Higher Care Costs Research Articles

Healthcare Utilization and Cost of Care Analysis of Patients with Sickle Cell Disease with High Vs. Low Biomarkers: A Retrospective Chart Review

Sickle cell disease (SCD) is a red blood cell (RBC) disorder that is associated with frequent and unpredictable vaso-occlusive episodes (VOEs) including pulmonary hypertension, acute chest syndrome, chronic anemia, priapism, splenic and renal dysfunction, and stoke. The total cost to manage a SCD patient with a life expectancy of 64 years is between $1.3-$2.1M. Within the United States alone, up to 67% of adults have ≥3 VOEs per yearthat accounts for most of the healthcare utilization, including 78% of emergency room (ER) visits and 95% of hospitalizations. Despite the same single gene mutation of beta-globin, the frequency of VOEs amongst patients is highly variable. The pathophysiology of VOEs involves a complex interplay between circulating blood cells and elevated plasma factors that promote abnormal interactions to the vascular endothelium. Nearly a half century ago studies demonstrated RBC adhesion strongly correlates with disease severity however only recently standardized testing has become available to assess adhesion clinically. More specifically, we developed a suite of RBC health biomarkers and deployed our flow adhesion bioassays in our landmark, observational study (ELIPSIS). We established that flow adhesion of whole blood to vascular cell adhesion molecule-1 (FA -WB-VCAM) at baseline stratified SCD patients with severe disease phenotypes and validated the clinical predictive value of FA-WB-VCAM two years post-ELIPSIS. The objective of this study was to determine whether baseline FA-WB-VCAM biomarker levels could predict patients more likely to receive direct healthcare contact (ER visits/hospital admissions) to manage SCD complications. This study was a retrospective assessment of clinical FA-WB-VCAM in individuals with SCD during steady state between January 2020 through March 2023. Flow adhesion assays were performed using pulsatile, shear flow (1.67Hz, 1.0 dyne/cm 2). SCD patients that received at least 3 steady state FA-WB-VCAM biomarker evaluations within 1-year were included in this analysis. Clinical site received an IRB waiver to obtain patient-reported ER visits and hospitalizations during relevant time periods. We calculated a composite adhesion index by averaging baseline FA-WB-VCAM biomarker evaluations and established SCD disease severity by quantifying the number of ER visits and hospital admissions one year after the most recent FA-WB-VCAM biomarker evaluation. The non-parametric Wilcoxon matched pairs signed rank test was used to test the statistical differences between groups. Data are presented as mean ± standard error of mean. A p-value < 0.05 was considered statistically significant. Out of a total of 3939 clinical tests performed, 366 samples were obtained for “baseline” indications. Of these, only 28 samples were analyzed from 9 unique patients who met the study criteria described above. The average flow adhesion of whole blood to VCAM-1 (FA-WB-VCAM) in SCD patients with high adhesion phenotypes (>400 cells/mm 2) was significantly higher than the low/moderate SCD cohort (mean high=603±78 cells/mm 2, mean low/moderate=343±28 cells/mm 2, p=0.02). More important, the high adhesion cohort had more ER visits (11 vs. 5) and hospitalizations (24 vs 9) and significantly higher healthcare costs ($35,871 vs. $13,563). This is the first healthcare cost analysis assessing the relationship between SCD patients stratified by their adhesive phenotype using the standardized, clinical adhesion biomarker FA-WB-VCAM, and healthcare utilization. The previous ELIPSIS study established that baseline FA-WB-VCAM stratifies patients based on their risk of developing self-reported VOCs during a 6-month longitudinal observation period and their risk of higher clinical disease severity in a 2-year follow-up study. Consistent with this data, the current study demonstrated that a cohort of SCD patients with elevated baseline adhesion phenotypes based on FA-WB-VCAM had a greater utilization of healthcare resources (ER visits and hospitalizations) and had a higher cost of care during the retrospective observation period. These data suggest that RBC health as indicated by “baseline” FA-WB-VCAM levels may predict lower health care utilization and costs, and that this biomarker may be a plausible surrogate endpoint to assess the pharmaco-economic impact of SCD-modifying therapies.

Predictors and outcomes of cardiac dyssynchrony among patients with heart failure attending Benjamin Mkapa Hospital in Dodoma, central Tanzania: A protocol of prospective-longitudinal study.

