Health Services Cost Review Commission Research Articles

A Comparative Evaluation of Severity of Acute Pancreatitis at Community and Referral Hospitals: Longitudinal Analysis of the Maryland Health Services Cost Review Commission (HSCRC) Database

A Comparative Evaluation of Severity of Acute Pancreatitis at Community and Referral Hospitals: Longitudinal Analysis of the Maryland Health Services Cost Review Commission (HSCRC) Database

Impact of surgeon and hospital volume on short‐term outcomes and cost of oropharyngeal cancer surgical care

To evaluate the impact of surgeon and hospital case volume and other related variables on short-term outcomes after surgery for oropharyngeal cancer. The Maryland Health Service Cost Review Commission database was queried for oropharyngeal cancer surgical case volumes from 1990 to 2009. Multivariable regression models were used to identify significant associations between surgeon and hospital case volume, as well as independent variables predictive of in-hospital death, postoperative wound complications, length of hospitalization, and hospital-related cost of care. Overall, 1,534 oropharyngeal cancer surgeries were performed during the study period. Complete financial data was available for 1,482 oropharyngeal cancer surgeries, performed by 233 surgeons at 36 hospitals. The only independently significant factors associated with the risk of in-hospital death were an APR-DRG mortality risk score of 4 (odds ratio [OR] = 14.0, P < .001) and total glossectomy (OR = 5.6, P = .020). Wound fistula or dehiscence was associated with an increased mortality risk score (OR = 5.9, P < .001), total glossectomy (OR = 6.9, P < .001), mandibulectomy (OR = 3.4, P < .001), and flap reconstruction (OR = 2.1, P = .038). Increased mortality risk score, total glossectomy, pharyngectomy, mandibulectomy, flap reconstruction, neck dissection, and Black race were associated with an increased length of stay and hospital-related costs. After controlling for all other variables, a statistically significant negative correlation was observed between surgery at a high-volume hospital and length of hospitalization and hospital-related costs. After controlling for other factors, high-volume hospital care is associated with a shorter length of hospitalization and lower hospital-related cost of care for oropharyngeal cancer surgery.

Volume‐based trends in surgical care of patients with oropharyngeal cancer

Positive volume-outcome relationships exist for diseases treated with technically complex surgery. Contemporary patterns of oropharyngeal cancer surgery by hospital and surgeon volume are poorly defined. The Maryland Health Service Cost Review Commission database was queried for hospital and surgeon oropharyngeal cancer surgical case volumes from 1990 to 2009. Overall, 1,534 oropharyngeal cancer surgeries were performed by 238 surgeons at 41 hospitals. Cases performed by high-volume surgeons increased from 18.9% in 1990 to 1999 to 24.8% in 2000 to 2009 (odds ratio [OR] = 1.5, P = .002), whereas cases performed at high-volume hospitals increased from 35.0% to 41.8% (OR = 1.7, P <.001). High-volume surgeons were significantly associated with university hospitals (OR = 25.9, P < .001) and were more likely to perform partial glossectomy (OR = 1.8, P = .002), total glossectomy (OR = 3.8, P < .001), and neck dissection (OR = 2.3, P < .001). High-volume hospitals were significantly associated with tonsillectomy (OR = 3.0, P < .001), partial glossectomy (OR = 1.4, P = .044), total glossectomy (OR = 4.3, P < .001), neck dissection (OR = 3.1, P < .001), flap reconstruction (OR = 1.9, P = .028), and prior radiation (OR = 5.0, P < .001). After controlling for other variables, oropharyngeal cancer surgery in 2000 to 2009 was associated with increased utilization of university hospitals (OR = 1.7, P < .001), increased mortality risk scores (OR = 3.1, P = .022), prior radiation (OR = 4.9, P = .011), and a decrease in partial glossectomy (OR = 0.5, P < .001), total glossectomy (OR = 0.4, P = .004), pharyngectomy (OR = 0.6, P = .007), and mandibulectomy (OR = 0.6, P = .022) procedures. The proportion of oropharyngeal cancer surgery patients treated by high-volume surgeons and hospitals increased significantly from 1990 to 1999 to 2000 to 2009, with a decrease in partial glossectomy, total glossectomy, pharyngectomy, and mandibulectomy procedures. These findings may be due to changing trends in the primary management of oropharyngeal cancer.

