Diagnosis-related Group Codes Research Articles

Management, Utilization, and Outcomes of Preterm Labor in an Integrated Health Care System.

Fetal fibronectin (fFN) testing and transvaginal ultrasound (TVUS) are diagnostic tools used to predict impending spontaneous preterm birth (sPTB) among women presenting with preterm labor (PTL). We evaluated the association between fFN testing or TVUS cervical length (CL) measurement in predicting sPTB, respiratory distress syndrome (RDS), neonatal intensive care unit (NICU) admission, and sPTB-related costs. We conducted a retrospective cohort study using data from the Kaiser Permanente Southern California electronic health system (January 1, 2009-December 31, 2020) using diagnostic and procedure codes, along with a natural language processing algorithm to identify pregnancies with PTL evaluations. PTL evaluation was defined as having fFN and/or TVUS assessment. Outcomes were ascertained using diagnostic, procedural, and diagnosis-related group codes. Multivariable logistic regression assessed the association between fFN and/or TVUS results and perinatal outcomes. Compared with those without PTL evaluations, those with positive fFN tests had higher adjusted odds ratio (adj.OR) for sPTB (2.95, 95% confidence interval [CI]: 2.64, 3.29), RDS (2.34, 95% CI: 2.03, 2.69), and NICU admission (2.24, 95% CI: 2.01, 2.50). In contrast, those who tested negative had lower odds for sPTB (adj.OR: 0.75, 95% CI: 0.70, 0.79), RDS (adj.OR: 0.67, 95% CI: 0.61, 0.73), and NICU admission (adj.OR: 0.74, 95% CI: 0.70, 0.79). Among those with positive fFN results, the odds of sPTB was inversely associated with CL. Health care costs for mothers and neonates were lowest for those with fFN testing only. This study demonstrates that positive fFN results were associated with an increased odds of sPTB, RDS, and NICU admission and the association with sPTB was inversely proportional to CL. Additionally, negative fFN results were associated with decreased odds of sPTB, RDS, and NICU admissions. fFN testing may predict these and other sPTB-related adverse outcomes hence its utility should be explored further. Moreover, fFN testing has some cost savings over TVUS. · Patients with positive fFN tests had higher odds of sPTB, RDS, and NICU admission.. · Inverse relationship between sPTB and CL among those with positive fFN tests was observed.. · Health care costs for mothers and neonates were lowest for those with fFN testing only..

Perinatal substance use disorder: Examining the impact on adverse pregnancy outcomes

ObjectiveSubstance use disorder is a growing concern in the USA, especially among pregnant women. This study was undertaken to assess the impact of substance use disorder on adverse pregnancy outcomes using a nationwide sample of inpatient pregnancy hospitalizations in the USA, and to elucidate the influence on each type of adverse pregnancy outcome. Study designA cross-sectional analysis of inpatient pregnancy hospitalizations in the USA from the Healthcare Cost and Utilization Project National Inpatient Sample from 2016 to 2020 was conducted. International Classification of Diseases – 10th revision and diagnosis-related group codes were used to identify inpatient pregnancy-related delivery hospitalizations with a substance use disorder and/or adverse pregnancy outcomes. Propensity score matching and multiple logistic regression analyses were undertaken to predict the likelihood of adverse pregnancy outcomes among pregnancy hospitalizations with and without substance use disorder. Subgroup analyses were performed to estimate the impact of substance use disorder on each adverse pregnancy outcome. ResultsFrom 3,238,558 hospitalizations, the prevalence of adverse pregnancy outcomes was substantially higher among pregnancy hospitalizations with substance use disorder (35.6 %) compared with pregnancy hospitalizations without substance use disorder (25.1 %, p < 0.001). After matching and model adjustment for sociodemographic covariates, substance use disorder was identified as an independent predictor of adverse pregnancy outcomes [adjusted odds ratio (aOR) 1.47, 95 % confidence interval (CI) 1.45–1.49]. In subgroup analyses based on type of adverse pregnancy outcome, the greatest exposure risks were fetal growth restriction (aOR 1.96, 95 % CI 1.91–2.01), antepartum hemorrhage (aOR 1.79, 95 % CI 1.73–1.85) and preterm birth (aOR 1.65, 95 % CI 1.62–1.68). ConclusionPatients with substance use disorder are at higher risk of adverse pregnancy outcomes, particularly fetal growth restriction, antepartum hemorrhage and preterm birth.

Assessment of Price Variation in Coronary Artery Bypass Surgery at US Hospitals.

Little is known about hospital pricing for coronary artery bypass grafting (CABG). Using new price transparency data, we assessed variation in CABG prices across US hospitals and the association between higher prices and hospital characteristics, including quality of care. Prices for diagnosis related group code 236 were obtained from the Turquoise database and linked by Medicare Facility ID to publicly available hospital characteristics. Univariate and multivariable analyses were performed to assess factors predictive of higher prices. Across 544 hospitals, median commercial and self-pay rates were 2.01 and 2.64 times the Medicare rate ($57 240 and $75 047, respectively, versus $28 398). Within hospitals, the 90th percentile insurer-negotiated price was 1.83 times the 10th percentile price. Across hospitals, the 90th percentile commercial rate was 2.91 times the 10th percentile hospital rate. Regional median hospital prices ranged from $35 624 in the East South Central to $84 080 in the Pacific. In univariate analysis, higher inpatient revenue, greater annual discharges, and major teaching status were significantly associated with higher prices. In multivariable analysis, major teaching and investor-owned status were associated with significantly higher prices (+$8653 and +$12 200, respectively). CABG prices were not related to death, readmissions, patient ratings, or overall Centers for Medicare and Medicaid Services hospital rating. There is significant variation in CABG pricing, with certain characteristics associated with higher rates, including major teaching status and investor ownership. Notably, higher CABG prices were not associated with better-quality care, suggesting a need for further investigation into drivers of pricing variation and the implications for health care spending and access.

