Diagnostic Related Groups Research Articles

Utilization and Reimbursements of Primary Total Joint Arthroplasty in Ambulatory Surgical Centers: Analysis of Medicare Part A and B Databases

BackgroundRecent changes in Medicare reimbursement policies have facilitated the shift of primary total joint arthroplasty (TJA) volume to ambulatory surgical centers (ASC). The ASCs potentially provide a more cost-effective alternative to a hospital-setting TJA. This study investigated Medicare primary TJA utilization and reimbursement trends at ACSs compared to inpatient and outpatient settings between 2019 and 2022. MethodsMedicare Part A and B claims data from the Centers for Medicare & Medicaid Services (CMS) databases were analyzed. Primary total knee arthroplasty (TKA) and total hip arthroplasty (THA) procedures were identified using Current Procedural Terminology (CPT) codes, Diagnostic Related Group (DRG) codes, and Comprehensive Ambulatory Payment Classification (C-APC) codes based on respective settings. The ASC utilization data was extracted based on year. Billing data for ASCs, hospital outpatient departments (HOPD), and inpatient TJA were compared. Monetary values were adjusted to 2022 dollars using the Consumer Price Index (CPI). ResultsFrom 2019 to 2022, 1,665,237 primary TJA claims were billed (TKA 1,079,846 claims; THA 585,391 claims), with a 6.1% increase in total utilization. The volume of ASC TJAs increased by 327.1% (TKA 193.8% from 2020 to 2022; THA 61.1% from 2021 to 2022). In the same period, average reimbursement for ASC TJAs rose by 3.9% (TKA 3.4%; THA 1.3%) but showed an 8.1% decline after adjusting for inflation (TKA -8.4%; THA -6.2%). By 2022, ASCs accounted for 8.6% of the total TJAs with the lowest reimbursement per procedure (TKA $8,472.3; THA $8578.7). This shift to ASCs corresponded with $235 million saved compared to inpatient settings and $137 million saved compared to HOPDs per year. ConclusionOur study highlights a marked increase in TJA volume at ASCs, with the procedure costing significantly less than HODP or inpatient TJAs. The findings underscore the growing acceptance of these centers as viable, cost-effective alternatives to traditional hospital settings. However, with the declining value of ASC reimbursements, continued monitoring of reimbursement policy is necessary to ensure the sustainability of these cost-effective ASCs for TJAs.

Hospital costs of COVID-19, post-COVID-19 condition and other viral pneumonias: a cost comparison analysis.

To compare hospital admission costs for coronavirus disease 2019 (COVID-19) cases to hospital admission costs for other viral pneumonia cases in Australia, and to describe hospital admission costs for post-COVID-19 condition. A cost comparison analysis of hospital admissions due to COVID-19 or other viral pneumonias between 1 January 2020 and 30 June 2021 at Victorian public health acute and subacute services. Demographic characteristics, clinical outcomes (including diagnoses, impairment, subacute admission, intensive care unit admissions, ventilation, and length of stay) and cost data (including diagnostic-related groups, and total, direct and indirect costs). During the study period, 3197 patients were admitted to hospital due to COVID-19 and 15 761 were admitted for other viral pneumonias. Admissions for COVID-19 cost 29% more than admissions for other viral pneumonias. Admissions for COVID-19 requiring intensive care unit admission incurred significantly higher mean costs (A$120 504 or US$90 595) compared with those not requiring intensive care unit admission (A$19 634 or US$14 761). The adjusted cost of admissions related to post-COVID-19 condition was A$11 090 or US$8 337, and these admissions were significantly more likely to be elective. Direct costs accounted for most of the costs for all groups, and admissions for post-COVID-19 condition used less allied health services than other groups. Given its recent emergence, cases of acute COVID-19 and post-COVID-19 condition have had a significant additional financial impact on Australian hospitals. Further studies are required to understand long term costs and identify trends over time in the context of increased vaccination rates and subsequent variants of severe acute respiratory syndrome coronavirus 2.

