Difference In Direct Costs Research Articles

Implementation of a Tenecteplase Protocol for Treatment of Acute Ischemic Stroke in a Health System.

Purpose. Alteplase is the standard of care for intravenous thrombolytic treatment of acute ischemic stroke, but recent evidence suggests that tenecteplase may be as safe and efficacious. The purpose of this study was to evaluate the direct cost savings, safety, and efficacy outcomes following the implementation of a tenecteplase protocol for acute ischemic stroke in the emergency departments within a health system. Methods. A multicenter retrospective medical record review was performed for 4 months prior to protocol implementation on patients who received alteplase and for 4 months post-implementation on patients who received tenecteplase. The primary outcome was the direct cost difference associated with tenecteplase. Secondary outcomes included reduction in National Institutes of Health Stroke Scale 24 hours after thrombolytic therapy, door-to-needle time, symptom onset to intravenous thrombolysis time, incidence of adverse effects, and death. Results. Pre-implementation, 102 received alteplase and post-implementation, 117 received tenecteplase. Four months of utilization of tenecteplase resulted in direct cost savings of $209,476.80 for the health system, which translates to roughly $2,000 per patient. Reduction in the National Institutes for Health Stroke Scale were similar between the two groups with -3.96 in alteplase and -3.18 in tenecteplase (p = 0.952). Median door-to-needle time was 44.5 minutes in alteplase and 49 minutes in tenecteplase. Adverse events occurred in 19 patients in alteplase and 19 in tenecteplase (p = 0.573). Death occurred in 9 patients in alteplase and 14 patients in tenecteplase (p = 0.376). Conclusion. A tenecteplase protocol was successfully implemented in the healthcare system resulting in direct cost savings with no significant differences in adverse events.

Comparison of the effects of sugammadex versus neostigmine for reversal of neuromuscular block on hospital costs of care

BackgroundSugammadex reversal of neuromuscular block facilitates recovery of neuromuscular function after surgery, but the drug is expensive. We evaluated the effects of sugammadex on hospital costs of care. MethodsWe analysed 79 474 adult surgical patients who received neuromuscular blocking agents and reversal from two academic healthcare networks between 2016 and 2021 to calculate differences in direct costs. We matched our data with data from the Healthcare Cost and Utilization Project-National Inpatient Sample (HCUP–NIS) to calculate differences in total costs in US dollars. Perioperative risk profiles were defined based on ASA physical status and admission status (ambulatory surgery vs hospitalisation). ResultsBased on our registry data analysis, administration of sugammadex vs neostigmine was associated with lower direct costs (–1.3% lower costs; 95% confidence interval [CI], –0.5 to –2.2%; P=0.002). In the HCUP-NIS matched cohort, sugammadex use was associated with US$232 lower total costs (95% CI, –US$376 to –US$88; P=0.002). Subgroup analysis revealed that sugammadex was associated with US$1042 lower total costs (95% CI, –US$1198 to –US$884; P<0.001) in patients with lower risk. In contrast, sugammadex was associated with US$620 higher total costs (95% CI, US$377 to US$865; P<0.001) in patients with a higher risk (American Society of Anesthesiologists physical status ≥3 and preoperative hospitalisation). ConclusionsThe effects of using sugammadex on costs of care depend on patient risk, defined based on comorbidities and admission status. We observed lower costs of care in patients with lower risk and higher costs of care in hospitalised surgical patients with severe comorbidities.

Societal costs of ovarian cancer in a population-based cohort – a cost of illness analysis