Cardiac Dyssynchrony is prevalent among patients with heart failure with high cost of care and potentially poor outcomes. Nevertheless, little is known about cardiac dyssynchrony among heart failure patients, especially in developing countries. This study aims at assessing the predictors and outcomes of cardiac dyssynchrony among heart failure patients attending the cardiology department at Benjamin Mkapa Referral Hospital in Dodoma, central Tanzania. The study will follow a prospective longitudinal design involving participants aged 18 years and above with heart failure attending the Cardiology Department at Benjamin Mkapa Hospital. Heart failure will be identified based on Framingham's score and patients will be enrolled and followed up for six months. Baseline socio-demographic and clinical characteristics will be taken during enrollment. Outcomes of interest at six months include worsening of heart failure, readmission and death. Continuous data will be summarized as Mean (SD) or Median (IQR), and categorical data will be summarized using proportions and frequencies. Binary logistic regression will be used to determine predictors and outcomes of Cardiac Dyssynchrony among patients with heart failure.

Addressing barriers to health care among Black Alaskans: contributions by social work research to an agenda of health equity

ABSTRACT Black Alaskans face serious barriers to health care. This paper reports on qualitative results of a health needs assessment to understand the health challenges facing Black Alaskans. Utilizing exploratory thematic analysis, the findings indicate that Black Alaskans experience barriers such as high cost of care, underinsurance, lack of information and education, a shortage of BIPOC health providers, stigma, negative perceptions by health-care providers, and racism both in the community and in the health-care system. The paper concludes by discussing emerging health equity initiatives to advance responsive care for Black Alaskans.

Abstract 19142: Is Malnutrition Associated With Worse Outcomes in Patients With Acute Decompensated Heart Failure (ADHF)? ; Insights From Nationwide Inpatient Sample 2015-2020

Introduction: Is Malnutrition associated with worse outcomes in patients admitted with acute decompensated heart failure? Insights from nationwide inpatient sample 2015-2020 Hypothesis: Heart Failure affects >5 million US patients resulting in >1 million annual hospitalizations due to Acute Decompensated Heart Failure (ADHF). The impact of malnutrition on hospitalized patients with ADHF is not well described. Patients with heart failure are prone to malnutrition because of reduced intake, cytokine dysfunction, and increased basal metabolic rate. We aim to assess the effect of malnutrition on hospital outcomes in ADHF. Methods: Using the NIS database we identified all the patients who were admitted for ADHF with history of heart failure with reduced ejection fraction from 2015-2020. Predictors and effects of malnutrition were studied using univariate and multivariate models. Results: A total of 4,224,869 patients were admitted for ADHF from 2015-2020 among which 253,915 patients had associated malnutrition. Baseline characteristics and comorbidities are outlined in the table below. Patients with malnutrition had higher inpatient mortality (9.6% vs 3.61% p-value:0.0000), a longer length of stay (10.8 days vs 5.9 days p-value: 0.0000), doubling of the cost of care (147485 USD vs 74077 USD p-value:0.001). After adjusting for baseline co-morbidities patients with malnutrition had 2 times higher mortality (Odds ratio: 2.01, p-value: 0.0001) Conclusions: Our study demonstrates that Malnutrition in ADHF patients results in higher mortality, longer length of stay, and higher costs of care. This highlights the importance of optimizing of nutritional status in these patients.

Abstract 12085: Emergency Heart Failure Mortality Risk Grade (EHMRG) Score Quintiles Correlate With Short and Long-Term Healthcare Costs

Introduction: The use of the EHMRG model in the emergency department (ED) has been demonstrated to improve outcomes for patients presenting with acute heart failure (HF). It is unknown if the EHMRG model also correlates with healthcare costs, which has not been examined in other HF risk models. Hypothesis: We hypothesized that patients with higher EHMRG risk scores, i.e., sicker, would have higher costs of care in short-term (30-day) and longer-term (up to 2 year) time horizons. Methods: We examined direct costs of care from a health payer perspective using the original EHMRG derivation cohort of 11,857 patients hospitalized with acute HF in Ontario, Canada (from 2004) and linking to population-based case-costing databases. Costs were stratified by the quintiles of the EHMRG risk score (Q1 = lowest risk, Q5 = highest risk). Costs (in 2021 Canadian dollars) were categorized into hospital, physician, drug, home care, long term care (LTC), and other costs. Results: Patients in the lowest EHMRG risk quintile (Q1), compared to higher quintiles (Q2-Q5) had lower total cost of care in both the short-term ($8,113 vs $9,442, $10,557, $12,078 and $15,005, p <0.001) and long-term ($46,661 vs $55,904, $58,904, $63,286 and $64,229, p<0.001). This positive correlation between EHMRG risk quintile and cost of care was also observed for hospital costs ($26,388 [Q1] vs $35,659 [Q5], p<.0001) and LTC costs ($1,236 [Q1] vs $6,316 [Q5], p<.0001) at all time intervals, including at 2 years shown here. Physician costs and drug costs were positively correlated with EHMRG risk quintiles at 30 days (physician: $1,241 [Q1] vs $1,762 [Q5], p<0.0001; drug: $219 [Q1] vs $282 [Q5], p<.0001), and negatively correlated at 2 years (physician: $7,943 [Q1] vs $7,175 [Q5], p<.0001; drug: $4,539 [Q1] vs $4,377 [Q5], p<.0001). There was an increasing trend of costs irrespective of the formulation of the EHMRG risk score as 7-day risk quintile, 30-day risk quintile, or 30-day risk tertile. Conclusion: The EHMRG7 risk score was positively correlated with healthcare costs from 30 days to 2 years after initial ED presentation. This novel correlational study demonstrated that in the absence of an associated intervention, higher mortality risk in HF patients portends higher costs in short and long-term follow-up.