SINAVE’s quality: completeness for Meningococcal Disease – Northern Portugal, 2020-2022

Abstract Due to Meningococcal’s Disease (MD) severity and impact in public health, in Portugal it is mandatory to notify the suspicious cases to implement effective control measures. MD cases are notified in the National Surveillance System (SINAVE), which triggers epidemiological investigation, risk assessment and community intervention. The quality of SINAVE is defined by various attributes, being their evaluation crucial to improve and guarantee quality standards. Our goal is to evaluate the external and internal completeness of SINAVE for MD in northern Portugal from 2020 to 2022. We have conducted a cross-sectional study, using MD cases from 2020 to 2022. External Completeness was estimated using a two-source capture-recapture method, with data from SINAVE and Diagnostic-Related Group (DRG) cases. Hospital readmissions’, duplicates and cases from other regions were excluded. Internal completeness of SINAVE was accessed for each case and for each non-mandatory variable. For external completeness (EC) analysis, 21 of the 23 DRG cases were eligible for matching. Out of 31 SINAVE confirmed cases, 20 were eligible for matching. EC of SINAVE was 66,7%. For internal completeness (IC) analysis, we excluded 7 cases that did not meet the criteria for inclusion. The mean IC was 73,5% (min 38,5%, max 85,7%) when analysing by case. When assessing each of the 30 non-mandatory variables of the reports, 7 (23,3%) had an IC of 100% and 13 (43,3%) had an IC of 0%, the mean value was 49,7%. SINAVE assessment, as a routine, is crucial to identify the need for improvement. Completeness is fundamental to ensure an effective public health response. Our results confirm under-reporting and incomplete report of MD. There is a need to strengthen the improvement of data quality of SINAVE. Future studies may be important to estimate true incidence of MD and compare the results for other diseases in order to improve public health actions. Key messages • Meningococcal disease requires timely public health intervention. • valuation of the surveillance system is crucial, with completeness playing an important role for data quality and prompt response.

ABCDEF: Tool to transform the systems for the registry of institutional information

Health systems require instruments that allow the generation of real, concrete, specific and objective information that can be named, classified, shared and compared internationally. Nowadays, this premise is possible, thanks to the specific and particular characteristics of information technologies needs in health, the speed in the generation of knowledge, the technological changes in telecommunications and its current development. However, there are areas of opportunity in information systems that make difficult this paradigm. Many of these areas are in the hands of health professionals themselves, who work directly with primary sources of information. Given this panorama, by applying an awareness and measurement tool, we can contribute to identifying areas of opportunity in order to favor the adequate recording of information, mainly hospital discharges, which has an impact on the biased and incorrect generation of morbidity statistics and hospital mortality, the diversion of financial, human, and material resources and, of course, the impossibility of implementing hospital management tools such as diagnostic related groups (DRG). It is interesting that in order for certain areas of opportunity to occur, in this case those related to the clinical record, it is investigated the feeling that each worker has about the work environment in their organization, that is to say, about the work environment, if they feel taken into account, trained, fed back, valued and part of the positive change in their work environment so that they feel motivated to do their work in accordance with regulations.

Recent Medicare Billing Trends of Hospitals and Surgeons for Revision Hip and Knee Total Joint Arthroplasty: Is the Value of a Surgeon’s Work Decreasing?

BackgroundRevision hip and knee total joint arthroplasty (TJA) is associated with higher health care costs and work burden than primary TJAs. However, previous studies demonstrated a decrease in the value of reimbursements for revision TJA, causing concerns for hospitals and surgeons regarding the financial sustainability of these resource-expensive procedures. This study aimed to investigate the Medicare billing trends of hospitals and surgeons for revision TJA between 2017 and 2022. MethodsMedicare claims and payments for revision TJA were identified from the Centers for Medicare and Medicaid Services Part A and B databases. Hospital claims for revision TJA were identified through Diagnostic-Related Groups (467, 468). Surgeon claims were identified using Current Procedural Terminology codes for revision hip (27134, 27137, 27138) and knee (27486, 27487) TJA. Yearly charges, reimbursements, and markup ratios (MR = charge/reimbursement) were analyzed. All monetary values were adjusted to the 2022 U.S. dollars. ResultsA total of 43,125 surgeons and 152,974 hospital claims were included in this study. From 2017 to 2022, the total volume of revision TJA decreased by 19.4%. Hospital reimbursements remained relatively unchanged, with a decrease of 1.4%, while hospital charges increased by 11.8%, resulting in a 13.3% increase in the MR. For surgeons, reimbursements decreased by 13.8%, and charges decreased by 11.0%, leading to a 3.3% increase in the MR. The proportion of surgeon reimbursement to hospital reimbursement decreased from 8.5 to 7.5%. ConclusionsThe comparison of the billing trends of hospitals and surgeons showed the relatively stable value of hospital reimbursement while the value of surgeon reimbursement continued to decline, implying the decreasing fiscal value of physicians’ work. The study suggests the need for sustainable financial incentives for surgeons performing revision TJA and strategies to control hospital charges to alleviate financial burdens and improve patient access to revision TJA.