Racial disparities in ovarian cancer surgical care: A population-based analysis

ObjectiveTo investigate differences according to racial classification in the frequency of ovarian cancer-related surgical procedures and in access to high-volume surgical providers among women undergoing initial surgery for ovarian cancer. MethodsThe Maryland Health Services Cost Review Commission database was accessed for women age >18years undergoing a surgical procedure that included oophorectomy for a malignant ovarian neoplasm between 7/1/01 and 6/30/09. Multivariate logistic regression analyses were used to evaluate for differences in the likelihood of selected surgical procedures and access to high-volume surgical providers (surgeons≥10 cases/year; hospitals≥20 case/year) according racial classification. ResultsA total of 2487 patients were identified who underwent a primary surgical procedure that included oophorectomy for a malignant ovarian neoplasm: White=1884 (75.4%), African-American=400 (16.1%), and other/unknown=203 (8.2%). Compared to White patients, African-American patients were significantly younger (mean age 55.4years vs 59.9years, P<0.0001) and less likely to have commercial insurance (28.5% vs 39.5%, p<0.0001). Compared to White patients, African-American racial classification was associated with a statistically significant and independent lower likelihood of hysterectomy (OR=0.53, 95%CI=0.42–0.66, p<0.0001), colon resection (OR=0.65, 95%CI=0.48–0.87, p=0.004), lymphadenectomy (OR=0.67, 95%CI=0.50–0.91, p=0.01), and surgery by a high-volume surgeon (OR=0.55, 95%CI=0.44–0.69, p<0.0001). ConclusionsAmong women undergoing initial surgery for ovarian cancer, African-American patients are significantly less likely to be operated on by a high-volume surgeon and to undergo important ovarian cancer-specific surgical procedures compared to White patients.

Impact of surgeon and hospital volume on short‐term outcomes and cost of laryngeal cancer surgical care

To evaluate the impact of surgeon and hospital case volume and other related variables on short-term outcomes after surgery for laryngeal cancer. The Maryland Health Service Cost Review Commission database was queried for laryngeal cancer surgical case volumes from 1990 to 2009. Multivariate logistic regression analyses and multiple linear regression models were used to evaluate for significant associations between surgeon and hospital case volume, as well as other independent variables and the risk of in-hospital death, postoperative wound complications, length of hospital stay, and hospital-related cost of care. Overall, 1,981 laryngeal cancer surgeries were performed with complete financial data available for 1,885 laryngeal cancer surgeries, performed by 284 surgeons at 37 hospitals. The only independently significant factor associated with the risk of in-hospital death was an APR-DRG mortality risk score of 4 (odds ratio [OR] = 10.7, P < .001). Postoperative wound fistula or dehiscence was associated with an increased mortality risk score (OR = 3.1, P < .001), total laryngectomy (OR = 12.4, P = .013), and flap reconstruction (OR = 3.8, P = .001). Increased mortality risk score, partial or total laryngectomy, flap reconstruction, and Black race were associated with an increased length of stay and hospital-related costs. After controlling for all other variables, a statistically significant negative correlation was observed between surgery at a high-volume hospital and both length of hospital stay (geometric mean = -1.5 days, P = .003). and hospital-related costs (geometric mean = -$6,061, P = .003). After controlling for other factors, high-volume hospital care is associated with a shorter length of hospitalization and lower hospital-related cost of care for laryngeal cancer surgery.

