Higher Total Hospital Costs Research Articles

Identifying causes for high readmission rates after stoma reversal

Unplanned readmissions after colorectal surgery impact patient and financial outcomes. Our goal was to identify factors related to readmission in ostomy reversal patients. Review of a prospective department database was performed from 2006 to 2012 to identify patients who underwent an ostomy reversal. Patients were stratified into nonreadmitted and readmitted within 30 days of ostomy reversal. The main outcome measures were predictors of readmission and characteristics of patients readmitted and not readmitted. A total of 351 ostomy reversals (86 % ileostomy and 14 % colostomy) were analyzed; 44 patients were readmitted (12.5 %). Readmitted and nonreadmitted patients were similar in age, body mass index, gender, comorbidities, indications for the index operation, and time to ostomy reversal. Readmitted patients had longer operative times (p = 0.002) and length of stay (p = 0.001), more intraoperative blood loss (p = 0.003), intraoperative complications (p = 0.005), ICU requirements (p < 0.0001), need for temporary nursing at discharge (p < 0.001), and higher total hospital costs than nonreadmitted patients (p = 0.0162). Longer operative time [odds ratio (OR) 1.006, 95 % confidence interval (CI) 1.001-1.012], intraoperative complications (OR 7.334, 95 % CI 1.23-43.761), ICU stay (OR 1.291, 95 % CI 1.18-1.893), delayed discharge (OR 1.085, 95 % CI 1.003-1.173), and discharge to skilled nursing facility (OR 6.936, 95 % CI 1.531-31.332) were independent predictors of readmission. Ostomy type had no independent effect on readmission. Differences in perioperative and outcomes variables exist between readmitted and nonreadmitted patients after ostomy reversal. Longer operative times, intraoperative complications, intensive care unit care, longer length of stay, and skilled nursing at discharge were independently predictive of readmission. These findings can be used to identify high-risk patients prospectively, potentially improving clinical outcomes and healthcare utilization.

Impacts of Health Insurance Benefit Design on Percutaneous Coronary Intervention Use and Inpatient Costs among Patients with Acute Myocardial Infarction in Shanghai, China

Currently, the most popular hospital payment method in China is fee-for-service (FFS) with a global budget cap. As of December 2009, a policy change means that heart stents are covered by public health insurance, whereas previously they were not. This policy change provides us an opportunity to study how a change in insurance benefit affected the quantity and quality of hospital services. The new policy introduced incentives for both patients and providers: it encourages patient demand for percutaneous coronary intervention (PCI) services and stent use (moral hazard effect), and discourages hospital supply due to the financial pressures of the global cap (provider gaming effect). If the provider's gaming effect dominates the moral hazard effect, actual utilisation and costs might go down, and vice versa. Our hypothesis is that patients in the higher reimbursement groups will have fewer PCIs and lower inpatient costs. We aimed to examine the impact of health insurance benefit design on PCI and stent use, and on inpatient costs and out-of-pocket expenses for patients with acute myocardial infarction (AMI) in Shanghai. We included 720 patients with AMI (467 before the benefit change and 253 after) from a large teaching tertiary hospital in Shanghai. Data were collected via review of hospital medical charts, and from the hospital billing database. Patient information collected included demographic characteristics, medical history and procedure information. All patients were categorised into four groups according to their actual reimbursement ratio: high (90-100 %), moderate (80-90 %), low (0-80 %) and none (self-paid patients). Multiple regression and difference-in-difference (DID) models were used to investigate the impacts of the health insurance benefit design on PCI and stent use, and on total hospital costs and patients' out-of-pocket expenses. After the change in insurance benefit policy, compared with the self-paid group, PCI rates for the moderate and low reimbursement groups increased by 22.2 and 20.3 %, respectively, and decreased by 48.7 % for the high reimbursement group. The change in insurance benefit policy had no impact on the number of stents used. The high reimbursement group had the lowest hospital costs, and the low reimbursement group had the highest hospital costs, regardless of benefit policy change. The general linear regression results showed that the high reimbursement group had higher total hospital costs than the self-paid group, but were the lowest among all reimbursement groups after the benefit policy change (DIDh = 1,202.21, P = 0.0096). There were no significant changes in the other two groups, and there were no differences in the out-of-pocket costs across any of the insured groups. Our results suggest that the benefit policy change did not impact life-saving procedures or reduce patients' burden of disease among AMI patients. The effect of 'provider gaming' was the strongest for the high reimbursement group as a result of the global budget cap pressure. The current FFS with a global budget cap is of low efficiency for cost containment and equity improvement. Payment method reforms with alignment of financial incentives to improve provider behaviour in practicing evidence-based medicine are needed in China.