Importance of Hospital Performance Indicators in Contracting and Financing Medical Services in Surgical Wards.

In the Romanian healthcare system, public hospitals' contract for the provision of healthcare services with the National Health Insurance Services (NHIS) is the main source of revenue in a hospital's income and expenditure budget. In Romania, for acute diseases, payment is made on a per-case basis for hospitals financed under the diagnostic-related groups (DRG) system, which is calculated according to the indicators achieved. The main objective of the study aimed at the quantitative and comparative analysis of hospital performance indicators used in the calculation of the contracted amount with NHIS, in order to quantify the results and evaluate the effectiveness of the measures taken in the surgical wards of the Emergency Clinical County Hospital of Oradea (ECCHO) compared to the annual average values at the national level, in the period 2012-2022. The indicators, such as the number of beds, number of cases, average length of hospitalization (LOH), and case complexity index (CCI), were analyzed at the level of the ECCHO, a tertiary care hospital in the surgical wards. Rehabilitation and modernization of wards, laboratories, operating theatres, and high-performance equipment have been made possible through efficient management and monthly monitoring of medical and financial activity. The average LOH actually carried out on the surgical wards has been decreasing over the 11 years analyzed, with a lower number of hospital days than at the national level. The CCI achieved by the hospital's surgical wards has had an increasing evolution throughout the period analyzed, higher than the national value. The maximum amount contracted and the amount contracted by the hospital is higher when the LOH and CCI indicators achieved by each section are included in the formula than the indicators established at the national level. A lower LOH and a higher CCI than the national values facilitated the contracting of a higher amount. Optimization of the indicators by hospital performance is correlated with improved funding by the NHIS. Increasing the contracted amount facilitates the contracting of an exponential annual number of cases, resulting in more efficient medical services in the surgical wards.

Predicting hospital length of stay using machine learning on a large open health dataset

BackgroundGovernments worldwide are facing growing pressure to increase transparency, as citizens demand greater insight into decision-making processes and public spending. An example is the release of open healthcare data to researchers, as healthcare is one of the top economic sectors. Significant information systems development and computational experimentation are required to extract meaning and value from these datasets. We use a large open health dataset provided by the New York State Statewide Planning and Research Cooperative System (SPARCS) containing 2.3 million de-identified patient records. One of the fields in these records is a patient’s length of stay (LoS) in a hospital, which is crucial in estimating healthcare costs and planning hospital capacity for future needs. Hence it would be very beneficial for hospitals to be able to predict the LoS early. The area of machine learning offers a potential solution, which is the focus of the current paper.MethodsWe investigated multiple machine learning techniques including feature engineering, regression, and classification trees to predict the length of stay (LoS) of all the hospital procedures currently available in the dataset. Whereas many researchers focus on LoS prediction for a specific disease, a unique feature of our model is its ability to simultaneously handle 285 diagnosis codes from the Clinical Classification System (CCS). We focused on the interpretability and explainability of input features and the resulting models. We developed separate models for newborns and non-newborns.ResultsThe study yields promising results, demonstrating the effectiveness of machine learning in predicting LoS. The best R2 scores achieved are noteworthy: 0.82 for newborns using linear regression and 0.43 for non-newborns using catboost regression. Focusing on cardiovascular disease refines the predictive capability, achieving an improved R2 score of 0.62. The models not only demonstrate high performance but also provide understandable insights. For instance, birth-weight is employed for predicting LoS in newborns, while diagnostic-related group classification proves valuable for non-newborns.ConclusionOur study showcases the practical utility of machine learning models in predicting LoS during patient admittance. The emphasis on interpretability ensures that the models can be easily comprehended and replicated by other researchers. Healthcare stakeholders, including providers, administrators, and patients, stand to benefit significantly. The findings offer valuable insights for cost estimation and capacity planning, contributing to the overall enhancement of healthcare management and delivery.

Impact of Diagnostic-Related Groups Healthcare Payment Reform on Public Hospitals

The increasing reform of diagnosis-related groups (DRG) healthcare payment plays a crucial role in the reform of the medical and healthcare system, accelerating the high-quality development of public hospitals and serving as a critical path for their reform. The innovation of DRG healthcare payment methods can balance the financial income and expenditure of public hospitals, while also achieving a more harmonized balance of interests among hospitals, patients, and health insurance. This reform effectively controls the operating costs of hospitals, strictly regulates medical behaviors and quality management, and optimizes the patient treatment process. To quickly adapt to this reform trend, public hospitals need to seize the opportunities of healthcare system reform, adopt corresponding strategies to address the impact of DRG payment reform and achieve their own sustainable development goals in health.