Compliance With Federal Price Transparency Rules and Cost Estimation at United States Hospitals With Neurosurgical Training Programs.

The Centers for Medicare & Medicaid Services implemented federal requirements on January 1, 2021, under the Public Health Service Act that require hospitals to provide a list of payer-negotiated prices or "standard charges" in a machine-readable file and in a patient-friendly online estimator for standard services. We sought to assess compliance by United States hospitals associated with neurosurgical training programs with these federal requirements for 11 common neurosurgical procedures. We performed a cross-sectional analysis in March 2023 of 116 United States hospitals associated with a neurosurgical training program to assess compliance with the new federal requirements to have a machine-readable, downloadable file with standard charges and a patient-friendly online estimator for two spinal procedures. A total of 110/114 (96.5%) hospitals were compliant with the requirement for a machine-readable file with payer-negotiated prices. A total of 47/110 hospitals (42.7%) were compliant with downloadable machine-readable files and reported at least one payer-negotiated price for 1 of the 11 common neurosurgical procedures. A total of 45/110 (40.9%) used bundled Diagnosis-Related Group codes, and 18/110 (16.4%) did not contain any price information for neurosurgical procedures. For neurosurgical procedures, the percent difference between the average negotiated private insurance and Medicare price per procedure ranged from 17.5% to 77.6%. Medicare and private insurance data for each procedure were available on average for 10.3 states (SD = 3.8) and 15.6 states (SD = 4.8), respectively. While hospital compliance with federal requirements for machine-readable files with payer-negotiated prices was high, availability of payer-negotiated prices for 4 major insurance types across 11 common neurosurgical procedures based on Current Procedural Terminology codes was sparce. Consequently, meaningful conclusions on procedure-related charges for elective procedures are difficult for patients to make because of the unintelligible format of data and a lack of reporting of charges per Current Procedural Terminology code in a comprehensive manner.

Pseudoexfoliative Syndrome in Cataract Surgery-A Quality Register Study and Health Economic Analysis in the Split-Dalmatia County, Croatia.

To investigate the impact of pseudoexfoliation (PEX) syndrome on intraoperative phacoemulsification (PHACO) parameters and assess the economic cost of PHACO surgery for cataracts in patients with and without PEX syndrome. This was a retrospective quality register study on 5889 patients (6236 eyes) who underwent PHACO cataract surgery in the Eye Clinic, Clinical Hospital Centre Split, Croatia, over a 7-year period (May 2015 to December 2022), in accordance with the Guidelines of the Helsinki Declaration and approval from the Research Ethics Committee of the University Hospital Centre Split, Croatia. Inclusion criteria were patients with either presenile or senile cataract or cataract related to PEX syndrome who undertook PHACO procedure by the same experienced surgeon using the same PHACO device (Infiniti Vision System, Alcon Laboratories, Inc., Fort Worth, TX, USA). Eyes were categorized according to PEX presence- (PEX group) or absence (Group without PEX). The following recorded data about intraoperative PHACO parameters were collected: Cumulative Dissipated Energy (CDE), Ultrasound total time, PHACO time, torsional time, aspiration time, estimated fluid used, and duration of the surgical procedure. In the economic analysis, all PHACO parameters were considered, with a specific focus on the duration of the surgical procedure, costs associated with additional medical materials and devices, complications during surgery, and surgery procedure Diagnosis-Related Group (DRG) codes. A total of 4535 cases were eligible for inclusion in the study, 278 (6.13%) were diagnosed with PEX and 4257 (93.87%) had no PEX. Significantly higher PHACO parameters were observed in the PEX group. Similarly, a statistically significant increase in the values of all PHACO parameters was observed with the increase in nuclear lens density. Intraoperative complications were more frequent in the PEX group. Zonular weakness requiring the use of a capsular tension ring (CTR) and posterior capsular rupture occurred 30 and 13 times more often, respectively, in the PEX group. The expected cost of the PHACO procedure was found to be 1.4 times higher in patients with PEX, compared to those without PEX, for all types of nuclear cataract. All PHACO parameters are significantly higher in patients with PEX. The costs associated with PHACO surgery for cataracts are greater for patients with PEX and are not covered by the present DRG codes, which highlights the need to accordingly adjust the DRGs for PHACO procedures in PEX patients, in order to maintain the quality of healthcare provided for these vulnerable patients.