Abstract 18084: Coagulopathy and Hospital Outcome in Patients With Covid-19: An Insight From National Inpatient Sample

Introduction: SARS-CoV-2 infection has been linked to thrombosis and bleeding. In this study we aim to investigate coagulopathy rates, predictors and in-hospital outcomes in a nationally representative sample of COVID-19 patients. Methods: Using the 2020 National Inpatient Sample. We identified adult patients who were admitted with a principal diagnosis of COVID-19. Mortality difference, LOS, and COC were evaluated as indicators of healthcare resource usage. Regression analysis adjusted for baseline variables and comorbidities compared individuals who developed coagulopathy to those who did not. Logistic regression analysis was used to identify COVID-19 coagulopathy facrtors. p-value <0.05 indicated statistical significance. Results: Among 1,050,045 COVID-19 admissions, 12% (126,225 patients) developed coagulopathy. Those with coagulopathy group had higher rates of in-hospital mortality (aOR 1.31, CI 1.23-1.39, p <0.001), prolonged LOS (aMD 2.29 days, 95% CI 2.12-2.46, p<0.001), and increased COC (aMD 142615$, 95% CI 32905-41299, p<0.001) compared to those that did not develop coagulopathy. Factors associated with coagulopathy included male gender, black race, higher Charleston comorbidity index, and lowest income quartile Conclusion: Approximately 12% of patients developed coagulopathy, which was associated with increased in-hospital mortality, longer length of stay, and higher cost of care. These findings emphasize the importance of identifying and managing coagulation disorders in COVID-19 patients to improve outcomes and allocate healthcare resources effectively. Further research is needed to explore interventions and strategies for mitigating the impact of coagulopathy in this population

Abstract 16845: Heart Failure Hospitalist Service Line Have Decrease All Cause Readmission, Length of Stay and Cost at 3 UPMC Hospitals in Central Pennsylvania in 2022

Introduction: Heart Failure (HF) is an important health care issue given its high prevalence, mortality, and cost of care. Despite numerous evidence-based strategies in the literature aiming at reducing HF readmissions, patients with HF remain at high risk for subsequent hospitalization with 20 to 25% readmitted within 30 days. Methods: Patients with both primary diagnosis HF at UPMC Harrisburg/West Shore/Community General totaled to 1574 in 2022. Hospitalist, Cardiologist, teaching service N= 547 (36%); CHF hospitalist Team N=1027 (64%). Heart failure order set usage, length of stay, all-cause 30-day readmission rates, readmission with HF, cost per case were assessed between these two groups for 2022. Results: All-cause 30-day HF readmission rates at UPMC (Harrisburg, West Shore, Community General Hospitals) for all other providers (Hospitalist, Cardiologist, teaching service) is 32%. HF Hospitalist team at 3 UPMC hospitals had lower 30 day all cause readmission rates: 8.46%. All other providers length of stay was 7.7 days while length of stay while on HF hospitalist service was 6.3 days. Potential cost savings to UPMC hospitals greater than $2.3 million dollars since start of HF Hospitalist service line. Conclusions: HF patients rarely have a consistent provider when readmitted. To address this health care priority at a system level, UPMC Central Pennsylvania’s strategy of creating a HF hospitalist service line has shown to be a unique method to not only develop trusting relationships with our patients but also attain impressive results. The HF Hospitalist service line was created to support an environment of patient-centered care by providing continuity of care for HF admissions and HF patients admitted for non-HF medical issues. At this community-based healthcare system, HF Hospitalist outcomes include decreased 30 day all-cause readmission to an impressive 8.2%, and reduced 30 day HF readmissions 4.12%. This was done while reducing healthcare costs during the 5yrs of the HF Hospitalist service line now at 3 hospitals at UPMC.