Volume-Based Trends in Thyroid Surgery

to characterize contemporary patterns of thyroid surgical care and variables associated with access to high-volume care. cross-sectional analysis. maryland Health Service Cost Review Commission database. adults who underwent surgery for thyroid disease in Maryland between January 1, 1990, and July 1, 2009. overall, 21 270 thyroid surgical procedures were performed by 1034 surgeons at 51 hospitals. Procedures performed by high-volume surgeons increased from 15.7% in 1990-1999 to 30.9% in 2000-2009 (odds ratio [OR], 3.69; P < .001), while procedures performed at high-volume hospitals increased from 11.9% to 22.7% (3.46; P < .001). High-volume surgeons were more likely to perform total thyroidectomy (OR, 2.50; P < .001) and neck dissection (1.86; P < .001), had a shorter length of hospitalization (0.44; P < .001), and had a lower incidence of recurrent laryngeal nerve injury (0.46; P = .002), hypocalcemia (0.62; P < .001), and thyroid cancer surgery (0.89; P = .01). After controlling for other variables, thyroid surgery in 2000-2009 was associated with high-volume surgeons (OR, 1.76; P < .001), high-volume hospitals (2.93; P < .001), total thyroidectomy (2.67; P < .001), and neck dissection (1.28; P = .02) but was less likely to be performed for cancer (0.83; P < .001). the proportion of thyroid surgical procedures performed by high-volume surgeons and in high-volume hospitals increased significantly from 1990-1999 to 2000-2009, with an increase in total thyroidectomy and neck dissection. Surgeon volume was significantly associated with complication rates. Thyroid cancer surgery was less likely to be performed by high-volume surgeons and in 2000-2009 despite an increase in surgical cases. Further investigation is needed to identify factors contributing to this trend.

Volume‐based trends in laryngeal cancer surgery

Positive volume-outcome relationships exist for diseases treated with technically complex surgery. Contemporary patterns of laryngeal cancer surgery by hospital and surgeon volume are poorly defined. The Maryland Health Service Cost Review Commission database was queried for hospital and surgeon laryngeal cancer surgical case volumes from 1990 to 2009. Overall, 1,981 laryngeal cancer surgeries were performed by 288 surgeons at 41 hospitals. Cases performed by high-volume surgeons increased from 19% in 1990 to 1999 to 35% in 2000 to 2009 (odds ratio [OR] = 3.0, P<.001), whereas cases performed at high-volume hospitals increased from 33% to 39% (OR = 2.0, P<.001). High-volume surgeons were more likely to perform total laryngectomy (OR = 1.7, P = .001) and neck dissection (OR = 1.7, P = .002). High-volume hospitals were significantly associated with total laryngectomy (OR = 2.0, P = .003), neck dissection (OR = 1.8, P = .038), flap reconstruction (OR = 5.1, P = .021), prior radiation (OR = 3.0, P = .031), and increased mortality risk scores (OR = 3.2, P = .006). After controlling for other variables, laryngeal cancer surgery in 2000 to 2009 was associated with increased access to high-volume surgeons (OR = 1.9, P<.001) and high-volume hospitals (OR = 1.3, P = .040), a decrease in partial and total laryngectomy procedures (OR = 0.2, P<.001), an increase in neck dissection (OR = 2.2, P< 0.001), an increase in prior radiation (OR = 3.0, P<.001), increased case complexity scores (OR = 5.7, P<.001), and an increase in wound fistula or dehiscence (OR = 2.0, P = .015) compared with 1990 to 1999. The proportion of laryngeal cancer surgery patients treated by high-volume surgeons and hospitals increased significantly in 2000 to 2009 compared with 1990 to 1999, with a decrease in laryngectomy procedures and an increase in wound complications. These findings may be due to changing trends in primary management of laryngeal cancer.

Influence of Age on Revascularization Related Costs of Hospitalization Among Patients of Stable Coronary Artery Disease

The legitimacy of expensive revascularization procedures in patients with stable coronary artery disease (CAD) remains to be seen. In this study, resource utilization was compared across age-group categories of patients with stable CAD who underwent revascularization. Fiscal year 2006 discharge data maintained by the Maryland Health Services Cost Review Commission were examined. Current Procedural Terminology codes 36.1x and 36.0x were used to identify patients who underwent coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI), respectively. Patients with acute myocardial infarctions (International Classification of Diseases, Ninth Revision, Clinical Modification code 410.xx) were excluded to limit the study group to patients with stable CAD. Totals of 1,066, 2,909, 4,272, 4,514, and 1570 hospitalizations per 100,000 hospitalizations were observed in the age groups 40 to 50, 50 to 60, 60 to 70, 70 to 80, and > or =80 years, respectively. The costs of hospitalization were driven by length of stay and choice of revascularization procedure (CABG vs PCI). There was trend toward increasing total costs and longer hospital stays with increasing age (p for trend <0.001) in patients who underwent CABG. Although the adjusted costs and adjusted length of stay were significantly higher in the patients who underwent PCI who were aged > or =80 years than in those aged 40 to 50 years, the differences among other age-group categories were not statistically significant. In conclusion, older patients with stable CAD who undergo interventions represent a substantial expenditure. Hospitalization costs are driven by longer hospital stays and the choice of CABG compared to PCI. With data supporting aggressive medical management of such patients, it is advisable to rethink management strategies in these patients.