Sepsis-coded hospitalisations and associated costs in Australia: a retrospective analysis

ObjectiveTo report trends in Australian hospitalisations coded for sepsis and their associated costs.DesignRetrospective analysis of Australian national hospitalisation data from 2002 to 2021.MethodsSepsis-coded hospitalisations were identified using the Global Burden of Disease study sepsis-specific ICD-10 codes modified for Australia. Costs were calculated using Australian-Refined Diagnosis Related Group codes and National Hospital Cost Data Collection.ResultsSepsis-coded hospitalisations increased from 36,628 in 2002-03 to 131,826 in 2020-21, an annual rate of 7.8%. Principal admission diagnosis codes contributed 13,843 (37.8%) in 2002-03 and 44,186 (33.5%) in 2020-21; secondary diagnosis codes contributed 22,785 (62.2%) in 2002-03 and 87,640 (66.5%) in 2020-21. Unspecified sepsis was the most common sepsis code, increasing from 15,178 hospitalisations in 2002-03 to 68,910 in 2020-21. The population-based incidence of sepsis-coded hospitalisations increased from 18.6 to 10,000 population (2002-03) to 51.3 per 10,000 (2021-21); representing an increase from 55.1 to 10,000 hospitalisations in 2002-03 to 111.4 in 2020-21. Sepsis-coded hospitalisations occurred more commonly in the elderly; those aged 65 years or above accounting for 20,573 (55.6%) sepsis-coded hospitalisations in 2002-03 and 86,135 (65.3%) in 2020-21. The cost of sepsis-coded hospitalisations increased at an annual rate of 20.6%, from AUD199M (€127 M) in financial year 2012 to AUD711M (€455 M) in 2019.ConclusionHospitalisations coded for sepsis and associated costs increased significantly from 2002 to 2021 and from 2012 to 2019, respectively.

Clinical outcomes and cost savings from implementation of an objective scoring rubric to guide inpatient chemotherapy stewardship.

471 Background: The cost of cancer care is an enormous healthcare burden. Most inpatient chemotherapy (IC) is not reimbursed because of the diagnosis-related group code structure for reimbursement. We implemented the use of a novel objective scoring rubric to guide and automate IC stewardship at an academic cancer center to decrease the inappropriate use of costly IC in patients especially at the end of life. Methods: We created a scoring rubric based on treatment and patient specific criteria. Intravenous (IV) IC that is on formulary and standard of care is automatically approved. IV IC that is non-formulary requires evaluation using developed criteria including: type and phase of trial, FDA and NCCN approvals, performance status, line, and goal of therapy. Clinicians enter these criteria in a Redcap form which automatically calculates a score which is reviewed by 2 disease specific physicians and a clinical pharmacist for accuracy. If the threshold score is not met, IC is not approved for administration. We compared differences from the post-implementation time period (3/2022-10/2022) to the same time the year prior on our primary outcomes: inpatient mortality and drug costs. Analyses were conducted using Chi-square tests. Results: A total of 98 IC requests were submitted; 16% (16) were disapproved. Solid Tumor (ST) accounted for 52% (51) of requests with 48% (41) for Heme Malignancy (HM). Of the approved cases, ST comprised 61% (22) of deaths compared to 39% (14) of patients with HM. Of the disapproved cases that died, 55% (5) were ST and 45% (4) were HM. Requests for checkpoint inhibitors comprised 16% (15) of cases and 81% of those patients died (p= 0.028) with the majority (60%) dying in the hospital (p= 0.05). Among those who died, 26% (n=4; p=0.08) and 46% (n=7; p=0.01) died within 30 and 60 days of last chemotherapy administration, respectively. Pre-implementation the spend on IV NF chemotherapy was $744,105 and post was $549,363; a 26% ($194,741) reduction in cost. Conclusions: Physician choice for administration of IC aligned with objective criteria 84% of the time. Alternatively, this tool prevented inappropriate administration of IC 16% of the time. Checkpoint inhibitor administration was significantly associated with inpatient mortality. Our pilot indicates that there is a role for an objective tool for automated IC stewardship with an emphasis to limit inpatient immunotherapy.

Conversion THA With Concomitant Removal of Orthopaedic Hardware Should Be Reclassified as a Revision Surgery in the Medicare Severity Diagnosis-Related Group Coding Scheme: An Analysis of Cost and Resource Use.

Conversion THA, which we defined for this study as THA with concomitant removal of preexisting orthopaedic hardware, has been associated with increased hospital costs and perioperative complications compared with primary THA. Yet, conversion THA is classified as a primary procedure under the Medicare Severity Diagnosis-Related Group coding scheme, and hospitals are reimbursed based on the resource use expected for a routine primary surgery. Prior authors have argued for conversion THA to be reclassified as a revision procedure. Although prior research has focused on comparisons between conversion THAs and primary arthroplasties, little is known about the resource use of conversion THA compared with that of revision THA. (1) Do inpatient hospital costs, estimated using cost-to-charge ratios, differ between conversion THA and revision THA? (2) Do the median length of stay, intensive care unit use, and likelihood of discharge to home differ between conversion and revision THA? This was a retrospective study of the Medicare Provider Analysis and Review Limited Data Set for 2019. A total of 713,535 primary and 74,791 revision THAs and TKAs were identified initially. Exclusion criteria then were applied; these included non-fee-for-service hospitalizations, nonelective admissions, and patients with missing data. Approximately 37% (263,545 of 713,535) of primary and 34% (25,530 of 74,791) of revision arthroplasties were excluded as non-fee-for-service hospitalizations. Two percent (13,159 of 713,535) of primaries and 11% (8159 of 74,791) of revisions were excluded because they were nonelective procedures. Among the remaining 436,831 primary and 41,102 revision procedures, 31% (136,748 of 436,831) were primary THAs and 36% (14,774 of 41,102) were revision THAs. Two percent (2761 of 136,748) of primary THAs involved intraoperative removal of hardware and were classified as conversion THAs. After claims with missing data were excluded, there were 2759 conversion THAs and 14,764 revision THAs available for analysis. Propensity scores were generated using a multivariate logistic regression model using the following variables as covariates: gender, age, race, van Walraven index, hospital setting, geography, hospital size, resident-to-bed ratio, and wage index. After matching, 2734 conversion THAs and 5294 revision THAs were available for analysis. The van Walraven index, which is a weighted score of patient preoperative comorbidities, was used to measure patient health status. Hospital costs were estimated by multiplying cost-to-charge ratios obtained from the 2019 Impact File by total hospital charges. This methodology enabled the use of a large national database to mitigate the random effects of individual hospitals' unique practices and patient populations. Multivariable regression was performed after matching to determine the independent effects of surgery type (that is, conversion versus revision THA) on hospital cost, length of stay greater than 2 days, intensive care unit use, and discharge to home. There was no difference in the estimated hospital cost between conversion THA and revision THA (β = 0.96 [95% confidence interval 0.90 to 1.01]; p = 0.13). Patients undergoing conversion THA had increased odds of staying in the hospital for more than 2 days (odds ratio 1.12 [95% CI 1.03 to 1.23]; p = 0.01), increased odds of using the intensive care unit (OR 1.24 [95% CI 1.03 to 1.48]; p = 0.02), and decreased odds of being discharged to home (OR 0.74 [95% CI 0.67 to 0.80]; p < 0.001). The inpatient hospital cost of conversion THA is no different from that of revision THA, although patients undergoing conversion surgery have modestly increased odds of prolonged length of stay, intensive care unit use, and discharge to a nonhome location. These findings support the conclusion that reclassification of conversion THA is warranted. Orthopaedic surgeons must advocate for the reclassification of conversion THA using data-backed evidence or run the risk that orthopaedic procedures will be given decreased reimbursement. Level III, economic and decision analysis.