Background The societal cost associated with ovarian cancer (OC) is not well known. Increasing costs for new treatments and/or the impact of organizational changes motivates these costs to be described and communicated. This study aims to evaluate the cost of illness of OC in a population-based cohort. Material and methods All patients diagnosed with ovarian, fallopian tube, primary peritoneal cancer, and serous cancer of undesignated primary site (UPS) in 2011–2012 were followed for six years. Direct costs, i.e., costs for health care expenditures, were gathered from the regional healthcare database. Information on indirect costs, i.e., costs of loss of production due to sick leave, was retrieved from Statistics Sweden. Sub-group analyses were conducted regarding stage, income levels, residential area, and diagnosis. Results The cost of illness for all stages during the six years of follow-up was €201,086 per patient, where indirect costs constituted 43.7%. The mean cost of illness per year per patient for all stages was €33,514. Direct costs were higher in advanced stages compared to early stages for every year from diagnosis. During the first two years, there were no differences in indirect costs between early and advanced stages. However, during the third year there was a difference with higher indirect costs in advanced stages. There was no difference in direct costs depending on income levels. Regarding residential area, there was a difference in the outpatient cost during the index and second year with higher costs when chemotherapy and follow-up were provided at county hospitals, compared to at the tertiary hospital. Conclusions Indirect costs constituted a large part of the cost of illness over 6 years from diagnosis. This could indicate that even though treatment costs can be expected to rise with the introduction of new therapies, the societal cost may decrease when survival increase.

Comment on The Unbearable Lightness of Difference Between Statistical and Clinical Significance.

Comment on The Unbearable Lightness of Difference Between Statistical and Clinical Significance.

Short-Term Impact of Bracing in Multi-Level Posterior Lumbar Spinal Fusion.

Clinical practice in postoperative bracing after posterior lumbar spine fusion (PLF) is inconsistent between providers. This paper attempts to assess the effect of bracing on short-term outcomes related to safety, quality of care, and direct costs. Retrospective cohort analysis of consecutive patients undergoing multilevel PLF with or without bracing (2013-2017) was undertaken (n = 980). Patient demographics and comorbidities were analyzed. Outcomes assessed included length of stay (LOS), discharge disposition, quality-adjusted life years (QALY), surgical-site infection (SSI), total cost, readmission within 30 days, and emergency department (ED) evaluation within 30 days. Amongst the study population, 936 were braced and 44 were not braced. There was no difference between the braced and unbraced cohorts regarding LOS (P = .106), discharge disposition (P = .898), 30-day readmission (P = .434), and 30-day ED evaluation (P = 1.000). There was also no difference in total cost (P = .230) or QALY gain (P = .740). The results indicate a significantly lower likelihood of SSI in the braced population (1.50% versus 6.82%, odds ratio = 0.208, 95% confidence interval = 0.057-0.751, P = .037). There was no difference in relevant comorbidities (P = .259-1.000), although the braced cohort was older than the unbraced cohort (63 versus 56 y, P = .003). Bracing following multilevel posterior lumbar fixation does not alter short-term postoperative course or reduce the risk for early adverse events. Cost analysis show no difference in direct costs between the 2 treatment approaches. Short-term data suggest that removal of bracing from the postoperative regimen for PLF will not result in increased adverse outcomes.

Impact of Mobile Ex Vivo Lung Perfusion on Lung Transplant Finances

<h3>Purpose</h3> Donor lungs may be transported to the recipient while maintaining perfusion and ventilation, mobile Ex Vivo Lung Perfusion (mEVLP), utilizing the Transmedics Organ Care System (OCS). Although safe and effective, the impact of its adoption on lung transplant program finances has not been studied. <h3>Methods</h3> We reviewed adult lung transplants at our center between 2016 and 2020 for which the program received reimbursement. Transplants were dichotomized into those with use of standard cold preservation (STD) and those with use of mEVLP for preservation and transport. Baseline recipient characteristics, peri-operative data, outcomes and cost/reimbursement were collected and compared. Benefit-Cost Ratios (BCR) were calculated. <h3>Results</h3> We identified 17 STD transplants followed by 6 consecutive transplants with mEVLP reflecting a non-selective change in practice. LAS was significantly lower and use of intra-operative ECMO was more frequent in the mEVLP group. Post-operative ICU and hospital length of stay were comparable (median 5 and 26 days for STD, median 5 and 20 days for mEVLP). All patients survived to hospital discharge. Differences in direct costs and expected net revenue between STD and mEVLP were not statistically significant for all patients. BCR among Medicare patients was 2.32. <h3>Conclusion</h3> Mobile EVLP for allograft preservation was adopted in all lung transplants without a negative impact on program finances in this single center experience. The BCR for Medicare patients suggests that mEVLP may be cost-effective relative to standard preservation and warrants further study.