Impact of surgeon and hospital ovarian cancer surgical case volume on in-hospital mortality and related short-term outcomes

Objective To evaluate the impact of surgeon and hospital case volume, and other related variables, on short-term outcomes after surgery for ovarian cancer. Methods The Maryland Health Service Cost Review Commission database was accessed for ovarian cancer surgical cases including both oophorectomy and any staging/cytoreductive surgical procedure from 2001 to 2008. Multivariate logistic regression analyses and multiple linear regression models were used to evaluate for significant associations between surgeon and hospital case volume, as well as other independent variables, and the risk of in-hospital death, extent of surgery, length of hospital stay, and hospital-related cost of care. Results Overall, 1894 primary ovarian cancer operations were performed by 352 surgeons at 43 hospitals. After controlling for the effects of all variables, the only independently significant factors associated with the risk of in-hospital death were surgery by a high-volume surgeon and an APR-DRG mortality risk score of 4. Ovarian cancer surgery performed by a high-volume surgeon was associated with a 69% reduction in the risk of in-hospital death. Surgery at a high-volume hospital was an independent positive predictor of a cytoreductive procedure. A statistically significant negative correlation was observed between surgery at a high-volume hospital and both length of hospital stay and hospital-related cost. Conclusions After controlling for other factors, ovarian cancer surgery performed by a high-volume surgeon is associated with a 69% reduction in the risk of in-hospital death, while high-volume hospital care is associated with increased likelihood of cytoreduction, shorter length of stay, and lower hospital-related cost of care.

Analysis of Contemporary Trends in Access to High-Volume Ovarian Cancer Surgical Care

Positive volume-outcome relationships exist for cancers treated with technically complex surgery, including ovarian cancer. However, contemporary patterns of primary surgical care for ovarian cancer according to hospital and surgeon case volume remain poorly defined. The Maryland Health Service Cost Review Commission database was accessed for annual hospital and surgeon primary ovarian cancer surgical case volume for 2001-2008 and evaluated for statistically significant trends in access to high-volume surgical care compared with the earlier period for 1990-2000. chi(2) and logistic regression analyses were used to evaluate for significant trends in case volume distribution over time as well as factors associated with access to high-volume care. Overall, 2,475 primary ovarian cancer operations were performed by 472 surgeons at 43 hospitals. There was a statistically significant increase in the proportion of cases performed at high-volume centers from 22.8% in 1990-2000 to 61.1% in 2001-2008 (odds ratio = 5.30, 95% confidence interval = 4.68-6.00, P < .0001), while low-volume hospital case distribution decreased from 49.6 to 31.3%. Access to high-volume surgeons increased from 34.5% in 1990-2000 to 64.5% in 2001-2008 (odds ratio = 3.44, 95% confidence interval = 3.06-3.87, P < .0001), while the proportion of cases performed by low-volume surgeons decreased from 56.3 to 28.9%. After controlling for other variables, high-volume surgeons were significantly more likely to perform ovarian cancer surgery that included hysterectomy and staging/cytoreductive surgical procedures. The proportions of ovarian cancer patients undergoing primary surgery at high volume centers and by high-volume surgeons increased statistically significantly from 1990-2000 to 2001-2008. Further investigation is necessary to determine factors contributing to this favorable trend.