Current Medicare reimbursement for complex endovascular aortic repair is inadequate based on results from a multi-institutional cost analysis

ObjectiveComplex endovascular juxta-, para- and suprarenal abdominal aortic aneurysm repair (comEVAR) is frequently accomplished with commercially available fenestrated (FEVAR) devices or off-label use of aortoiliac devices with parallel branch stents (chEVAR). We sought to evaluate the implantable vascular device costs incurred with these procedures as compared with standard Medicare reimbursement to determine the financial viability of comEVAR in the modern era. MethodsFive geographically distinct institutions with high-volume, complex aortic centers were included. Implantable aortoiliac and branch stent device cost data from 25 consecutive, recent, comEVAR in the treatment of juxta-, para-, and suprarenal aortic aneurysms at each center were analyzed. Cases of rupture, thoracic aneurysms, reinterventions, and physician-modified EVAR were excluded, as were ancillary costs from nonimplantable equipment. Data from all institutions were combined and stratified into an overall cost group and two, individual cost groups: FEVAR or chEVAR. These groups were compared, and each respective group was then compared with weighted Medicare reimbursement for Diagnosis-Related Group codes 268/269. Median device costs were obtained from an independent purchasing consortium of >3000 medical centers, yielding true median cost-to-institution data rather than speculative, administrative projections or estimates. ResultsA total of 125 cases were analyzed: 70 FEVAR and 53 chEVAR. Two cases of combined FEVAR/chEVAR were included in total cost analysis, but excluded from direct FEVAR vs chEVAR comparison. Median Medicare reimbursement was calculated as $35,755 per case. Combined average implantable device cost for all analyzed cases was $28,470 per case, or 80% of the median reimbursement ($28,470/$35,755). Average FEVAR device cost per case ($26,499) was significantly lower than average chEVAR cost per case ($32,122; P < .002). Device cost was 74% ($26,499/$35,755) of total reimbursement for FEVAR and 90% ($32,122/$35,755) for chEVAR. ConclusionsResults from this multi-institutional analysis show that implantable device cost alone represents the vast majority of weighted total Medicare reimbursement per case with comEVAR, and that chEVAR is significantly more costly than FEVAR. Inadequate Medicare reimbursement for these cases puts high-volume, high-complexity aortic centers at a distinct financial disadvantage. In the interest of optimizing patient care, these data suggest a reconsideration of previously established, outdated, Diagnosis-Related Group coding and Medicare reimbursement for comEVAR.

Role of femoral head material on readmission and mortality rates following elective primary total hip arthroplasty in Medicare patients.

The role of different femoral head materials for total hip arthroplasty (THA) has been widely studied in the context of wear properties and corrosion. Cobalt chrome (CoCr) femoral heads are commonly used as a standard of comparison to other materials such as ceramic and oxidized zirconium (OxZi). This study aims to evaluate the impact of femoral head material on clinical outcomes in elective primary THA patients. Retrospective analysis of THA patients within the Medicare claims database between October 2017 and September 2020 using diagnosis-related group codes was conducted. Information collected included sex, age, Charlson Comorbidity Index, and femoral head type. Patients with CoCr femoral heads were compared against patients with either OxZi or ceramic femoral heads using 1:1 propensity score matching. Z-testing and Chi-square analysis were used to determine between-group significance. In total, 112,960 elective THA patients were included, with 56,480 in OxZi or ceramic and 56,480 in CoCr. Readmission rates were lower in patients that received OxZi or ceramic femoral heads at 30-day (p < 0.0001), 60-day (p < 0.0001), and 90-day postoperatively (p < 0.0001) compared to CoCr. Mortality rates were also lower in patients that received OxZi or ceramic femoral heads at 30-day (p = 0.004), 60-day (p = 0.018), and 90-day postoperatively (p = 0.009) compared to CoCr. CoCr femoral heads had higher rates of readmissions and mortality compared to OxZi or ceramic. Further analysis of bearing surface combinations and sub-group analyses to determine significance between-group differences is needed. Retrospective analysis.