'When I receive ARVs through my group, my heart settles': Participants' perceptions and experiences of Friends for Life Circles for Option B+ in Kampala and Mityana Districts, Uganda.

The Friends for Life Circles (FLC) was a parallel randomized controlled trial testing the efficacy of a group peer support intervention to support long-term adherence to Option B+ in Kampala and Mityana districts in Uganda. We explored FLC participants' experiences and perceptions of the intervention on adherence to Option B+ for PMTCT and potential implications for strengthening the PMTCT program. We collected data from six focus group discussions with lactating women enrolled in the FLC intervention, and from 14 key informant interviews with health workers, district and national level stakeholders, as well as male partners of FLC participants. Data were analysed using a content thematic approach in a continuous and iterative process. Women described the FLC intervention as acceptable and beneficial in enhancing their understanding of HIV and the need for ART. The FLC helped women, especially those newly diagnosed with HIV infection to come to terms with their diagnosis and overcome the fear of death linked to testing HIV positive, and provided opportunities to enhance ART initiation, resumption and adherence. The FLC provided safe spaces for women, to learn about ART, and to receive support from peers including adherence reminders through home visits and 'coded' reminder messages. Receiving ART from support groups protected members from stigma and long lines at health facilities. Fear of stigma, health system challenges, the high cost of caring for animals and lack of money to save in groups were key challenges noted. The FLC support groups were crucial in providing needed support for women to initiate, resume and adhere to lifelong ART for Option B+. It is important that women who test HIV positive and start ART for life receive psychosocial support from peers and health workers to improve chances of preventing HIV transmission from mothers to children.

Health economic analysis of inpatient prostate cancer treatment in Austrian hospitals

Abstract Background Prostate cancer (PrC) is the fourth most prevalent type of cancer worldwide. Its high incidence and 5-year survival rates contributing to high inpatient care costs make it an important public health issue. In Austria, surgery has been the most common inpatient procedure for PrC, despite clinical recommendations not clearly indicating its benefits over alternatives. No health economic comparison of these procedures has considered the period after treatment yet. We bridge this gap by analysing the health economic impact of treatment pathways. Methods We use a large administrative dataset of all inpatient PrC patients in Austria who received either only surgery or only radiation therapy from 2005-2014 (n = 34,286). To assess the health economic impact, we used diagnosis-related-group (DRG) points and length of stay (LOS). Monthly DRG points and LOS for each patient ±12-months around the index procedure were analysed using the difference in difference (DID) method. We controlled for age, and physical comorbidity burden using Charlson Comorbidity Index (CCI) scores. Results Looking at unadjusted averages, patients in the surgery group were significantly younger and had a lower CCI compared to the radiation group. Consequently, the surgery group had lower nominal average DRG points and LOS. However, when controlling for age and CCI, we found that radiation treatment was less resource intensive. A DID estimation found a shorter average LOS and lower DRG points for the radiation group compared to surgery for the 12 months post index. Conclusions We found significant additional costs and LOS times for surgical pathways following risk adjustment in Austria. This implies a potential excess burden of ∼4,400 hospitalisation days and ∼4 million DRG points (€4.8m) a year for the healthcare system during the observed period. Considering international evidence on higher patient burden in surgical pathways, these findings may call for clinical reconsiderations of PrC care. Key messages • Patient characteristics of different inpatient treatment pathways for PrC in Austria were very heterogenous. • Health economic outcomes in the post treatment period for PrC inpatient treatment were significantly better for radiation treatment compared to surgery.

Patients With Cirrhosis Have Higher Costs of Care, Longer Length of Stays, and More Perioperative Complications Following Total Knee Arthroplasty: A National Inpatient Sample-Based Study.

Background Cirrhosis is a growing disease affecting millions of people in the United States annually. Many cirrhosis patients undergo significant procedures and are met with increased risks such as encephalopathy, impaired immune response, ascites, variceal bleeding, renal disease, and increased malnutrition. Many cirrhosis patients need to undergo major surgical procedures such as total knee arthroplasty (TKA); however, perioperative complications following TKA in cirrhosis patients have not been studied. The purpose of this study was to analyze the demographic characteristics and perioperative complications of cirrhosis patients following TKA. Methods Using the National Inpatient Sample (NIS) database, we looked at retrospective data from the years 2016-2019 to analyze the incidence of perioperative complications, length of stay (LOS), and the cost of care (COC) among patients undergoing TKA who were categorized as cirrhosis patients, compared with those who are not. A propensity match was conducted to consider associated comorbidities that influence perioperative complications. Results Of the 558,256 patients analyzed who underwent TKA, 1670 (0.3%) were diagnosed with cirrhosis. After matching, cirrhosis patients had a longer LOS (4.22 vs. 3.68 days, p=0.016) and COC ($90,624 vs. 80676.87, p<0.001) than patients in the control group. Moreover, cirrhosis patients had a higher likelihood of developing acute renal failure (odds ratio (OR): 3.05, 95% CI: 2.07-4.50, p<0.001), blood loss anemia (OR: 1.60, 95% CI: 1.34-1.92, p<0.001), periprosthetic fracture (OR: 3.27, 95% CI: 1.31-8.18, p=0.007), periprosthetic infection (OR: 3.14, 95% CI: 1.99-4.95, p<0.001), and blood transfusions (OR: 1.62, 95% CI: 1.12-2.35, p=0.009) than patients in the control group. Conclusion The cirrhosis group had a significantly higher COC, longer LOS, and higher rates of perioperative complications than non-cirrhosis patients. This data will help providers make informed decisions about patient care and resource allocation for cirrhosis patients undergoing TKA.