PMS11 The Economic Burden of Osteoarthritis — Estimates of Direct and Indirect Costs in Sweden from the Biscuits Study

To estimate annual incremental costs of healthcare use and productivity loss due to osteoarthritis (OA) in Sweden. Data from ‘BISCUITS’, a large Nordic cohort study linking several registries, were used to estimate differences in average direct and indirect costs between patients with OA and controls (matched 1:1 based on age and sex) from the general population in Sweden for 2017. Patients ≥18 years with ≥1 diagnosis of OA (ICD-10: M15-M19) recorded in speciality or primary care (latter available for subset of patients) during 2011-2017 were included. Patients with a diagnosis of cancer (ICD-10: C00-C43/C45-C97) were excluded. Productivity loss (sick leave and disability pension) and associated indirect costs was estimated among working-age adults (18-64 years). In 2017, the incremental average annual costs of specialist healthcare use, drug use and productivity loss among adults with OA (n=489,393) relative to those without OA (n=489,393) were €2,935 per patient (p<0.001; average cost, OA: €6,688; controls: €3,753). Direct cost differences (€1,459; p<0.001) were mainly explained by higher surgery cost due to OA patients having more surgeries (€765; p<0.001). For the working-age population, cost difference associated with work absence (€2,878; p<0.001) constituted 66% of the total cost difference between patients with OA and controls (€4,370; p<0.001). In a subset of patients with primary care data (OA, n=194,548; controls, n=194,548), the cost difference of primary care (€481; p<0.001) constituted 44% of the difference in total direct costs (€1,106; p<0.001). From a societal perspective, the economic burden of OA is substantial within both specialty care and primary care populations in Sweden. With an anticipated increasing prevalence due to an ageing population and higher presence of risk factors such as obesity and reduced physical activity, finding more effective and safer therapeutic strategies for these patients will be important.

Economic evaluation of suture versus clip anastomosis in arteriovenous fistula creation

ObjectiveTechniques such as the use of nonpenetrating vascular clips for arteriovenous fistula (AVF) anastomotic creation have been developed in an effort to reduce fistula-related complications. However, the outcomes data for the use of clips have remained equivocal, and the cost evaluations to support their use have been largely theoretical. Therefore, the present study aimed to determine both the clinical and the cost outcomes of AVFs created with nonpenetrating vascular clips compared with the continuous suture technique during a 10-year period at a single institution. MethodsAll patients undergoing AVF creation in the upper extremity from 2009 through 2018 were retrospectively analyzed. The patient demographics and AVF outcomes were collected and compared stratified by the surgical technique used. A cost analysis was performed of a subgroup of patients from 2013 to 2018. ResultsDuring the 10-year study period, 916 AVFs were created (79% using the continuous suture technique and 21% using nonpenetrating vascular clips). Patient demographics and comorbid conditions did not differ between the two groups, and no differences were present in maturation, primary patency, assisted primary patency, or complication rates between the two groups at 1 year. The suture group had a shorter time to maturation (4.3 months vs 5.5 months; P < .01) and improved secondary patency compared with the clip group (77.13% vs 69.59%; P = .03) The cost analysis of the procedures revealed a significant difference in direct costs (suture, $1389.26 vs clip, $1716.51; P < .01) and contribution margin (suture, $1770.19 vs clip, $1128.36; P < .01) for the two groups. ConclusionsBoth suture and clip techniques in AVF creation demonstrated equivalent rates of maturation, primary patency, assisted primary patency, and complications at 1 year with higher expense associated with the use of clips. Thus, in an effort to reduce the economic burden of healthcare in the United States, the findings from the present study support the preferential use of the standard polypropylene suture technique when creating upper extremity AVFs.

Costs and Extra Length of Stay because of Neonatal Bloodstream Infection at a Teaching Hospital in Ghana.