Predictors of Prolonged Length of Stay After Pituitary Adenoma Resection: A Large Cohort Analysis Using the National Inpatient Sample (2016-2019).

In this nationwide retrospective study, the authors aimed to identify demographic, clinical, and baseline health risk factors predictive of a prolonged length of stay (PLOS) for patients with pituitary adenomas (PAs). The National Inpatient Sample dataset from 2016 to 2019 was utilized to identify all included hospitalizations for PA resection as identified by the appropriate diagnosis-related group code. Comorbidities were classified based on the Charlson Comorbidity Index mapping of ICD-10 codes, and PLOS was identified as any stay longer than 3 days. Univariable and multivariable logistic regression models, accounting for the sample design, were built to determine factors associated with PLOS and emergent surgery. Overall, 30 945 patients were included in this study with 10 535 patients having PLOS. Female patients experienced an increased odds of PLOS (odds ratio [OR]: 1.29; P < .001). Black patients (OR: 1.49; P < .001) and Hispanic patients (OR: 1.30; P = .003) had 1.49 times and 1.30 times the odds of PLOS compared to White patients, respectively. Compared to patients insured by Medicare, patients insured by Medicaid had an increased odds of PLOS (OR: 1.36; P = .007) as well as emergent surgery (OR: 5.40; P < .001). When stratified by emergent surgeries, Black patients (OR: 1.89; P < .001), Hispanic patients, (OR: 2.14; P < .001), and patients on Medicaid insurance (OR: 1.71; P < .001) were at an increased risk of emergent procedures. However, female sex (OR: 0.65; P < .001), upper third quartile (OR: 0.73; P = .017), and fourth quartile (OR: 0.69; P = .014) of patients categorized by zip code income were at decreased odds of an emergent procedure. Black and Hispanic patients, patients with Medicaid insurance, and patients of low socioeconomic status patients are at significantly higher risk of emergent PA resection and PLOS. Efforts to prevent emergent surgeries and shorten hospitalization after pituitary surgery may need to primarily focus on patient groups with select sociodemographic characteristics.

The financial burden associated with endovascular repair of thoracoabdominal and pararenal aortic aneurysms using physician-modified fenestrated-branched endografts

Objective/BackgroundEndovascular thoracoabdominal and pararenal aortic aneurysm repair is more complex and requires more devices than infrarenal aneurysm repair. It is unclear if current reimbursement covers the cost of delivering this more advanced form of vascular care. The objective of this study was to evaluate the economics of fenestrated-branched (FB-EVAR) physician-modified endograft (PMEG) repairs. MethodsWe obtained technical and professional cost and revenue data for four consecutive fiscal years (July 1, 2017, to June 30, 2021) at our quaternary referral institution. Inclusion criteria were patients who underwent PMEG FB-EVAR in a uniform fashion by a single surgeon for thoracoabdominal/pararenal aortic aneurysms. Patients in industry-sponsored clinical trials or receiving Cook Zenith Fenestrated grafts were excluded. Financial data were analyzed for the index operation. Technical costs were divided into direct costs that included devices and billable supplies and indirect costs including overhead. Results62 patients (79% male, mean age: 74 years, 66% thoracoabdominal aneurysms) met inclusion criteria. The mean aneurysm size was 6.0 cm, the mean total operating time was 219 minutes, and the median hospital length of stay was 2 days. PMEGs were created with a mean number of 3.7 fenestrations, using a mean of 8.6 implantable devices per case. The average technical cost per case was $71,198, and the average technical reimbursement was $57,642, providing a net negative technical margin of $13,556 per case. Of this cohort, 31 patients (50%) were insured by Medicare remunerated under diagnosis-related group code 268/269. Their respective average technical reimbursement was $41,293, with a mean negative margin of $22,989 per case, with similar findings for professional costs. The primary driver of technical cost was implantable devices, accounting for 77% of total technical cost per case over the study period. The total operating margin, including technical and professional cost and revenue, for the cohort during the study period was negative $1,560,422. ConclusionsPMEG FB-EVAR for pararenal/thoracoabdominal aortic aneurysms produces a substantially negative operating margin for the index operation driven largely by device costs. Device cost alone already exceeds total technical revenue and presents an opportunity for cost reduction. In addition, increased reimbursement for FB-EVAR, especially among Medicare beneficiaries, will be important to facilitate patient access to such innovative technology.

Surgical outcomes and cost analysis of a multi-specialty robotic-assisted surgery caseload in the Australian public health system.