Design, Synthesis, In Vitro Biological Evaluation and In Silico Molecular Docking Study of Benzimidazole-Based Oxazole Analogues: A Promising Acetylcholinesterase and Butyrylcholinesterase Inhibitors.

Alzheimer's disease (AD) is a degenerative neurological condition that severely affects the elderly and is clinically recognised by a decrease in cognition and memory. The treatment of this disease has drawn considerable attention and sparked increased interest among the researchers in this field as a result of a number of factors, including an increase in the population of patients over time, a significant decline in patient quality of life, and the high cost of treatment and care. The current work was carried out for the synthesis of benzimidazole-oxazole hybrid derivatives as efficient Alzheimer's inhibitors and as a springboard for investigating novel anti-chemical Alzheimer's prototypes. The inhibition profiles of each synthesised analogue against acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE) enzymes were assessed. All the synthesized benzimidazole-based oxazole analogues displayed a diverse spectrum of inhibitory potentials against targeted AChE and BuChE enzymes when compared to the reference drug donepezil (IC50 = 2.16 ± 0.12 M and 4.50 ± 0.11 µM, respectively). The most active AChE and BuChE analogues were discovered to be analogues 9 and 14, with IC50 values of 0.10 ± 0.050 and 0.20 ± 0.050 µM (against AChE) and 0.20 ± 0.050 and 0.30 ± 0.050 µM (against BuChE), respectively. The nature, number, position, and electron-donating and -withdrawing effects on the phenyl ring were taken into consideration when analysing the structure-activity relationship (SAR). Molecular docking studies were also carried out on the active analogues to find out how amino acids bind to the active sites of the AChE and BuChE enzymes that were being studied.

Assumptions, Perceptions, and Experiences of Behavioral Health Providers Using Telemedicine: Qualitative Study.

The urgent and reactive implementation of telemedicine during the pandemic does not represent a long-term, strategic, and proactive approach to optimizing this technology. The assumptions, perceptions, and experiences of the behavioral health providers using telemedicine can inform system-wide and institutional-level strategies to promote longitudinal maintenance of care delivery, which can reduce the use of high-cost care due to new symptom onset and symptom exacerbation related to service interruptions. We aim to identify the assumptions, perspectives, and experiences of behavioral health clinicians and providers using telemedicine to inform the development of an optimized, sustainable approach to telemedicine implementation. This qualitative study applies the domains of the Consolidated Framework for Implementation Research (CFIR) to structure data collection and analysis from behavioral health providers using telemedicine via an audiovisual connection in the New England region. In total, 12 providers across levels of care were recruited for a 60-minute interview, developed from the CFIR interview guide. Atlas Ti Qualitative Software (version 23; ATLAS.ti Scientific Software Development GmbH) was used to coordinate and facilitate coding among 3 reviewers. Deductive coding was provided from the CFIR interview guide, allowing for data to be categorized by domain and construct. Constructs were analyzed for descriptive themes and tabulated for response frequency. Uncoded data were reviewed and coded in vivo to explore variables contributing to participant perceptions of experience with telemedicine use. Descriptive themes, then analytical themes, were identified. Analytical themes and tabulated frequency of response data were summarized. Finally, a sentiment analysis was completed to derive tone and meaning from the data. Results are reported within the CFIR domains: intervention characteristic, outer setting, inner setting, characteristics of individuals, and process. The findings with ≥90% agreement include "best practice standards were not known"; "telemedicine was believed to be efficient and time-saving for the patient and provider, maximizing productivity and thus increasing access to care"; "telemedicine provided an additional option for patients to access services, promoting sustained continuity and timeliness of care"; "participants did not identify any clear goals related to telemedicine use"; "demonstrated positive affective responses to telemedicine use"; "expressed high efficacy with telemedicine utilization"; and "strong leadership support." These findings support the development of interstate compacts advancing licensure across state lines; payment parity across modalities of care to ensure the financial vitality of behavioral health services; improved dissemination of telehealth training and resources, and telehealth training in academic programs of the health professions; seamless, dynamic workflows to accommodate the changing needs of patient and care continuity; emergency response protocols; and community partnerships to provide private spaces needed for a therapeutic encounter. Future research exploring the patient's experience with telemedicine is needed for all stakeholders to be represented in developing a sustainable, integrated system.