BackgroundThere are no published studies on the costs of hospital-acquired neonatal bloodstream infection (BSI) in Ghana. Therefore, this study aims to calculate the cost and extra length of stay (LOS) of neonatal BSI. A prospective case–control study was undertaken at the neonatal intensive care unit (NICU) of Korle Bu Teaching Hospital (KBTH) in Ghana.MethodsThe clinical data of 357 neonates were prospectively analysed. Overall, 100 neonates with BSI and 100 control neonates without BSI were matched by weight, sex and type of delivery. The direct and indirect costs to neonates and their caregivers was obtained on a daily basis. The cost of drugs was confirmed with the Pharmacy Department at KBTH. A count data model, specifically negative binomial regression, was employed to estimate the extra LOS in the NICU due to neonatal BSI. The study analyzed the total, average and marginal costs of neonatal BSI for the case and control groups from the perspective of the patients/carers/providers.ResultsFifty-four percent of the total sample were born with a low birth weight. Neonates with BSI recorded higher costs compared with neonates without BSI. The highest difference in direct costs was recorded among neonates with extremely low birth weight (US$732), which is 67% higher than similar neonates without BSI. The regression estimates show a significant correlation between neonatal BSI and LOS in the NICU (p < 0.001). Neonates with BSI stayed an additional 10 days in the NICU compared with their matched cohort. The LOS varies significantly depending on the neonate’s weight at birth. The extra days range from 1 day for neonates defined as macrosomia to 15 extra days for extremely low birth weight neonates.ConclusionsNeonatal BSI was significantly associated with prolonged LOS. The continuous presence of experienced medical staff, as well as parents, to monitor newborns during their stay on the ward has enormous economic burden on both hospitals and caregivers.

Cost variance across obesity class for women undergoing laparoscopic hysterectomy by high-volume gynecologic surgeons.

Health-care costs are affected by obesity with both the direct and indirect costs of health care increasing as body mass index (BMI) increases. However, one important aspect of obesity that lacks rigorous study is what impact BMI has on direct surgical cost. We performed a retrospective cohort study of women undergoing a laparoscopic hysterectomy at our single academic university center between January 2012 and December 2017. Women were excluded if their surgery was performed by anyone other than those surgeons with subspecialty training in minimally invasive gynecologic surgery (MIGS), if their hysterectomy was performed by a modality other than conventional laparoscopy or with robotic assistance, or if the indication for hysterectomy was related to any gynecologic malignancy. We identified 600 patients who underwent laparoscopic hysterectomy during the study period. Women who underwent robotic hysterectomy, compared to laparoscopic, had a shorter operative time, lower estimated blood loss, and shorter length of stay. Mean direct cost (± standard deviation) for the cohort was $6398.53 ± $2304.67, age was 44.5 ± 7.5years, and BMI was 32.2 ± 7.6. Direct cost for all laparoscopic hysterectomies was evaluated across the five different BMI quintiles and no significant difference between groups was found. There was no significant difference in direct cost across procedures between obese and non-obese patients (p = 0.62) and this remained true when separated out by surgical modality. However, when evaluating morbidly obese patients, there appears to be a trend toward cost reduction with robotic hysterectomy compared to conventional laparoscopy. It does not appear that BMI has a statistically significant impact on direct cost between robotic-assisted and conventional laparoscopic hysterectomy. However, these findings may be due to surgical proficiency and warrant further investigation among surgeons with lesser volume.

Direct, Absenteeism, and Disability Cost Burden of Obesity Among Privately Insured Employees: A Comparison of Healthcare Industry Versus Other Major Industries in the United States.

To compare obesity-related costs of employees of the healthcare industry versus other major US industries. Employees with obesity versus without were identified using the Optum Health Reporting and Insights employer claims database (January, 2010 to March, 2017). Employees working in healthcare with obesity were compared with employees of other industries with obesity for absenteeism/disability and direct cost differences. Multivariate models estimated the association between industries and high costs compared with the healthcare industry. Obesity-related absenteeism/disability and direct costs were higher in several US industries compared with the healthcare industry (adjusted cost differences of $-1220 to $5630). Employees of the government/education/religious services industry (GERS) with obesity (BMI of 30 or greater) had significantly higher odds of direct costs at the 80th percentile and above (odds ratio vs healthcare industry = 2.20; P < 0.05). Relative to the healthcare industry, employees of other industries, especially GERS, incurred higher obesity-related costs.