Dermatological emergencies and determinants of hospitalization in Switzerland: A retrospective study.

Dermatologic conditions are estimated to account worldwide for approximately 8% of all visits at emergency departments (EDs). Although rarely life-threatening, several dermatologic emergencies may have a high morbidity. Little is known about ED consultations of patients with dermatological emergencies and their subsequent hospital disposal. We explore determinants and clinical variables affecting patients' disposal and hospitalization of people attending the ED at a Swiss University Hospital, over a 56-month observational period, for a dermatological problem. De-identified patients' information was extracted from the hospital electronic medical record system. Generalized estimating equations were used to explore determinants of patient's disposition. Out of 5096 consecutive patients with a dermatological main problem evaluated at the ED, 79% of patients were hospitalized after initial assessment. In multivariable analyses, factors which were significantly associated with an increased admission rate included length of ED stay, age ≥ 45 years, male sex, distinct vital signs, high body mass index, low oxygen saturation, admission time in the ED and number and type of dermatological diagnoses. Only 2.2% of the hospitalized patients were admitted to a dermatology ward, despite the fact that they had dermatological diagnoses critically determining the diagnostic related group (DRG) payment. The number of patients managed by dermatologists during in-patient treatment significantly decreased over the study period. Our study identifies a number of independent predictors affecting the risk of hospital admission for patients with dermatological conditions, which may be useful to improve patients' disposal in EDs. The results indicate that the dermatological specialty is becoming increasingly marginalized in the management of patients in the Swiss hospital setting. This trend may have significant implications for the delivery of adequate medical care, outcomes and cost-effectiveness. Dermatologists should be more engaged to better position their specialty and to effectively collaborate with nondermatologists to enhance patient care.

Cost analysis of care and blood transfusions in patients with Major Obstetric Haemorrhage in Ireland.

Obstetric haemorrhage is the leading cause of maternal morbidity and mortality worldwide. We aimed to estimate the economic cost of Major Obstetric Haemorrhage (MOH) and the cost of therapeutic blood components used in the management of MOH in Ireland. We performed a nationwide cross-sectional study utilising top-down and bottom-up costing methods on women who experienced MOH during the years 2011-2013. Women with MOH were allocated to Diagnostic Related Groups (DRGs) based on the approach to MOH management (MOH group). The total number of blood components used for MOH treatment and the corresponding costs were recorded. A control group representative of a MOH-free maternity population was designed with predicted costs. All costs were expressed in Euro (€) using 2022 prices and the incremental cost of MOH to maternity costs was calculated. Cost contributions are expressed as percentages from the estimated total cost. A total of 447 MOH cases were suitable for sorting into DRGs. The estimated total cost of managing women who experienced MOH is approximately €3.2 million. The incremental cost of MOH is estimated as €1.87 million. The estimated total cost of blood components used in MOH management was €1.08 million and was based on an estimated total of 3997 products transfused. Red blood cell transfusions accounted for the highest contribution (20.22%) to MOH total cost estimates compared to other blood components. The total cost of caring for women with MOH in Ireland was approximately €3.2 million with blood component transfusions accounting for between one third and one half of the cost.

A99 HIGHER HOSPITAL INPATIENT RACIAL DIVERSITY IS ASSOCIATED WITH BETTER OUTCOMES AMONG HISPANIC AND INDIGENOUS AMERICAN PATIENTS FOR FIVE COMMON GASTROINTESTINAL DIAGNOSES