Minority and Lower Socioeconomic Status Patients Receive Ankle Fracture Care at Higher Cost Sites

Category: Ankle; Trauma Introduction/ Purpose: Socioeconomic disparities exist in the delivery of orthopedic care. Inequitable outcomes based on socioeconomic status (SES), including income, race, and geography, have been studied in association with outcomes following lower extremity trauma care. As orthopedic surgical care shifts increasingly towards providing care in hospital outpatient departments (HOPD) and freestanding ambulatory surgery centers (ASC), there is an opportunity to address socioeconomic disparities. We aimed to assess the association between patient SES and the outpatient facility type (HOPD versus ASC) where ankle fracture care was performed. We hypothesize: (1) White patients are more likely to receive care at ASCs, (2) Minority and lower income patients are more likely to receive care at HOPDs, and (3) Total charges for care are higher for minority and lower income patients. Methods: Data in patients ≥16 years old was sourced from the State Inpatient Database and Healthcare Utilization Project State Ambulatory Surgery Database (SASD) (for Florida, North Carolina, and Wisconsin) from 2016-2019. These 3 states were selected because their SASDs include a variable defining the location of service as a hospital outpatient department (HOPD) or ASC. Cases were identified using CPT codes converted to ICD-10 procedural codes for ankle fracture open reduction and internal fixation (ORIF). 85,749 cases were included: 50,411 (59%) inpatient, 28,536 (33%) HOPD, and 6,802 (8%) ASC, representing approximately 20% of inpatient and 11.5% of outpatient cases performed in the United States. Patient and facility characteristics were abstracted. Appropriate statistical analyses were conducted to describe and compare differences between facility type and patient characteristics. Results: Significant race and income disparities exist in outpatient ankle fracture care by facility type. Most patients receiving care were White (71%). Of the patients who received care at an HOPD, 32% were Black compared to 6% at ASCs (OR 0.795, CI 0.728-0.869). Of patients receiving care at an HOPD, 27% were other minorities compared to 9% at ASC (OR 1.213, CI 1.213- 1.309). More patients at HOPDs were in the lowest income level (26%) compared to ASC (18%). Factors found to associated with higher charges for surgery included patient being of minority race, patient of lower income level, and surgery performed at HOPD versus ASC. Conclusion: Ankle fractures treated at ASCs were more likely to be White and of higher income. These socioeconomic and racial/ethnic disparities are also associated with receiving care with higher total charges. These data indicate inequitable access to ankle fracture care performed at ASC facilities. More attention to social determinants of health is critical in the context of ankle fracture care to address potential inequitable outcomes and higher cost of care.

A socioecological description of the influencing factors to midwives' management of preeclampsia in a Ghanaian tertiary hospital.

In low-resource settings, midwives are the first contact for women with preeclampsia and lead the coordination of care. Unfavourable preeclampsia outcomes create a burden for women, families, and the health system. It is therefore important to understand the unique context of midwives' practice and the complex factors that influence the delivery of maternal healthcare. This qualitative study explored the perspectives of key stakeholders in a tertiary hospital in Ghana regarding the facilitators and barriers influencing midwives' provision of preeclampsia care using a socioecological model. Semi-structured interviews were conducted with 42 participants comprising senior managers (n = 7) and hospital midwives (n = 35) in 2021. Thematic analysis used Braun and Clarke's six-step method, and the findings were organised within four levels of the socioecological model: individual, interpersonal, organisational, and public policy. Two main themes were identified: 1) Facilitators of preeclampsia management, and 2) Barriers to preeclampsia management. Facilitators were identified at three levels (individual, interpersonal, and organisational) and included midwives' knowledge of preeclampsia; midwives' self-efficacy; midwives' skillset to enhance preeclampsia care; collaborative practice; and strategies for preeclampsia care quality improvement. At the individual level, the barriers were inadequate pre-service preparation, lack of evidence-based midwifery care, and colleagues' work attitudes. Hierarchical decision-making and staff views of women's risk perceptions were identified as barriers at the interpersonal level. At the organisational level, the barriers were: scarce resources and staff shortages, and a lack of midwifery-specific guidelines. Two barriers were identified within the public policy level: the high cost of preeclampsia care and issues with the referral system. Multi-faceted factors play a significant role in midwives' management of preeclampsia. Hence context-specific multi-level interventions have the potential to improve the quality-of-care women in Ghana receive.