Economic Burden of Acute Stroke Care in Beneficiaries and Non-Beneficiaries under Social Security Schemes at Tertiary Care Hospitals of Western Rajasthan

Objective:A cost of illness study was conducted with aims to asses various cost of acute stroke care and its determinants among beneficiary (patients enrolled in any social security scheme) and non beneficiary (patients not enrolled in any social security scheme) of various social security schemes.Method:A cross-sectional study was conducted at government hospitals in western Rajasthan from March to May 2019. All consecutive stroke patients were enrolled during study period. Data related to socio-demographic, disease-related and cost-related data was collected by direct patient and main caregiver’s interview. Primary study outcome was description of direct and indirect cost of acute stroke care among beneficiary and non beneficiary patients. Secondary outcome was description of determinants of cost or significant cost-driven variables.Results:Total of 126 stroke patients were enrolled in 3 months. Mean age was 57.67 ± 15.0 and male: female ratio was 82:44. Both beneficiary and non-beneficiary patients were similar in baseline characteristic except monthly income (P < 0.01) Mean hospital stay was 6.52 ± 2.23 Total out of pocket direct cost among beneficiary was INR 12727.21 [95% C.I. 8658.50, 16795.92] and among non beneficiary was INR 23649.68 [95%C.I. 18591.37, 28707.99]. There was significant difference indirect cost of beneficiary and non-beneficiary patients (P < 0.01). Mean Indirect cost (wages loss) among beneficiary was INR 12414.75 [95% C.I. 9691.13, 15138.37] and among non-beneficiary was INR 16460 [95% C.I. 13044.81, 19875.19]. There was no significant difference in Indirect cost of beneficiary and non-beneficiary patients (P = 0.06). Monthly income, stroke severity (modified Rankin score) and hospital stay were significant direct cost determinants.Conclusion:Public health insurance scheme reduces direct cost of acute stroke care significantly. Severity of stroke and prolonged hospital stay were main cost-driven variables.

A Cost-Minimization Analysis of Intraoperative Costs in Arthroscopic Bankart Repair, Open Latarjet, and Distal Tibial Allograft.

Background:The optimal surgical treatment of anterior shoulder instability remains controversial.Hypothesis:(1) Implants and facility-related costs are the primary drivers of variation in direct costs between arthroscopic Bankart and Latarjet procedures, and (2) distal tibial allograft (DTA) is more costly than Latarjet as a function of the graft expense.Study Design:Cross-sectional study; Level of evidence, 3.Methods:Intraoperative cost data were derived for all arthroscopic anterior stabilizations and Latarjet and DTA procedures performed at a single academic institution from January 2012 to September 2017. Cost comparisons were made between those undergoing arthroscopic stabilization and Latarjet and between Latarjet and DTA. Multivariate regressions were performed to determine the difference in direct costs accounting for various patient- and surgery-related factors.Results:A total of 87 arthroscopic stabilizations, 44 Latarjet procedures, and 5 DTA procedures were performed during the study period. Arthroscopic Bankart repair was found to be 17% more costly than Latarjet, with suture anchor implant cost being the primary driver of cost. DTA was 2.9-fold more costly than Latarjet, with greater costs across all domains. Multivariate analysis also found the number of prior arthroscopic procedures performed (P = .007) and whether the procedure was performed in an ambulatory or inpatient setting (P < .0001) to be significantly associated with higher direct costs.Conclusion:Latarjet is less costly than arthroscopic Bankart repair, largely because of implant cost. Value-driven strategies to narrow the cost differential could focus on performing these procedures in an outpatient setting in addition to reducing overall implant cost for arthroscopic procedures. Perceived potential benefits of DTA over Latarjet may be outweighed by higher costs.