Abstract Background There is evidence that gastrointestinal disease (GI) outcomes are poorer among patients from underrepresented backgrounds. However, the impact of hospital patient racial diversity on GI outcomes is understudied. Aims We aimed to investigate the impact of hospital patient racial diversity on GI outcomes Methods Using the 2019 National Inpatient Sample (NIS), racial diversity was defined by the percentage of Hispanic or Indigenous American patients discharged from each hospital. GI discharge diagnoses were defined by diagnostic related group. We included GI bleeding, inflammatory bowel diseases, GI obstruction, cirrhosis, and alcoholic hepatitis. Logistic regression was used to predict major complication rates or comorbidity (MCC), long length of stay (LOS), and high total charges. Control variables included age, gender, payer type, patient location, area-associated income quartile, hospital characteristics including size, urban vs. rural, teaching vs. nonteaching, region, and the interaction of the percentage of Hispanic and Indigenous Americans with patient race. Results were validated with the 2018 NIS dataset. Results Our analysis cohort of 537,830 hospitalizations included 252,225 GI bleeding discharges, 59,310 gastrointestinal obstruction discharges, 106,820 cirrhosis and alcoholic hepatitis discharges, and 119,475 inflammatory bowel diseases discharges. In the unadjusted analyses, MCC rates were higher among Hispanic (24.8%) and Indigenous American patients (30.4%), compared to Whites (18.3%). In adjusted analyses, compared to white patients, Hispanic patients had higher MCC rates [adjusted odds ratio (OR) 1.21, 95% Confidence Interval (CI) 1.15-1.28]. The same trend was seen among Indigenous American patients [OR 1.25, (95% CI) 1.09-1.43]. However, as hospital Hispanic diversity increased, inpatient MCC outcomes for Hispanics improved [OR 0.93, (95% CI) 0.87-1.14], and were even better among Indigenous American patients as hospital inpatient Indigenous American diversity increased [OR 0.83, (95% CI) 0.73-0.94] (Table 1). A similar improvement in MCC with increasing Hispanic and Indigenous American diversity was observed in the 2018 validation cohort. Table 1 highlights impact of increasing diversity on LOS and total charges. Conclusions Increasing hospital inpatient Hispanic and Indigenous American diversity is associated with better outcomes for these underrepresented minority groups. More research is needed on the impact of cultural competence and linguistic concordance on patient outcomes. Funding Agencies None

A budget impact analysis of a powered hybrid mattress to prevent pressure ulcers in the Austrian inpatient setting: An original research.

Pressure ulcer is a considerable health problem and is associated with an increased hospital length of stay (LOS), nursing effort, costs, and reduced quality of life. The aim of this analysis is to compare the economic, clinical, and nursing benefit after the implementation of the powered hybrid mattress Dyna-Form Mercury Advance SMARTcare® in 2019 with the situation in 2017 (rental systems Arjo BariAir® and Arjo TheraKair Visio®, and purchased foam mattresses Arjo Simuflex®) using a single center. In the framework of a budget impact analysis, a difference-in-difference approach was used to compare pre-implementation longitudinal data (2017) with post-implementation data (2019). The longitudinal data comprise the mattress resource use, patient characteristics, and LOS. The care effort was gathered based on a full survey of all 75 members of the nursing staff using the online tool "LimeSurvey." In this survey, the resource use of the different mattress systems was identified in terms of time (minutes or days). This analysis was performed from the hospital perspective and included direct costs of mattress systems, Austrian diagnostic-related group costs for the hospital stay and nursing staff costs for 2019. Based on 1253 patients "at-risk," the total yearly costs implementing the powered hybrid mattress amounts to 654,248€ compared with 901,469€ when using Arjo products. The budget impact shows a cost advantage of 247,221€. Furthermore, the powered hybrid mattress system leads to fewer nursing-staff time in minutes per year (-1,031,097 min [1,993,204 vs. 3,024,302]); 242€ are saved per patient. Compared with the Arjo products, fewer inpatient cases of pressure ulcers (-44 cases [0 vs. 44]) were documented. Despite the higher total outlay of costs associated with the powered hybrid mattress, the long-term savings potential showed a significant cost advantage per annum for the single center. Therefore, the use of the hybrid mattress leads to considerable economic, clinical, and nursing benefits.

Analysis of Hospital Length of Stay in Each Diagnostic -Related Groups (DRGs) Carried Out Using the Smart Hospital Research Application

Abstract Background The application of business intelligence (BI) tools in hospitals can enhance the quality and efficiency of care by providing insights into diagnostic, therapeutic, and business processes. BI tools aid in infection monitoring, clinical decision -making, and analysis of hospitalisation durations within Diagnostic-Related Groups (DRGs), identifying inefficiencies and optimizing resource use. Objectives This study aims to analyse hospital length of stay and identify the DRGs with the most inefficient hospitalization times using the BI -driven Smart Hospital application. Materials and methods The Smart Hospital application, developed on the Qlik Sense BI platform, analysed data from the National Health Fund (NFZ), Statistics Poland, e -health Centre (CEZ), and hospitalisations billed by DRG sections. The dataset included 20,376,405 hospitalisations from 2017–2019. Results The average length of stay (ALOS) was 6.2 days, with an effective length of stay (ELOS) of 4.33 days. Ineffective hospitalisation days totalled 30,307,086, accounting for 28.99% of all hospitalizations. The most inefficient DRGs were E53G (Cardiovascular failure), A48 (Complex stroke treatment), N01 (Childbirth), T07 (Trauma conservative treatment), and D28 (Respiratory and thoracic malignancies), contributing to about 14% of all ineffective hospital days. Conclusions Understanding the factors influencing hospitalisation durations in DRGs can improve patient flow management. Future research should compare treatment effectiveness concerning hospitalisation duration to develop optimal strategies for specific patient groups.