This study aims to compare surgical outcomes and in-hospital cost between robotic-assisted surgery (RAS), laparoscopic and open approaches for benign gynaecology, colorectal and urological patients and to explore the association between cost and surgical complexity. This retrospective cohort study included consecutive patients undergoing RAS, laparoscopic or open surgery for benign gynaecology, colorectal or urological conditions between July 2018 and June 2021 at a major public hospital in Sydney. Patients' characteristics, surgical outcomes and in-hospital cost variables were extracted from the hospital medical records using routinely collected diagnosis-related groups (DRG) codes. Comparison of the outcomes within each surgical discipline and according to surgical complexity were performed using non-parametric statistics. Of the 1,271 patients included, 756 underwent benign gynaecology (54 robotic, 652 laparoscopic, 50 open), 233 colorectal (49 robotic, 123 laparoscopic, 61 open) and 282 urological surgeries (184 robotic, 12 laparoscopic, 86 open). Patients undergoing minimally invasive surgery (robotic or laparoscopic) presented with a significantly shorter length of hospital stay when compared to open surgical approach (P < 0.001). Rates of postoperative morbidity were significantly lower in robotic colorectal and urological procedures when compared to laparoscopic and open approaches. The total in-hospital cost of robotic benign gynaecology, colorectal and urological surgeries were significantly higher than other surgical approaches, independent of the surgical complexity. RAS resulted in better surgical outcomes, especially when compared to open surgery in patients presenting with benign gynaecology, colorectal and urological diseases. However, the total cost of RAS was higher than laparoscopic and open surgical approaches.

Implementation of the novel use of an objective scoring rubric to reduce utilization of inpatient non-formulary chemotherapy.

e13535 Background: The cost of cancer care is an enormous healthcare burden. Most inpatient chemotherapy (IC) is not reimbursed because of diagnosis-related group codes. We implemented the use of a novel objective scoring rubric to guide and automate IC stewardship at an academic cancer center to decrease the inappropriate use of costly inpatient therapies in patients especially at the end of life. Methods: We created a scoring rubric based on treatment and regimen specific criteria. IC that is on formulary and standard of care is automatically approved. IC that is non-formulary requires evaluation using the developed criteria. Treatment factors include: type and phase of trial, and FDA and NCCN approvals. Patient factors include: performance status, line and goal of therapy. Clinicians must complete the criteria via a form in RedCap which then automatically calculates a score which is then reviewed by 2 disease specific physicians and a clinical pharmacist for accuracy. If the threshold score is met, IC is approved and if it is not met, IC is not approved for administration. Our primary outcome is cost savings and clinical outcomes. Results: Pre-implementation the cost of IV NF chemotherapy from 3/2021-10/2021 was $744,105 and post –implementation from 3/2022-10/2022 was $549,363 which is a 26% ($194,741) reduction in cost. 98 cases were reviewed over this time period. 82 (84%) cases were approved and 16 (16%) were disproved. The total cost of approved cases was $482,694 and the cost savings of disproved cases was $68,121 (14%). 51 were Solid Tumor (ST) requests and 47 were for Heme Malignancy (HM) requests. Clinical outcomes of the approved cases are illustrated. 16% of cases were submissions for immunotherapy (nivolumab, pembrolizumab) and 81% of those patients died. Conclusions: 84% of the time our cancer physicians chose the administration of IC that aligned with objective criteria which is reassuring and serves to validate the use of this tool. Alternatively, this tool prevented inappropriate administration of chemotherapy 16% of the time. Our pilot indicates that there is a role for an objective tool for automated IC stewardship.[Table: see text]

Perioperative Acute Ischemic Stroke in Patients with Atrial Fibrillation.

Anticoagulation therapy is commonly interrupted in patients with atrial fibrillation (AF) for elective procedures. However, the risk factors of acute ischemic stroke (AIS) during the periprocedural period remain uncertain. We performed a nationwide analysis to evaluate AIS risk factors in patients with AF undergoing elective surgical procedures. Using the Nationwide Readmission Database, we included electively admitted adult patients with AF and procedural Diagnosis-Related Group codes from 2016 to 2019. Diagnoses were identified based on International Classification of Disease, 9th revision-Clinical Modification (ICD-10 CM) codes. We constructed a logistic regression model to identify risk factors and developed a new scoring system incorporating CHA2 DS2 VASc to estimate periprocedural AIS risk. Of the 1,045,293 patients with AF admitted for an elective procedure, the mean age was 71.5 years, 39.2% were women, and 0.70% had a perioperative AIS during the index admission or within 30 days of discharge. Active cancer (adjusted OR [aOR] = 1.58, 95% confidence interval [CI] = 1.42-1.76), renal failure (aOR = 1.14, 95% CI = 1.04-1.24), neurological surgery (aOR = 4.51, 95% CI = 3.84-5.30), cardiovascular surgery (aOR = 2.74, 95% CI = 2.52-2.97), and higher CHA2 DS2 VASc scores (aOR 1.25 per point, 95% CI 1.22-1.29) were significant risk factors for periprocedural AIS. The new scoring system (area under the receiver operating characteristic curve [AUC] = 0.68, 95% CI = 0.67 to 0.79) incorporating surgical type and cancer outperformed CHA2 DS2 VASc (AUC = 0.60, 95% CI = 0.60 to 0.61). In patients with AF, periprocedural AIS risk increases with the CHA2 DS2 VASc score, active cancer, and cardiovascular or neurological surgeries. Studies are needed to devise better strategies to mitigate perioperative AIS risk in these patients. ANN NEUROL 2023.

Identification of pregnancies and their outcomes in healthcare claims data, 2008-2019: An algorithm.