PCN378 PHARMACOECONOMIC ANALYSIS OF ATEZOLIZUMAB PLUS NAB-PACLITAXEL IN THE TREATMENT OF TRIPLE-NEGATIVE BREAST CANCER

Breast cancer with a triple negative phenotype (TNBC) is aggressive form of the disease. The survival at stage 4 is 1 year at most. The goal of the study was assessment of a new option for inoperable TNBC (presence of PD-L1 ≥1%): atezolizumab in combination with nab-paclitaxel. A decision analysis model was used followed by Markov modeling. The cost-effectiveness analysis (CEA) with incremental cost-effectiveness ratio (ICER) calculation was performed. The combination of atezolizumab+nab-paclitaxel and nab-paclitaxel monotherapy regimens were evaluated. Overall survival (OS) was taken as an effectiveness criterion. Budget impact analysis (BIA) was performed with a one-year and three-year perspective in order to assess the difference in direct costs between the current therapy practice (excluding the use of the combination under consideration) and the expected practice (taking into account the use of the combination). TNBC therapy has a high cost in both combination therapy and monotherapy regimens. The use of atezolizumab plus nab-paclitaxel option increased the median OS from 15.5 to 25 months. At the same time, the total costs of using the combined regimen were €124,987 for two years, which is 2.6 times more expensive than nab-paclitaxel monotherapy. ICER for the combined regimen amounted to €8,155, which is significantly less than society willingness-to-pay threshold that equals €27,341 (triple GDP per capita). In addition, ICER value for atazodizumab+nab-paclitaxel is significantly lower than the incremental indicators for alternate therapeutic options used for other curable forms of breast cancer, e.g., trastuzumab emtansine in comparison with lapatinib+capecitabine (€272,669 for the LYG, and €329 475 for QALYs). BIA demonstrated the absence of significant impact on the level of costs for providing patients with breast cancer in general. The use of atezolizumab plus nab-paclitaxel for the TNBC treatment is an economically feasible option for patients with a poor prognosis.

The Utility of Cervical Spine Bracing as a Postoperative Adjunct to Single-level Anterior Cervical Spine Surgery.

Background Context:Use of cervical bracing/collar subsequent to anterior cervical spine discectomy and fusion (ACDF) is variable. Outcomes data regarding bracing after ACDF are limited.Purpose:The purpose of the study is to study the impact of bracing on short-term outcomes related to safety, quality of care, and direct costs in single-level ACDF.Study Design/Setting:This retrospective cohort analysis of all consecutive patients (n = 578) undergoing single-level ACDF with or without bracing from 2013 to 2017 was undertaken.Methods:Patient demographics and comorbidities were analyzed. Tests of independence (Chi-square, Fisher's exact, and Cochran–Mantel–Haenszel test), Mann–Whitney–Wilcoxon tests, and logistic regressions were used to assess differences in length of stay (LOS), discharge disposition (home, assisted rehabilitation facility-assisted rehabilitation facility, or skilled nursing facility), quality-adjusted life year (QALY), surgical site infection (SSI), direct cost, readmission within 30 days, and emergency room (ER) visits within 30 days.Results:Among the study population, 511 were braced and 67 were not braced. There was no difference in graft type (P = 1.00) or comorbidities (P = 0.06–0.73) such as obesity (P = 0.504), smoking (0.103), chronic obstructive pulmonary disease hypertension (P = 0.543), coronary artery disease (P = 0.442), congestive heart failure (P = 0.207), and problem list number (P = 0.661). LOS was extended for the unbraced group (median 34.00 + 112.15 vs. 77.00 + 209.31 h, P < 0.001). There was no difference in readmission (P = 1.000), ER visits (P = 1.000), SSI (P = 1.000), QALY gain (P = 0.437), and direct costs (P = 0.732).Conclusions:Bracing following single-level cervical fixation does not alter short-term postoperative course or reduce the risk for early adverse outcomes in a significant manner. The absence of bracing is associated with increased LOS, but cost analyses show no difference in direct costs between the two treatment approaches. Further evaluation of long-term outcomes and fusion rates will be necessary before definitive recommendations regarding bracing utility following single-level ACDF.

Minimally Invasive Treatment for Benign Prostatic Hyperplasia: Economic Evaluation from a Standardized Hospital Case Costing System.