The Use of Ambulatory Patient Groups for Regulation of Hospital Ambulatory Surgery Revenue in Maryland

The Maryland Health Services Cost Review Commission (HSCRC or the commission) is a government agency with the authority to establish rates for both inpatient and outpatient services for all general acute care hospitals in the state. By law and consistent with the state's unique Medicare waiver, all payers (including Medicare and Medicaid) must pay hospitals on the basis of these rates. The HSCRC has used diagnosis related groups to set case-mix-adjusted limits on the revenue per discharge for inpatient services (similar to Medicare inpatient prospective payment nationally) yet, the Maryland rate-setting system for outpatient services has not embodied incentives to control utilization of services. Beginning in the state's fiscal year 2008, the HSCRC is implementing regulation of ambulatory surgery services using ambulatory patient groups to provide better incentives to control utilization, and to facilitate comparisons of the case-mix-adjusted charges per ambulatory surgery case across hospitals. Maryland has been an innovator in the design and successful implementation of payment systems and other incentive mechanisms to constrain hospital cost, maintain payment equity, and ensure access to needed hospital care. The HSCRC's adoption of all patient refined diagnosis related groups and the hospital-specific relative value method for establishing diagnosis related group weights in 2005 was relevant to the Centers for Medicare and Medicaid Services' decision to move to Medicare severity diagnosis related groups beginning in federal fiscal year 2008, and to consider the use of hospital-specific relative value weights. The HSCRC's decision to use ambulatory patient groups for ambulatory surgery is an attempt to apply the most effective features of inpatient payment systems, prospective payment, including incentives to control service volumes. As such, it represents a radical departure from prevailing payment arrangements in that it seeks to remove the traditional distinction between inpatient and outpatient surgical services, a distinction that has blocked the development of effective and well-integrated outpatient payment systems for decades. This article describes the policy rationale for this system, the analysis that was performed, and the methods that will be used to control the revenue per case and compare the relative charges of the hospitals.

Racial Differences in Hospital Discharge Disposition among Stroke Patients in Maryland

The objective of this retrospective study was to assess the evidence for racial differences in discharge disposition among patients hospitalized for stroke. Hospital discharge data from the Maryland Health Services Cost Review Commission were used in the analysis. The data covered the period from January 2000 to September 2003. Discharge-disposition categories were ordered such that higher numbers corresponded to less desirable outcomes: 1 = discharge to home; 2 = discharge to any medical care facility; 3 = death. We analyzed the influence of black race on the discharge disposition by estimating a partial proportional odds logit regression model that included demographic and clinical covariates. The study inclusion criteria were 1) stroke (ICD9 431-434; 436-438) as a primary admission diagnosis and 2) patient race identified as black or white. Patients discharged against medical advice were excluded. The sample contained 51,564 stroke hospitalizations. Based on the relative odds ratios (OR; 95% confidence interval [CI]), black males were more likely to be discharged to higher ranked (i.e., less desirable) discharge categories (OR = 1.66; CI 1.55-1.77) compared to white males. Black females were more likely to die (OR = 1.14; CI 1.02-1.28) and more likely either to die or to be discharged to medical care (OR = 1.38; CI 1.24-1.54) compared to white males. Blacks are at greater mortality risk following stroke hospitalizations and face less desirable discharge dispositions if they survive. These results are consistent with prior reports of lower survival rates among blacks and are robust to adjustments for various confounding factors.

Shoulder Arthroplasty versus Hip and Knee Arthroplasties

Although outcomes of shoulder, hip, and knee arthroplasties have been well-described, there have been no studies directly comparing the outcomes of these procedures as treatments for osteoarthritis. We compared the inpatient mortality, complications, length of stay, and total charges of patients who had shoulder arthroplasty for osteoarthritis with those of patients who had hip and knee arthroplasties for osteoarthritis. A review of the Maryland Health Services Cost Review Commission discharge database identified 994 shoulder arthroplasties, 15,414 hip arthroplasties, and 34,471 knee arthroplasties performed for osteoarthritis from 1994 to 2001. There were no in-hospital deaths after shoulder arthroplasty, whereas 27 (0.18%) and 54 (0.16%) deaths occurred after hip and knee arthroplasties, respectively. Compared with patients who had hip or knee arthroplasties, patients who had shoulder arthroplasties had, on average, a lower complication rate, a shorter length of stay, and fewer total charges. The latter had 1/2 as many in-hospital complications, were 1/6 as likely to have a length of stay 6 days or greater, and were 1/10 as likely to be charged more than $15,000. We believe shoulder arthroplasty is as safe as the more commonly performed major joint arthroplasties.

