults, with an incidence of approximately 82,000 new cases annually in the United States (Lewis et al., 2020). Over the past decade, immunotherapy has become increasingly important in lymphoma treatment. Rituximab was the first monoclonal antibody approved for oncological care and has become the gold-standard for management of B-cell malignancies. Over the years, checkpoint inhibitors, drug-antibody conjugates, bispecific antibodies, and chimeric antigen receptor T (CAR T) cell therapy have also been incorporated into guidelines of standard care. The first CAR T therapy for the treatment of diffuse large B-cell lymphoma was FDA approved in October 2017. Approval for follicular, mantle cell, and other types of lymphoma soon followed. Outpatient administration of immunotherapy has become progressively more frequent due to the convenience and associated lower costs. However CAR T therapy is still largely administered inpatient, as institutions hesitate to transition to an outpatient setting due to logistical barriers and concerns for toxicity (Myers et al., 2021). This study evaluates trends and outcomes of hospitalizations for immunotherapy in patients with lymphoma over a decade. METHODS Using the National Inpatient Sample (NIS) database from 2010 to 2019, we identified adult patients with immunotherapy as the primary reason for admission and those who also had a secondary diagnosis of lymphoma using ICD-9 and ICD-10 codes. Trends for in-hospital mortality, total hospital charges, and length of hospital stay were evaluated. Multivariate logistic regression analysis was conducted to adjust for confounders. J-point analysis was used to assess statistical significance of incidence trends. RESULTS From 2012 to 2016 there was a gradual decrease in the total number of admissions for immunotherapy for lymphoma (Figure 1). However, starting in 2017 there was a reversal of this trend, and the number of admissions started increasing. By 2019, the proportion of patients with lymphoma admitted for immunotherapy, compared to that of all other cancers, increased to 51% from 21% in 2010 (p<0.01, Table 1). Additionally, there was a statistically significant increase in the mean length of stay, from 4.3 to 11.7 days (p < 0.01), and total charges for admissions increased from $65,815 in 2010 to $706,145 in 2019 (p < 0.01). CONCLUSIONS Our study showed an increase in the number of immunotherapy admissions for lymphoma starting in 2017, which coincides with the introduction of CAR T therapy for this subset of cancers. In 2019, lymphoma became the most frequent malignancy in patients receiving inpatient immunotherapy. Over the period studied, there was a 2.7-fold increase in the length of stay and a ten-fold increase in total charges. Although inpatient administration of checkpoint inhibitors and bispecific antibodies might be contributing to the trend, these therapies are significantly less costly than CAR T therapy. We speculate the significant increase in charges and length of stay primarily represents the impact of the introduction of CAR T-cells for the therapy of lymphomas. Further studies are needed to better characterize the economic burden and systemic impact of inpatient administration of CAR T therapy and other immunotherapies in the treatment of lymphomas. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Racial and Ethnic Disparities in Acute Coronary Syndrome: A Nationally Representative Sample.

Disparities in acute coronary syndrome (ACS) outcomes exist between racial and ethnic groups. We aimed to evaluate disparities in resource utilization and inpatient outcomes across multiple ethnic and racial groups using contemporary data. We identified hospital discharges for ACS in the United States using the National Inpatient Sample from 2015 to 2018. The International Classification of Diseases, Tenth Revision, Clinical Modification codes were used to identify variables of interest. The primary outcomes were in-hospital complications, length of stay, and total hospital charge. Statistical analysis was performed using STATA version 17. Our analysis included 1,911,869 ACS discharges. Our sample was made up of 78.6% White, 12.1% Black, and 9.3% Hispanic patients. Hispanic and Black patients presenting with ACS were younger and had more cardiometabolic comorbidities than their White counterparts, especially hypertension, diabetes mellitus, and obesity. Despite social determinants of health being more likely to be unfavorable for Hispanics than their White counterparts, they were more likely to incur higher total hospital charges than their White counterparts. Black patients were the least likely to undergo revascularization procedures. Despite these differences, White patients had higher in-hospital mortality rates than Black and Hispanic patients. In this nationally representative study, despite having higher cardiometabolic comorbidity burden, lower socioeconomic status, and percutaneous intervention, Black and Hispanic patients experienced lower mortality rates than their White counterparts. Hispanic patients incurred the highest amount of total hospital charges for an ACS admission.

Gender-affirming Chest Reconstruction: Does Hospital Volume Influence Admission Charges?

Gender-affirming Chest Reconstruction: Does Hospital Volume Influence Admission Charges?

Clinical Outcomes and Direct Medical Expenditures Associated With Intensive Care Unit Admission for Inpatients With COVID-19 in Jordan: A Retrospective Cohort Study

ObjectivesThis study aimed to describe clinical outcomes and medical expenditures associated with COVID-19 admissions. In addition, this study aimed to investigate the impact of patients’ characteristics and baseline comorbidities on intensive care unit (ICU) admission, mortality, and medical expenditures for hospitalized patients with COVID-19.MethodsThis retrospective cohort study included all hospitalized patients with confirmed COVID-19 in Prince Hamza Hospital and King Abdullah University Hospital, during the period from March 2020 to June 2021. Medical records and pharmacy data were followed and reviewed throughout their admissions. The ICU admission, inpatient mortality, hospital length of stay, and inpatient charges were described. Predictors of ICU admission and inpatient charges were evaluated.ResultsA total of 7694 COVID-19 hospital admissions were included. Approximately 1189 patients (15.5%) were admitted to ICU and 21.4% died in the hospital. The fatality rate among those admitted to ICU was 82.6% compared with 10.2% for non-ICU admitted patients. The average admission charge and charge per admission day were 1598.2 and 200.2 Jordanian dinar, respectively, and both charges were higher in ICU admitted patients than non-ICU admitted patients. Being older in age, smoker or ex-smoker, and having chronic diseases were all significantly associated with a higher likelihood of ICU admission and mortality among admitted patients.ConclusionsICU admission in patients with COVID-19 is associated with poor clinical outcomes and substantial medical expenditures and is more likely among older adults, smokers, and those with chronic diseases.