Minimally invasive alternatives to transurethral resection of the prostate (TURP) such as prostate arterial embolization (PAE) and photoselective vaporization of the prostate (PVP) are being explored as adjuncts in the care of patients with benign prostatic hyperplasia. However, there are conflicting reports of the costs of these procedures. The purpose of this study was to compare the direct and indirect hospital costs of TURP, PAE and PVP. A chart review was performed in patients who underwent TURP, PVP and PAE from April 2015 to March 2017. All hospital costs were collected in accordance with the Ontario Case Costing Initiative, a standardized medical case costing system. Costs were characterized as direct or indirect and fixed or variable. Probabilistic sensitivity analysis was conducted to study cost uncertainty. During the study period, a total of 209 men underwent TURP, 28 PVP and 21 PAE. Mean age (years) was as follows: TURP 71.43; PVP 73.66; PAE 70.77 (p = 0.366). Mean length of stay (days) was as follows: TURP 1.63; PVP 1.55; PAE 1 (p = 0.076). Total costs of the PAE group ($3829, SD $1582) were less than both PVP ($5719, SD $1515) and TURP groups ($5034, SD $1997, p < 0.001). There was no significant difference in direct costs between the groups. Monte Carlo simulation demonstrated that PAE was the least costly alternative majority of the time. The total hospital costs of PAE at our institution are significantly lower than those of PVP and TURP.

Propensity Score-Matched Analysis of Clinical and Financial Outcomes After Robotic and Laparoscopic Colorectal Resection

PurposeThe study aims to evaluate the clinical and financial outcomes of the use of robotic when compared to laparoscopic colorectal surgery and any changes in these over time. MethodsFrom the Premier Perspective database, patients who underwent elective laparoscopic and robotic colorectal resections from 2012 to 2014 were included. Laparoscopic colorectal resections were propensity score matched to robotic cases for patient, disease, procedure, surgeon specialty, and hospital type and volume. The two groups were compared for conversion, hospital stay, 30-day post-discharge readmission, mortality, and complications. Direct, cumulative, and total (including 30-day post-discharge) costs were evaluated. Clinical and financial outcomes were also separately assessed for each of the included years. ResultsOf 36,701 patients, 32,783 (89.3%) had laparoscopic colorectal resection and 3918 (10.7%) had robotic colorectal resection; 4438 procedures (2219 in each group) were propensity score matched. For the entire period, conversion to open approach (4.7 vs. 3.7%, p=0.1) and hospital stay (mean days [SD] 6 [5.3] vs. 5 [4.6], p=0.2) were comparable between robotic and laparoscopic procedures. Surgical and medical complications were also the same for the two groups. However, the robotic approach was associated with lower readmission (6.3 vs. 4.8%, p=0.04). Wound or abdominal infection (4.7 vs. 2.3%, p=0.01) and respiratory complications (7.4 vs. 4.7%, p=0.02) were significantly lower for the robotic group in the final year of inclusion, 2014. Direct, cumulative, and total (including 30-day post-discharge) costs were significantly higher for robotic surgery. The difference in costs between the two approaches reduced over time (direct cost difference: 2012, $2698 vs. 2013, $2235 vs. 2014, $1402). ConclusionRobotic colorectal surgery can be performed with comparable clinical outcomes to laparoscopy. With greater use of the technology, some further recovery benefits may be evident. The robotic approach is more expensive but cost differences have been diminishing over time.

Economic burden of comorbidities in psoriasis patients in the United States: results from a retrospective U.S. database