Access to Certified Burn Centers in the United States: The Geospatial and Transport Cost of Transfer.

Specialized burn centers are critical to minimizing burn-associated morbidity and mortality. However, American Burn Association-verified burn centers are unequally distributed across the United States, and fewer centers are available for pediatric patients relative to adults. The economic burden of transporting patients to these centers contributes significantly to the high cost of burn care. This study quantifies inequitable burn care access in the contiguous United States due to age group and location as a function of physical proximity to a verified burn center and transportation cost. County-level distances to the nearest verified adult or pediatric burn center were determined and mapped. Distance calculations for each population were combined with transport cost data (2022 CMS Ambulance Fee Schedules) to estimate transportation costs for each population (adult vs pediatric, urban vs rural). Pediatric patients reside 30.5 miles further than adults from the nearest center, significantly increasing transportation costs. Ground and air transport costs also increased for rural versus urban patients. Notably, rural patients face almost double the cost of air transport. While physical proximity to burn care appears to differ only modestly across age and region, this marginal increase in distance is associated with significant economic impact. This study highlights physical and economic barriers to burn care access faced by rural and pediatric patients and underscores the critical need to improve equity in burn care access. Future studies should expand on this report's findings to more fully characterize the additional costs associated with inequitable burn care access.

State of cancer care in India and opportunities for innovation.

Cancer is one of the leading causes of morbidity and mortality in India. Despite recent medical and technological advances, the cancer burden in India remains high and continues to rise. Moreover, substantial regional disparities in cancer incidence and access to essential medical resources exist throughout the country. While innovative and effective cancer therapies hold promise for improving patient outcomes, several barriers hinder their development and utilization in India. Here we provide an overview of these barriers, including challenges related to patient awareness, inadequate infrastructure, scarcity of trained oncology professionals, and the high cost of cancer care. Furthermore, we discuss the limited availability of cancer clinical trials in the country, along with an examination of potential avenues to enhance cancer care in India. By confronting these hurdles head-on and implementing innovative, pragmatic solutions, we take an indispensable step toward a future where every cancer patient in the country can access quality care.

Healthcare price transparency in North America and Europe.

Healthcare price transparency is an effort to inform patient decision-making, but also to decrease prices and their variation across healthcare systems for equivalent medical services. The initiative is meaningful only for medical services that are shoppable-such as imaging examinations-for which patients incur out-of-pocket costs. Therefore, several countries in which patients commonly share a portion of their healthcare costs have been implementing mandates to improve healthcare price transparency. However, the provisional implementation has many issues, especially in the United States, including provider non-compliance and limited accessibility of price transparency tools by the general public. Many of the existing tools are not user-friendly, are difficult to navigate, focus on charges and health plan negotiated rates rather than patients' out-of-pocket costs, and disclose prices on the service level instead of per episode of care. As such, the disclosed amounts are often not reliable. Many price transparency tools also lack valid and measurable quality metrics, which can result in a selection of high-cost care as a proxy for high-value care, as well as an increase in healthcare prices when providers want to imply they offer high-quality care. Nevertheless, the impact of the initiatives on patients' decision-making and healthcare costs remains unclear. While transparency initiatives are patient-centric, efforts should be made to increase patient engagement, provide accurate patient-specific out-of-pocket cost information, compare available treatment and provider alternatives, and couple price information with quality metrics to enable making fully informed decisions.

Outcomes of Nonvariceal Upper Gastrointestinal Bleeding in Patients With Cirrhosis: A National Analysis.