Hospitalization rates and costs of care of patients with sickle‐cell anemia in the state of Maryland in the era of hydroxyurea

The multicenter study of hydroxyurea (MSH) in sickle-cell anemia (SCA) demonstrated that patients treated with hydroxyurea (HU) had a 44% decrease in hospitalizations when compared with those taking placebo. A subsequent study looking at the cost-effectiveness of HU showed that decreased hospitalizations for painful crisis accounted for the majority of cost savings in those taking HU. The purpose of this study was to examine whether the expected decrease in hospital utilization occurred after the approval of HU in Maryland. We used data collected by the Maryland Health Services Cost Review Commission to obtain SCA discharge data for Maryland from FY1995 through FY2003. We also reviewed the inpatient and outpatient charts of all adults with SCA admitted to a large university hospital during 2003. Hospitalization rates for adults with SCA in Maryland have increased significantly since approval of HU. While the total costs of inpatient care in Maryland are estimated to have increased by 31% above inflation from 1995 to 2003, the costs of inpatient care for adult SCA patients has increased by almost 60% above inflation. By comparison, there has been no significant increase in the pediatric hospitalization rate. We found that 70% of patients in one hospital who were appropriate candidates for HU were not taking the medication. Hospital utilization among adults with SCA has increased significantly. There are likely many factors that have played a role in this increase. One factor that appears to be involved is the underutilization of HU.

Risk areas for pediatric acute care: asthma differs from upper and lower respiratory illness

Objective To determine if emergency department utilization for pediatric respiratory illness varies across small geographic jurisdictions within a large urban city. Design A retrospective analysis of Maryland Health Services Cost Review Commission Emergency Department discharge data. Setting/patients All non-neonatal, Baltimore City residents <18 years old with valid diagnoses admitted and discharged from emergency departments (ED) in the state of Maryland from April 1, 1997 to December 31, 2000 ( n=245,339). Main outcome measures Crude and adjusted ED visit rates for asthma, upper and lower respiratory illnesses (per 1000 population). To evaluate the effect of geography on pediatric ED visit rates, odds of an asthma ED visit, URI, or LRI vs. non-respiratory ED visit were compared across regions of the city. Results We determined that residential areas with high ED utilization rates for upper and lower respiratory illnesses, as well as non-respiratory illnesses correlate with regions of high ED utilization for asthma, even after adjusting for race, gender and age of the population. The regions with high odds ratios that an ED visit was for asthma were different from those with high ORs for URI and LRI after also controlling for poverty. Conclusions This suggests that poverty accounts for high utilization of the ED in urban settings, but suggests that environmental exposures that increase the risk of ED care for asthma differ from those that lead to URI and LRI.

Costs of Care for Hospitalized Adults with Sickle Cell Anemia (SCA) in Maryland (MD) Have Skyrocketed: 1995–2003.