Effect of capitation payment method on health outcomes, healthcare utilization, and referrals in Ghana.

Different provider payment systems generate different incentives for patients, providers, and purchasers. Ghana introduced the National Health Insurance Scheme (NHIS) in 2003 and has made reforms to its provider payment methods to create incentives in providers for cost containment. Starting with the fee for service method, it shifted to the Diagnostic Related Group (DRG) method in 2008 to improve cost containment. In 2012 the NHIS began piloting capitation method of payment which has been suspended since 2017 to allow for thorough review. This study uncovers the association between capitation payment system and patient health outcomes, utilization of healthcare services and referral patterns in Ghana based on data collected between November 2012 and January 2013. Using a cross-sectional data on 500 malaria patients who were enrollees of the NHIS from the two payment plans (i.e., capitation and DRG plan), ordered logit, negative binomial and logit regression results showed that patients under capitation were 11.9% less likely to report better health and had 1.583 fewer visits relative to patients under DRG. In relation to referrals, capitated providers were more likely to refer patients than under DRG plans. In the capitated region, better health outcomes were reported by patients of private health facilities. Capitation in Ghana was associated with under-provision of care, hence decreasing any efficiency gain from the reform. Implementors of capitation need to ensure a good monitoring and evaluation system for adequate provision of quantity and quality of care. Some limitations of this study include the use of cross sectional rather that panel data which follows individuals over time and therefore may be more able to provide definite information about cause-and-effect relationships. It also does not account for events before and after the introduction of any payment method. Overall, this study provides valuable information on the implementation policy for reintroducing capitation.

Palliative care assessment and outcomes in patients admitted for heart failure in an Australian quaternary healthcare service

Abstract Background/Introduction Heart failure (HF) has high mortality and healthcare utilisation, and despite patients having similar palliative care needs to cancer patients(1), they are much less likely to have their PC needs assessed and managed (2-3). Expert consensus guidelines from cardiology and palliative care groups recommend early integration of a palliative approach in addition to usual care, but the complex and unpredictable trajectory of HF, lack of referral criteria and misunderstandings about PC are potential barriers that affect specialist PC referrals. Given the issues surrounding integration of PC in HF patients, we sought to understand the use of PC by patients with HF at our institution. Purpose To characterise the pattern and predictors of referrals of HF patients to the inpatient PC service in an Australian quaternary health service. Methods A single-centre retrospective cohort study was performed using electronic medical record data in consecutive patients admitted for HF at a quaternary health service in Australia, over a 12 month period from July 2019 to June 2020. All adults ≥ 18 years of age and admitted for HF were identified using the Diagnostic Related Group (DRG) admission code for ‘Heart Failure and Shock’. Results The 502 patients admitted for HF were elderly (median age 82 years, IQR 15) and 50% were male. Functional status was poor, with 29% unable to care for themselves and 56% requiring some level of assistance. General medicine was the major admitting unit with 67% (n=338 of 502) of patients, and the cardiology and advanced heart failure units admitted 12% (n=59) and 5% (n=26) of patients, respectively. Conversely, the main treating team in the ambulatory setting was cardiology in 51% (n=253). HF patients had high mortality rate at 32% during the median follow up time of 27 months (interquartile range 8 months). Seven percent (n=37 of 502) were referred to inpatient specialist PC, and often in the terminal phase. High dependency (defined as Australian-modified Karnofsky Performance Status 10-40) (62% vs 28%, p<0.01) and New York Heart Association class III-IV symptoms (86% vs 42%, p<0.01) were associated with referral, but one or more previous admission for HF in the last 12 months was not (35% vs. 28%, p=0.35). In all HF patients, symptoms were poorly assessed and discussion about prognosis occurred in 10% despite the high mortality. Referral to inpatient PC resulted in more prescribing of symptom medications on discharge (41% vs 2%, p<0.01) and referral to community PC (46% vs 1%, p<0.01). Conclusion Referral to inpatient specialist PC in hospitalised HF patients is low relative to the morbidity and mortality in these patients. In addition, treating teams do not routinely assess symptoms or discuss disease trajectory. More work is needed to ensure that HF patients’ PC needs are integrated into care as recommended by expert consensus.Table 1

Prevalence and Impact of Feeding-Related Events on Hospital Stay in Preterm and Term Newborns.