Pregnancy is a condition of broad interest across many medical and health services research domains, but one not easily identified in healthcare claims data. Our objective was to establish an algorithm to identify pregnant women and their pregnancies in claims data. We identified pregnancy-related diagnosis, procedure, and diagnosis-related group codes, accounting for the transition to International Statistical Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) diagnosis and procedure codes, in health encounter reporting on 10/1/2015. We selected women in Merative MarketScan commercial databases aged 15-49 years with pregnancy-related claims, and their infants, during 2008-2019. Pregnancies, pregnancy outcomes, and gestational ages were assigned using the constellation of service dates, code types, pregnancy outcomes, and linkage to infant records. We describe pregnancy outcomes and gestational ages, as well as maternal age, census region, and health plan type. In a sensitivity analysis, we compared our algorithm-assigned date of last menstrual period (LMP) to fertility procedure-based LMP (date of procedure + 14 days) among women with embryo transfer or insemination procedures. Among 5,812,699 identified pregnancies, most (77.9%) were livebirths, followed by spontaneous abortions (16.2%); 3,274,353 (72.2%) livebirths could be linked to infants. Most pregnancies were among women 25-34 years (59.1%), living in the South (39.1%) and Midwest (22.4%), with large employer-sponsored insurance (52.0%). Outcome distributions were similar across ICD-9 and ICD-10 eras, with some variation in gestational age distribution observed. Sensitivity analyses supported our algorithm's framework; algorithm- and fertility procedure-derived LMP estimates were within a week of each other (mean difference: -4 days [IQR: -13 to 6 days]; n = 107,870). We have developed an algorithm to identify pregnancies, their gestational age, and outcomes, across ICD-9 and ICD-10 eras using administrative data. This algorithm may be useful to reproductive health researchers investigating a broad range of pregnancy and infant outcomes.

Abstract P6-08-10: Cash, Commercial Negotiated Prices, and Correlations with Neighborhood Poverty Levels for Shoppable Breast Cancer Services

Abstract Introduction: On January 1, 2021, the Centers for Medicare and Medicaid Services (CMS) implemented the Hospital Price Transparency Final Rule to promote price competition and improve hospital care affordability. Hospitals in the US are required to disclose, among other items, the cash prices and the payer-specific negotiated prices for CMS-specified, high-volume common services. We investigated the compliance rate and descriptive costs for breast cancer services in the central New Jersey region. Methods: We collected CMS-specified hospital services representing 4 unique Current Procedural Terminology (CPT)/diagnosis related group codes (screening mammography, US guided biopsy, mastectomy, partial lumpectomy). Cash prices and payer-specific negotiated prices for these services were obtained from Turquoise Health, a data service company that specializes in collecting pricing information from hospitals. We collected the median cash price, the proportion of hospitals for which the cash price was lower than its median commercial negotiated price, interquartile ranges (IQR) for cash prices across all services by practice type, and the correlation between cash price of service and neighborhood poverty level. Results: 106 hospitals in a 50-mile radius from central New Jersey were reviewed, representing 22 academic and 84 community clinics. Of these, only 4 hospitals disclosed both their cash price and commercially negotiated price for all services. Overall, there was a correlation for mammography cash price and neighborhood level of poverty (Rs -0.34, p = 0.026). No correlations were noted for the other services. Cash prices varied substantially across hospitals, as evidenced by large IQR for US-guided biopsy $ 1877.19 (1647.05 – 5388.2), mastectomy $6417.00 (4847.34 – 48166.69), and lumpectomy $3820.00 (3021.76 – 17041.84) in academic centers. When compared to community hospitals, academic institutions were more likely to set their cash prices below negotiated insurance prices. Discussion: Of the 106 hospitals investigated, only 4 disclosed both their cash price and commercially negotiated price. As evidenced by the negative correlation between the cash median cash price of screening mammography and neighborhood level of poverty, hospitals encourage entry into the health system. Unfortunately, downstream costs for diagnosis and treatment are unpredictable and present major challenges in preventing financial toxicity and assuring health equity. Because of its descriptive nature, this study was unable to identify factors or outcomes associated with the cash price variation. Uninsured or underinsured patients who choose to take the cash price offered by hospitals remain extremely vulnerable. Citation Format: Alexandra Noveihed, Naveena Lall, Qasim S. Hussaini, Roy Elias, Arjun Gupta, Ramy Sedhom. Cash, Commercial Negotiated Prices, and Correlations with Neighborhood Poverty Levels for Shoppable Breast Cancer Services [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P6-08-10.

Higher Surgeon Volume is Associated With a Lower Rate of Subsequent Revision Procedures After Total Shoulder Arthroplasty: A National Analysis.