Emergency department utilization for ovarian hyperstimulation syndrome

BackgroundOvarian hyperstimulation syndrome (OHSS) is a rare, but serious, risk of assisted reproductive technologies. In severe cases, patients may present to the emergency department (ED) for assessment, treatment of related complications, and even in-patient admission. Significant effort has been made to reduce the incidence and complications of OHSS; however, it is unknown if these strategies have decreased patient presentation for treatment in the ED. PurposeTo assess ED utilization for OHSS over time and to examine admission rates, patient demographics, and charges. MethodsRetrospective longitudinal study utilizing data from the Nationwide Emergency Department Sample Database and the National ART Surveillance System. All ED visits between 2006 and 2016 with an ICD-9 or −10 diagnosis of OHSS were included. Demographics including age, geographic location, and income quartile and alternative diagnoses, admission rates, overall charges, and number of stimulation cycles annually were assessed. ResultsThe number of ovarian stimulation cycles steadily increased from 2006 (n = 110,183) to 2016 (n = 157,721), while the number of OHSS-related ED visits remained relatively stable (APC 2.08, p = 0.14). Admission rates for OHSS decreased from 52.7% in 2006 to 33.1% in 2016 (APC −4.43%, p < 0.01). The average charge for OHSS-related ED visits almost doubled from 2006 to 2016 (APC 8.53, p < 0.01) and was significantly higher than charges for non-OHSS-related visits for age-matched controls (p < 0.01). ConclusionDespite an increase in total stimulation cycles, there was no significant change in the estimated number of patients presenting to the ED; however, admission rates significantly declined. These observations suggest a possible shift in the severity and/or management of OHSS during the study period.

Reoperation Through a Prosthetic-Reinforced Abdominal Wall and Its Association With Postoperative Outcomes and Longitudinal Health Care Utilization

Prosthetic reinforcement of critically sized incisional hernias is necessary to decrease hernia recurrence, but long-term prosthetic-mesh footprint may increase complication risk during subsequent abdominal operations. To investigate the association of prior incisional hernia repair with mesh (IHRWM) with postoperative outcomes and health care utilization after common abdominal operations. This was a population-based, retrospective cohort study of patients undergoing inpatient abdominal surgical procedures during the period of January 2009 to December 2016, with at least 1 year of follow-up within 5 geographically diverse statewide inpatient/ambulatory databases (Florida, Iowa, Nebraska, New York, Utah). History of an abdominal operation was ascertained within the 3-year period preceding the index operation. Patients admitted to the hospital with a history of an abdominal operation (ie, bariatric, cholecystectomy, small- or large-bowel resection, prostatectomy, gynecologic) were identified using the International Classification of Diseases, Ninth Revision and Tenth Revision, Clinical Modification procedure codes. Patients with prior IHRWM were propensity score matched (1:1) to controls both with and without a history of an abdominal surgical procedure based on clinical and operative characteristics. Data analysis was conducted from March 1 to November 27, 2021. The primary outcome was a composite of adverse postoperative outcomes (surgical and nonsurgical). Secondary outcomes included health care utilization determined by length of hospital stay, hospital charges, and 1-year readmissions. Logistic and Cox regression determined the association of prior IHRWM with the outcomes of interest. Additional subanalyses matched and compared patients with prior IHR without mesh (IHRWOM) to those with a history of an abdominal operation. Of the 914 105 patients undergoing common abdominal surgical procedures (81 123 bariatric [8.9%], 284 450 small- or large-bowel resection [31.1%], 223 768 cholecystectomy [24.5%], 33 183 prostatectomy [3.6%], and 291 581 gynecologic [31.9%]), all 3517 patients (age group: 46-55 years, 1547 [44.0%]; 2396 majority sex [68.1%]) with prior IHRWM were matched to patients without a history of abdominal surgical procedures. After matching, prior IHRWM was associated with increased overall complications (odds ratio [OR], 1.43; 95% CI, 1.27-1.60), surgical complications (OR, 1.51; 95% CI, 1.34-1.70), length of hospital stay (mean increase of 1.03 days; 95% CI, 0.56-1.49 days; P < .001), index admission charges (predicted mean difference of $11 896.10; 95% CI, $6096.80-$17 695.40; P < .001), and 1-year unplanned readmissions (hazard ratio, 1.14; 95% CI, 1.05-1.25; P = .002). This trend persisted even when comparing matched patients with prior IHRWM to patients with a history of abdominal surgical procedures, and the treatment outcome disappeared when comparing patients with prior IHRWOM to those without a previous abdominal operation. Reoperation through a previously prosthetic-reinforced abdominal wall was associated with increased surgical complications and health care utilization. This risk appeared to be independent of a history of abdominal surgical procedures and was magnified by the presence of a prosthetic-mesh footprint in the abdominal wall.