Nursing assessment of milk flow regulation and associated apnea, bradycardia, and desaturation (ABD events) contribute to considerations for the discharge of newborns from the acute care setting. Research regarding infant feeding-related (FR) events (sucking and swallowing difficulties) and ABD events in moderate to late-preterm and full-term infants is lacking. This study observes the impact of FR and ABD events during feeding on hospital length of stay (LOS) and healthcare utilization (cost) in moderate-to-late preterm newborns, as well as full-term infants. In a retrospective study, bottle-fed infants admitted to the level II specialty care nursery of an academic community hospital in Southern California were observed for FR and ABD events. Statistical analyses were used to determine the impact of FR events on adjusted LOS, to evaluate the interaction between FR event status and adjusted LOS on total hospital charges, and to assess the statistical independence between FR events and diagnostic-related group severity. The full sample of patient records included 308 infants born between 32- and 44-week gestational age between April 1, 2018, and October 31, 2022. LOS was twice as long in infants who had FR events. Total median charges were higher in the group with FR events at $160,165 versus $64,380 with non-FR events. Increased knowledge in the epidemiology and nursing care of infants experiencing milk flow regulation and associated ABD events is critical for informing practices and guidelines related to the prevention of related morbidities.

Improving Value in Colorectal Cancer Care: An Economic Analysis of Enhanced Recovery Protocols at a Community Hospital.

Enhanced recovery protocols (ERPs) have been shown to improve the outcomes of gastrointestinal cancer care, leading to reduced morbidity of gastrointestinal treatment and reduced delays in systemic therapy. ERP implementation has also previously shown a reduction in length of stay (LOS) without changing the readmission rate; however, the economic cost associated with these measures has not yet been quantified. The aim of this study was to evaluate the economic costs of ERP implementation for colorectal cancer at a community hospital. The Diagnostic Related Group (DRG) codes were used to assess costs associated with the hospitalizations of cases in the ERP versus non-ERP groups. The American Hospital Association (AHA) Annual Survey from 1999 to 2015 was used to provide the expenses per day for inpatient hospitalization in the United States. Postoperative LOS, average healthcare costs, and postoperative complications between ERP-protocol and non-ERP protocol groups were analyzed using analysis of variance (ANOVA) and independent t-tests. The AHA survey estimated that $2,265 was incurred per day for non-profit hospitals in Florida and $2,346 was incurred per day for the United States. For all DRG codes, the ERP-participating group was associated with a shorter LOS and reduced health care costs. LOS-associated cost was compared between ERP and non-ERP groups: for DRG 329, the total savings was $162,118.8 (n = 12 non-ERP versus n = 8 ERP, P = 4.39 × 10-18); for DRG 330, $314,552.64 (n = 36 non-ERP versus n = 24 ERP, P = 2.72 × 10-22); and for DRG 331, $89,302.73 (n = 11 non-ERP versus n = 23 for ERP, P = 4.19 × 10-20). The implementation of an ERP protocol for colorectal cancer was associated with significantly reduced costs in a community hospital.

Large Variation in Listed Chargemaster Price for Total Joint Arthroplasty Among Top Orthopaedic Hospitals in the United States.

Chargemasters are lists of all services offered by a hospital and their associated cost. This study analyzes chargemaster data to determine price differences among different hospitals for total joint arthroplasty. In May 2020, the chargemaster data for highly rated orthopaedic hospitals were accessed, and the diagnostic-related group (DRG) codes related to primary and revision total joint arthroplasty were analyzed (DRGs 466, 467, 468, 469, and 470). The prices listed for each hospital were averaged, and descriptive statistics were calculated. Furthermore, Medicare reimbursement was collected. A subanalysis was performed to determine relationships between geographic and demographic information. The median price for a major hip or knee joint arthroplasty without complications was $68,016 (range: $39,927 to $195,264). The median price of a revision of hip or knee arthroplasty without complications was $90,966 (range: $58,967 to $247,715). The cost of living in the city in which the hospitals are located was weakly correlated with procedure pricing, whereas the median income had no notable relationship to chargemaster pricing. The published cost of DRG codes in arthroplasty is widely variable among the top 20 US orthopaedic hospitals, with little correlation to the cost of living or median income of the area.