Background: In 1998 the FDA approved the use of hydroxyurea (HU) for use in patients (pts) with SCA. The trial on which the approval was based demonstrated that adult pts that were on HU had fewer hospitalizations, fewer episodes of acute chest syndrome and required fewer transfusions than those patients that were not on HU. The authors of this original study were able to calculate a cost savings of over 20 million dollars a year if every eligible patient in the US were taking HU. There is currently no literature that addresses changes in hospital utilization for SCA outside the setting for a clinical study since the implementation of HU.Methods: Using data collected for the MD Health Services Cost Review Commission, we looked at admission data for the State of MD from FY1995 through FY2003. The ICD9 coding system is an international classification system which groups related disease entities and procedures. The following ICD9 codes were used to identify individuals with SCA: 28261 (sickle cell Hgb SS without crisis), and 28262 (sickle cell, hgb SS with crisis). In order to control for population growth we estimated the total number of individuals with SCA in MD using 1990 and 2000 census data and a prevalence of SCA of 1 in 600 African Americans. Negative binomial and ordinary least squares regression models were used to test the trends in hospitalization rates and length of stay. An inflation factor from the Producer Price Index (PPI) was used to compare 2003 inpatient costs to 1995 inpatient costs. Mann-Whitney tests and t-tests were used to compare the ages, average costs per hospitalization and length of stay among patients admitted to JHH in FY2003.Results: The rate of adult SCA admissions per estimated African American SCA patient in MD increased from 1.006 in 1995 to 1.29 in 2003 (p < 0.001). The average length of hospital stay decreased from 6.16 to 4.99 over the same time period (p<0.001). The cost of adult inpatient SCA care in 2003 was 60% higher than would be expected by inflation alone. For comparison, the total cost of adult inpatient care in MD in 2003 was 31% higher than expected by inflation alone. Pediatric SCA data for the time period showed that hospitalization rates and length of stay did not change, while 2003 costs were increased by 40% above 1995 costs adjusting for inflation. The total cost of pediatric inpatient care in 2003 for MD was 20% above expected inflation. Ratios of 2003 costs to 1995 costs corrected for inflation and broken down by category can be seen in figure 1 for adults, peds and all MD hospital admissions. No one category clearly explains the cost differences seen over time for any group.Conclusions: The number of adults admitted with SCA has increased over the last 9 years. Importantly the costs of caring for these patients has increased by almost 60% while the costs of caring for the general population has increased by only 31%. This has occurred while the LOS has significantly decreased. The reasons for the cost increases are unclear and further investigation is warranted. [Display omitted]

Infliximab for inpatient psoriasis management – is there a role?

Background: While outpatient management is a realistic goal for most psoriasis patients, inpatient hospitalization may be required for severe acute exacerbations. The paradigm of inpatient psoriasis treatment has changed as reflected in an overall decline in admissions as well as the introduction of several new agents for patients with moderate to severe disease. With these changes as well as the changes in inpatient health care delivery, the costs of inpatient psoriasis therapy need to be re‐examined. Purpose: To determine the mean charges and length of stay associated with inpatient admissions for psoriasis and compare these with the potential charges for infliximab administration in the inpatient setting. Methods: Inpatient psoriasis admissions were identified from the State of Maryland Health Services Cost Review Commission (HSCRC) non‐confidential database from 1994 to 2003. The mean length of stay and total charges associated with psoriasis admissions were determined and adjusted to current values based upon the hospital costs component of the Consumer Price Index (CPI). The potential charges for infliximab administration were then estimated according to a presumed treatment paradigm and based on median Medicare reimbursement rates. Results: The mean length of stay for an inpatient psoriasis patient was 4.9 days, and the mean CPI adjusted total charges from 1994 to 2003 were $6736. In 2003, the mean total charges for a psoriasis admission were $7578. The total estimated charges for a 2‐day inpatient hospitalization with infliximab administration were $6256. Conclusions: Although infliximab therapy is not currently approved for psoriasis therapy it does have efficacy and may be a first‐line therapy for inpatient treatment. Additionally, the high cost of infliximab may be offset by a decreased overall length of stay and its use is therefore potentially justified.

Hospitalization Rates in Patients with Sickle Cell Disease (SCD) in the State of Maryland (MD): No Change Since Approval of Hydroxyurea (HU).