BackgroundPsoriasis is a multifactorial, inflammatory, skin disease associated with various comorbidities. The cost of those comorbidities is not well characterized. The present study assesses the incremental burden of comorbidities on healthcare resource utilization, direct costs and indirect costs associated with short-term disabilities among patients with psoriasis in the United States.MethodsA retrospective, U.S. cohort analysis was conducted using a large claims database. Adult psoriasis patients with at least two diagnoses of psoriasis during the years 2010 and 2011 (one psoriasis diagnosis had to happen in the year 2010) and with continuous enrollment of medical and pharmacy benefits in the years 2010 and 2011 were included. Psoriasis patients were categorized and compared according to the presence or absence of pre-selected comorbidities in the year 2010. Adjusted annual direct (costs associated with outpatient, emergency room, and inpatient claims, and outpatient pharmacy claims) and indirect costs (short-term disabilities) was assessed in patients with and without comorbidities using a regression analysis, controlling for age, gender, and psoriasis severity in year 2010.ResultsIn total, 56,406 patients (mean [SD]) age, 51.6 [14.6] years) were included in the analysis. The most prevalent comorbidities were hypertension (34.3%), hyperlipidemia (33.5%), cardiovascular disease (17.7%), diabetes (14.2%), and psoriatic arthritis (9.9%). Psoriasis patients with comorbidities used more healthcare resources than those without comorbidities. The incidence rate ratio (IRR) (95% CI) for patients with cardiovascular disease was 1.5 (1.4 − 1.5) for outpatient visits, 2.6 (2.4 − 2.8) for hospitalizations, and 2.3 (2.2 − 2.5) for ER visits, showing higher IRRs across all three types of resource use. The mean annual adjusted direct cost differences (i.e., incremental adjusted costs) in psoriasis patients with and without comorbidities were $9914.3, $8386.5, and $8275.1 for psoriatic arthritis, peripheral vascular disease, and cardiovascular disease, respectively. The mean annual incremental adjusted indirect costs of short-term disabilities were $1333, $1195, $994.9, and $996.6 for cerebrovascular disease, obesity, peripheral vascular disease, and depression, respectively.ConclusionThe presence of comorbidities was associated with higher healthcare resource utilization and costs among patients with psoriasis.

Impact of Palliative Care Screening and Consultation in the ICU: A Multihospital Quality Improvement Project

ContextThere are few multicenter studies that examine the impact of systematic screening for palliative care and specialty consultation in the intensive care unit (ICU). ObjectiveTo determine the outcomes of receiving palliative care consultation (PCC) for patients who screened positive on palliative care referral criteria. MethodsIn a prospective quality assurance intervention with a retrospective analysis, the covariate balancing propensity score method was used to estimate the conditional probability of receiving a PCC and to balance important covariates. For patients with and without PCCs, outcomes studied were as follows: 1) change to “do not resuscitate” (DNR), 2) discharge to hospice, 3) 30-day readmission, 4) hospital length of stay (LOS), 5) total direct hospital costs. ResultsIn 405 patients with positive screens, 161 (40%) who received a PCC were compared to 244 who did not. Patients receiving PCCs had higher rates of DNR—adjusted odds ratio (AOR) = 7.5; 95% CI 5.6–9.9) and hospice referrals—(AOR = 7.6; 95% CI 5.0–11.7). They had slightly lower 30-day readmissions—(AOR = 0.7; 95% CI 0.5–1.0); no overall difference in direct costs or LOS was found between the two groups. When patients receiving PCCs were stratified by time to PCC initiation, early consultation—by Day 4 of admission—was associated with reductions in LOS (1.7 days [95% CI −3.1, −1.2]) and average direct variable costs (−$1815 [95% CI −$3322, −$803]) compared to those who received no PCC. ConclusionReceiving a PCC in the ICUs was significantly associated with more frequent DNR code status and hospice referrals, but not 30-day readmissions or hospital utilization. Early PCC was associated with significant LOS and direct cost reductions. Providing PCC early in the ICU should be considered.

Intra-Household Gender Disparity in School Choice: Evidence from Private Schooling in India

This paper explores gender inequality within households in the decision of private versus government school choice in India. Using a three-period longitudinal dataset on rural households from Uttar Pradesh, a northern state of India, this paper estimates a household fixed effects model that also takes into account non-random enrollment decision. The results show that there is an intra-household gender gap of 5.4 percentage points in private school enrollment among children aged 6 to 19 years. Female disadvantage in private school choice is significant among both younger and older children, and is rising over time. Moreover, a larger cost-difference between private and government schools is associated with a significantly higher gender gap. The village-specific difference in direct cost, particularly school fees, is the most prominent factor in explaining the gender gap. Robustness analysis considering the potential endogeneity of the cost variables indicates that the coefficients are unlikely to be driven by omitted variables.