We sought to evaluate hospital outcomes of cirrhosis patients with nonvariceal upper gastrointestinal bleeding (NVUGIB). NVUGIB is common in patients with cirrhosis. However, national outcome studies of these patients are lacking. We utilized the 2014 Nationwide Readmission Database to evaluate NVUGIB in patients with cirrhosis, further stratified as no cirrhosis (NC), compensated cirrhosis (CC), or decompensated cirrhosis (DC). Validated International Classification of Diseases, Ninth Revision, Clinical Modification codes captured diagnoses and interventions. Outcomes included 30-day readmission rates, index admission mortality rates, health care utilization, and predictors of readmission and mortality using multivariable regression analysis. Overall, 13,701 patients with cirrhosis were admitted with NVUGIB. The 30-day readmission rate was 20.8%. Patients with CC were more likely to undergo an esophagogastroduodenoscopy (EGD) within 1 calendar day of admission (74.1%) than patients with DC (67.9%) or NC (69.4%). Patients with DC had longer hospitalizations (4.1d) and higher costs of care ($11,834). The index admission mortality rate was higher in patients with DC (6.2%) than in patients with CC (1.7%, P<0.001) or NC (1.4%, P<0.001). Predictors of 30-day readmission included performing an EGD >1 calendar day from admission (OR: 1.21; 95% CI, 1.00 to 1.46) and DC (OR: 1.78; 95% CI, 1.54 to 2.06). DC was a predictor of index admission mortality (OR: 3.68; 95% CI, 2.67 to 5.05). NVUGIB among patients with DC is associated with higher readmission rates, mortality rates, and health care utilization compared with patients with CC and NC. Early EGD is a modifiable variable associated with reduced readmission rates. Early identification of high-risk patients and adherence to guidelines may improve clinical outcomes.

The effect of cocaine on patients undergoing total hip arthroplasty

BackgroundCocaine use has surged in the past decade, with 4.8 million Americans (1.7% of the population greater than 12) reporting use in 2021, leading to a healthcare burden of 1.3 billion dollars. Cocaine users experience prolonged hospital stays, higher costs, worse surgical outcomes, increased risk of medical conditions, and inflammation-related osteoarthritis. The study aims to identify factors influencing length of stay, costs, and perioperative complications in cocaine users undergoing total hip arthroplasty (THA) to reduce these risks. MethodsThis study utilized the NIS database, providing comprehensive information on patient demographics, length of stay, hospital costs, and complications. Statistical analyses were conducted using SPSS software, including propensity matching and significance testing, to compare outcomes between cocaine users (CU) and non-cocaine users (NCU) undergoing total hip arthroplasty. ResultsAfter propensity matching, cocaine users had a significantly longer LOS (4.8 days) in comparison to non-cocaine users (2.6 days) (p < 0.001). Similarly, the CU group had a larger of care (87984.9) than the NCU group (69149.2) (p < 0.001). Cocaine users had significantly higher rates of blood loss anemia (OR: 3.24, 95% CI: 2.21, 4.73), blood loss anemia (OR: 1.59, 95% CI: 1.12, 2.24), blood transfusion (OR: 2.23, 95% CI: 1.04, 4.78), periprosthetic dislocation (OR: 6.57, 95% CI: 1.47, 29.32), and periprosthetic infection (OR: 4.59, 95% CI: 1.54, 13.68) than patients in the non-cocaine user's group. ConclusionCocaine users had a significantly longer length of stay, higher costs of care, and an increased number of post-operative complications compared to non-cocaine users. These data contribute to understanding the potential ramifications of cocaine users undergoing THA.

Highly Purified Human Menopausal Gonadotropin (HP-hMG) Versus Recombinant Follicle-Stimulating Hormone (rFSH) for Controlled Ovarian Stimulation in USPredicted High-Responder Patients: A Cost-Comparison Analysis.

Infertility imposes considerable clinical and economic burden, and the high costs of fertility care are a major barrier to payers. This study assessed the cost differences of highly purified human menopausal gonadotropin (HP-hMG) versus recombinant follicle stimulating hormone (rFSH) for controlled ovarian stimulation (COS) protocols in predicted high-responders from the US payer perspective. A discrete event simulation model was built to perform a cost-comparison analysis of HP-hMG versus rFSH in a cohort of predicted high-responders undergoing up to three embryo transfer cycles, informed by efficacy data from the MEGASET-HR trial. The model considered an event-based treatment pathway and transition probabilities were derived from MEGASET-HR. A variable time horizon was employed, and deterministic and probabilistic sensitivity analyses conducted. Subjects undergoing COS with HP-hMG and rFSH demonstrated comparable live birth rates following three in vitro fertilization (IVF) cycles, with 161 live births with HP-hMG and 152 live births with rFSH, per 310 high-responders. The total cost saving per live birth in subjects receiving HP-hMG versus rFSH was US$3024. These cost savings were largely driven by the need for fewer embryo transfers to achieve similar efficacy outcomes and a reduced rate of ovarian hyperstimulation syndrome. Following deterministic sensitivity analysis, HP-hMG remained cost saving in all baseline parameter variations. No parameters led to rFSH providing cost savings when compared with HP-hMG. Comparable clinical outcomes can be achieved at a lower cost when using HP-hMG versus rFSH based COS protocols in a cohort of predicted high-responders. Such cost savings may reduce the economic burden infertility currently presents to US healthcare providers and those seeking fertility care.