Studies assessing the relationship between surgeon volume and outcomes have shown mixed results, depending on the specific procedure analyzed. This volume relationship has not been well studied in patients undergoing total shoulder arthroplasty (TSA), but it should be, because this procedure is common, expensive, and potentially morbid. We performed this study to assess the association between increasing surgeon volume and decreasing rate of revision at 2 years for (1) anatomic TSA (aTSA) and (2) reverse TSA (rTSA) in the United States. In this retrospective study, we used Centers for Medicare and Medicaid Services (CMS) fee-for-service inpatient and outpatient data from 2015 to 2021 to study the association between annual surgeon aTSA and rTSA volume and 2-year revision shoulder procedures after the initial surgery. The CMS database was chosen for this study because it is a national sample and can be used to follow patients over time. We included patients with Diagnosis-related Group code 483 and Current Procedural Terminology code 23472 for TSA (these codes include both aTSA and rTSA). We used International Classification of Diseases, Tenth Revision, procedural codes. Patients who underwent shoulder arthroplasty for fracture (10% [17,524 of 173,242]) were excluded. We studied the variables associated with the subsequent procedure rate through a generalized linear model, controlling for confounders such as patient age, comorbidity risk score, surgeon and hospital volume, surgeon graduation year, hospital size and teaching status, assuming a binomial distribution with the dependent variable being whether an episode had at least one subsequent procedure within 2 years. The regression was fitted with standard errors clustered at the hospital level, combining all TSAs and within the aTSA and rTSA groups, respectively. Hospital and surgeon yearly volumes were calculated by including all TSAs, primary procedure and subsequent, during the study period. Other hospital-level and surgeon-level characteristics were obtained through public files from the CMS. The CMS Hierarchical Condition Category risk score was controlled because it is a measure reflecting the expected future health costs for each patient based on the patient's demographics and chronic illnesses. We then converted regression coefficients to the percentage change in the odds of having a subsequent procedure. After controlling for confounding variables including patient age, comorbidity risk score, surgeon and hospital volume, surgeon graduation year, and hospital size and teaching status, we found that an annual surgeon volume of ≥ 10 aTSAs was associated with a 27% decreased odds of revision within 2 years (95% confidence interval 13% to 39%; p < 0.001), while surgeon volume of ≥ 29 aTSAs was associated with a 33% decreased odds of revision within 2 years (95% CI 18% to 45%; p < 0.001) compared with a volume of fewer than four aTSAs per year. Annual surgeon volume of ≥ 29 rTSAs was associated with a 26% decreased odds of revision within 2 years (95% CI 9% to 39%; p < 0.001). Surgeons should consider modalities such as virtual planning software, templating, or enhanced surgeon training to aid lower-volume surgeons who perform aTSA and rTSA. More research is needed to assess the value of these modalities and their relationship with the rates of subsequent revision. Level III, therapeutic study.

Abstract TMP103: Acute Ischemic Stroke Readmission In Patients With Periprocedural Atrial Fibrillation

Introduction: Anticoagulation therapy are commonly interrupted in patients with atrial fibrillation (AF) for elective procedures. However, risk factors of subsequent stroke during the periprocedural period is uncertain. We performed a nationwide analysis to evaluate risk factors for acute ischemic stroke (AIS) readmission in patients with AF admitted for elective procedure. Methods: Using the Healthcare Cost and Utilization Project (HCUP) Nationwide Readmission Database, we included electively admitted adult patients, who had AF diagnosis and procedural Diagnosis-related group code from 2016 to 2019. AF, AIS and other diagnosis were identified based on standard ICD-10 CM codes. Patients who had history of stroke or stroke during the index admission were excluded. We constructed a Cox regression model to determine hazard ratios (HR) of demographic, clinical factors and procedural type associated with AIS readmission. Results: Of the 1,048,422 patients with AF admitted for elective procedure, the mean age was 71.5 and 39.1% were female, and 1625 (0.15%) had AIS readmission within 30 days of discharge. In the adjusted Cox regression model, age (adjusted HR 1.05, 95% CI 1.04-1.06, P &lt; 0.001), female sex (aHR 1.22, 95% CI 1.05-1.41, P = 0.009), cancer (aHR 1.45, 95% CI 1.89-1.76, P &lt; 0.001), congestive heart failure (aHR 1.22, 95% CI 1.03-1.44, P = 0.021), diabetes (aHR 1.33, 95% CI 1.14-1.55, P &lt; 0.001), neurological surgery (aHR 2.27, 95% CI 1.69-3.06, P &lt; 0.001), cardiovascular surgery (aHR 1.59, 95% CI 1.32-1.91, P &lt; 0.001). Furthermore, higher CHADS 2 VASC 2 score (aHR 1.29 by one point, 95% CI 1.22-1.37, P &lt; 0.001) were associated with AIS readmission. Conclusion: AF patients with higher CHADS 2 VASC 2 score and those undergoing cardiac or neurological surgeries are at higher risk of perioperative stroke. Studies are needed to tailor anticoagulation management during the perioperative time to reduce perioperative AIS risk in such patients.

Medical Costs Associated With Diabetes Complications in Medicare Beneficiaries Aged 65 Years or Older With Type 1 Diabetes.

To estimate medical costs associated with 17 diabetes complications and treatment procedures among Medicare beneficiaries aged ≥65 years with type 1 diabetes. With use of the 2006-2017 100% Medicare claims database for beneficiaries enrolled in fee-for-service plans and Part D, we estimated the annual cost of 17 diabetes complications and treatment procedures. Type 1 diabetes and its complications and procedures were identified using ICD-9/ICD-10, procedure, and diagnosis-related group codes. Individuals with type 1 diabetes were followed from the year when their diabetes was initially identified in Medicare (2006-2015) until death, discontinuing plan coverage, or 31 December 2017. Fixed-effects regression was used to estimate costs in the complication occurrence year and subsequent years. The cost proportion of a complication was equal to the total cost of the complication, calculated by multiplying prevalence by the per-person cost divided by the total cost for all complications. All costs were standardized to 2017 U.S. dollars. Our study included 114,879 people with type 1 diabetes with lengths of follow-up from 3 to 10 years. The costliest complications per person were kidney failure treated by transplant ($77,809 in the occurrence year and $13,556 in subsequent years), kidney failure treated by dialysis ($56,469 and $41,429), and neuropathy treated by lower-extremity amputation ($40,698 and $7,380). Sixteen percent of the total medical cost for diabetes complications was for treating congestive heart failure. Costs of diabetes complications were large and varied by complications. Our results can assist in cost-effectiveness analysis of treatments and interventions for preventing or delaying diabetes complications in Medicare beneficiaries aged ≥65 years with type 1 diabetes.