Hemoadsorption Using CytoSorb® in Patients with Infective Endocarditis: A German-Based Budget Impact Analysis.

A considerable number of infective endocarditis (IE) patients require cardiac surgery with an increased risk for postoperative sepsis. Intraoperative hemoadsorption may diminish the risk of postoperative hyperinflammation with potential economic implications for intensive care unit (ICU) occupation. The present study aimed to theoretically investigate the budget impact of a reduced length of ICU stay in IE patients treated with intraoperative hemoadsorption in the German healthcare system. Data on ICU occupation were extrapolated from a retrospective study on IE patients treated with hemoadsorption. An Excel-based budget impact model was developed to simulate the patient course over the ICU stay. A base-case scenario without therapy reimbursement and a scenario with full therapy reimbursement were explored. The annual eligible German IE patient population was derived from official German Diagnostic-Related Group (DRG) volume data. One-way deterministic sensitivity analysis and multivariate analysis were performed to evaluate the uncertainty over the model results. The use of intraoperative hemoadsorption resulted in EUR 2298 being saved per patient in the base-case scenario without therapy reimbursement. The savings increased to EUR 3804 per patient in the case of full device-specific reimbursement. Deterministic and probabilistic sensitivity analyses confirmed the robustness of savings, with a probability of savings of 87% and 99% in the base-case and full reimbursement scenario, respectively. Intraoperative hemoadsorption in IE patients might have relevant economic benefits related to reduced ICU stays, resulting in improved resource use. Further evaluations in larger prospective cohorts are warranted.

Improving Gastrointestinal Cancer Care by Enhanced Recovery Protocol Implementation

Background: Enhanced recovery protocols (ERPs) have become the standard of care for patients undergoing elective small bowel surgeries but have not yet been adequately studied in community hospitals. In this study, a multidisciplinary ERP was developed and implemented at a community hospital to include minimal anesthesia, early ambulation and enteral alimentation, and multimodal analgesia. The aim of this study was to determine the effects of the ERP on postoperative length of stay (LOS), readmission (RA) rates following bowel surgery, and postoperative outcomes. Methods: The study design was a retrospective review of patients undergoing major bowel resection at Holy Cross Hospital (HCH) from January 1, 2017 to December 31, 2017. Patient charts for diagnostic-related group (DRG) 329, 330, and 331 were retrospectively reviewed at HCH in 2017 to compare outcomes in ERP versus non-ERP cases. The Medicare claims database (CMS) was also retrospectively reviewed to compare HCH data to the national average LOS and RA for the same DRG codes. Mean values for LOS and RA were statistically compared to determine significant differences between ERP versus non-ERP patients at HCH and national CMS data versus HCH patients. Results: LOS was analyzed for each DRG at HCH. At HCH, for DRG 329, the mean LOS for non-ERP was 13.0833 days (n = 12) versus 3.375 days (n = 8) (P ? 0.001) for ERP. For DRG 330, the mean LOS for non-ERP was 10.861 days (n = 36) versus 4.583 days (n = 24) (P ? 0.001) for ERP. For DRG 331, the mean LOS for non-ERP was 7.272 days (n = 11) versus 3.348 days (n = 23) (P = 0.004) for ERP. LOS was also compared to national CMS data. The LOS at HCH for DRG 329 improved from the 10th to 90th percentile (n = 238,907); DRG 330 improved from the 10th to the 72nd percentile (n = 285,423); DRG 331 improved from 10th to 54th percentile (n = 126,941) (P < 0.001). The RA at HCH in ERP and non-ERP cases was 3% at 30 and 90 days. CMS RA for DRG 329 was 25.1% at 90 days and 9.9% at 30 days; DRG 330 RA was 18.3% at 90 days and 6.6% at 30 days; DRG 331 RA was 11% at 90 days and 3.9% at 30 days. Conclusion: Implementation of ERP following bowel surgery at HCH significantly improved outcomes, in comparison to non-ERP cases, national CMS data, and Humana data. Further research on ERP for other fields and its impact on outcomes in other community settings is recommended. World J Oncol. 2023;14(2):135-144 doi: https://doi.org/10.14740/wjon1534