Background : In 1998 the FDA approved the use of HU for use in patients (pts) with SCD. The trial on which the approval was based demonstrated that adult pts that were on HU had fewer hospitalizations, fewer episodes of acute chest syndrome and required fewer transfusions than those patients that were not on HU. The authors of this original study were able to calculate a cost savings of over 20 million dollars a year if every eligible patient in the US were taking HU. There is currently no literature that addresses the use of HU outside the setting of a clinical study.Methods: We reviewed the inpatient and outpatient charts of all adults with SCD, admitted to Johns Hopkins Hospital (JHH) in FY2003. We also reviewed hospital admission data for MD in FY2003 and FY1995, using data from the MD Health Services Cost Review Commission. Data was pulled using the following ICD9 codes 28260,28261,28263,28269,28262. An estimate of total number of individuals with SCD in MD was made using 1990 and 2000 census data and a prevalence of SCD of 1 in 400 African Americans (AA). Fisher's exact test was used to compare proportions. As readmission data was unavailable we assumed that the rates of readmission were similar for 1995 and 2003.Results : Review of the JHH data (Table 1) showed that 25% of pts with SCD accounted for half of the hospital days for all pts with SCD and almost 40% of total charges. 66% of eligible pts with Hgb SS were not receiving HU. The reasons for not being on HU varied; 4/9 did not have regular outpatient follow-up, 1 was pregnant, 2 had compliance issues related to side effects, 1 patient refused to take HU and 1 patient started during FY2003. For the pts with hgb SC disease, the indications for use of HU are not established and in our pt cohort those that had received HU in the past did not attain significant benefit without toxicity. Based on US census data the number of individuals of African decent, 18 years and older with SCD in MD for 2003 was 2760. By comparison the number estimated to be in MD in 1995 was 2361. The number of adult admissions for the diagnosis of SCD to hospitals in MD in FY1995 was 1313 and in FY2003 it was 1961. The number of admissions per estimated AA adult with SCD in MD for 1995 was .56 and for 2003 was .71. (p<0.001) The annual costs of caring for hospitalized adult sickle cell pts in MD in 1995 was $6.7 million compared to over $10 million for FY2003. The percent of total hospital expenditures spent on SCD admissions in MD was 0.12% in 1995 and doubled to 0.21% in 2003. Pediatric data over the same time period demonstrated an increase in number of hospitalizations 909 in 1995 compared to 1202 in 2003. When the ratios of admissions per estimated number of pediatric sickle cell pt. in MD were compared for the two time periods there was no statistically significant difference.Conclusions : Hospital generated data for MD demonstrates that admissions and costs of caring for adult sickle cell pts have increased significantly since the approval of HU by the FDA. Data from JHH shows that a large number of eligible patients are not taking HU. Further investigation into the issues affecting hospitalizations of individuals with SCD and the use of HU in this patient population is warranted.Characteristics of SCD Patients Admitted to JHHAll SCD patients≥ 3 admissions/yr (%)Total Patients10927(25)Total Hospital days1266615(49)Total Admits225124 (55)Total Charges ($)2,796,0881,090,348(39)Number on HUUnknown4

Effects of Race on Mortality and Use of Hospital Services in Maryland, 1998

This study analyzes administrative data from the Maryland Health Services Cost Review Commission to compare differences by race in the use of 17 major procedures performed in hospitals and the corresponding mortality rates. African Americans discharged from Maryland hospitals were less likely than whites to have received most of these procedures while hospitalized. The largest differences were seen for "referral sensitive surgeries" such as percutaneous transluminal coronary angioplasty, coronary artery bypass graft surgery, total knee replacement, and total hip replacement. In contrast, African Americans were found to have substantially higher rates than white patients in the use of four procedures performed in the hospital: amputation of part of the lower limb, surgical debridement, arteriovenostomy, and bilateral orchiectomy. The types of procedures for which African American hospital patients have higher rates raise questions about whether there is a need for more comprehensive and continuous follow-up care with primary care physicians for the underlying health conditions associated with these procedures.

Is there a relationship between service integration and differentiation and patient outcomes?

To examine the level of service integration within Maryland hospitals and service differentiation across the hospital system or network and its affect on heart failure patient clinical and economic outcomes. Maryland Health Services Cost Review Commission Inpatient Data for 1997 and 1998 were used for secondary data analysis. Retrospective cross sectional. Independent variables were the level of service integration and differentiation created from the 1998 American Hospital Association Annual Survey based on the work of Bazzoli et al. The primary dependent variables were readmission, in-hospital mortality, length of stay and costs. Patients discharged from Maryland hospitals with a diagnosis that grouped to DRG 127 (heart failure) were extracted. Multivariate linear and logistic models clustered by hospital were used to analyse results at the patient level. A higher likelihood of readmission was found as the level of Community Differentiation increased. Although costs were higher as Total Differentiation increased in 1998, these results were not validated by 1997 data. No significant relationship was found between integration of services and outcomes. Similar outcomes were achieved regardless of the level of service integration or differentiation. Community hospitals produce similar patient outcomes at the same cost for this diagnosis.