Association of Patient Preferences for Participation in Decision Making With Length of Stay and Costs Among Hospitalized Patients

Patient participation in medical decision making has been associated with improved patient satisfaction and health outcomes. However, there is little evidence concerning its effects on resource utilization. Patient participation in medical decision making has been hypothesized to decrease excess utilization but might be expected to increase utilization when other decision makers have incentives to reduce utilization, as under prospective payment systems for hospital care. To examine the relationship between patient preferences for participation in medical decision making and health care utilization among hospitalized patients. Survey study in an academic research setting. A survey that included questions about preferences to receive medical information and to participate in medical decision making was administered to all patients admitted to the University of Chicago Medical Center general internal medicine service between July 1, 2003, and August 31, 2011, and completed by 21,754 (69.6%) of admitted patients. The survey data were linked with administrative data, including length of stay and total hospitalization costs. We used generalized linear models to measure the association of patient preference for participation in decision making with length of stay and costs. The mean length of stay was 5.34 days, and the mean hospitalization costs were $14,576. While 96.3% of patients expressed a desire to receive information about their illnesses and treatment options, 71.1% of patients preferred to leave medical decision making to their physician. Preference to participate in decision making increased with educational level and with private health insurance. Compared with patients who had a strong desire to delegate decisions to their physician, patients who preferred to participate in decision making concerning their care had a 0.26-day (95% CI, 0.06-0.47 day) longer length of stay (P = .01) and $865 (95% CI, $155-$1575) higher total hospitalization costs (P = .02). Patient preference to participate in decision making concerning their care may be associated with increased resource utilization among hospitalized patients. Variation in patient preference to participate in medical decision making and its effects on costs and outcomes in the presence of varying physician incentives deserve further examination.

A prospective, randomized trial of Roux-en-Y reconstruction with isolated pancreatic drainage versus conventional loop reconstruction after pancreaticoduodenectomy

Postoperative pancreatic fistula (POPF) is a major and serious complication after pancreaticoduodenectomy (PD). There have been no prospective randomized trials evaluating POPF rates in Roux-en-Y reconstruction (RYR) with isolated pancreatic drainage versus conventional loop reconstruction (CLR). The authors hypothesized that RYR decreases the incidence and severity of POPF in patients after PD. Between January 2006 and April 2012, the findings for 216 patients were analyzed in this multicenter, prospective trial in China. After providing appropriate preoperative informed consent, patients were randomly assigned to either RYR or CLR after completion of pancreaticoduodenal resection. We referred to the Johns Hopkins fistula definition and classified POPF as grade A, B, or C according to the International Study Group of Pancreatic Fistula classification. The incidence of POPF was similar in the RYR (15.7%, 17/107) and CLR (17.6%, 19/109) groups. Both univariate and multivariate logistic regression analyses revealed that the factor most highly associated with POPF was ampullary or duodenal disease (P < .05). The incidence of type B POPF was higher in the CLR than in the RYR group. Furthermore, patients with POPF in the CLR group had a significantly longer postoperative hospital stay (31.9 ± 6.9 days) and higher total hospital costs than did the patients in the RYR group (P < .05). These data do not support the hypothesis that RYR is associated with a lower incidence of POPF than is CLR. However, they do indicate that RYR may contribute to decreasing fistula severity, duration of stay, and hospital expense.

Hyperglycemia is associated with increased length of stay and total cost in patients hospitalized for congestive heart failure

Objectives: Hyperglycemia is a well-known marker of poor clinical outcomes in acute myocardial infarction and critical illness; however, its effect in congestive heart failure (CHF) is controversial. We hypothesized that persistent hyperglycemia is associated with increased length of stay (LOS) and increased total cost in patients admitted with CHF. Methods: We studied 203 consecutive patients admitted with a primary diagnosis of CHF. Patient characteristics, admission glucose, mean blood glucose (MBG) during the entire hospital stay, length of stay, total cost, and readmission rates were assessed. Persistent hyperglycemia was defined as a MBG level ≥140 mg/dl. Results:Patients with persistent hyperglycemia had longer mean LOS (8.1 vs 5.2 days, p = 0.001) and higher total hospital costs (median $8940 vs $6892, p = 0.01) independent of diabetes status. Similarly, prolonged hospital stay >7 days (38% vs 21%; p = 0.01) and total cost >$10,000/patient (46% vs 29%; p = 0.01) were seen more commonly in patients with poor glucometrics. Neither admission glucose >140 mg/ dL or diabetes status was predictive of total costs or LOS. In multivariate linear regression, only MBG ≥ 140 mg/dl was associated with increased LOS and total cost. Patients with persistent hyperglycemia also had higher 6 months all-cause readmission rates (51% vs 37%; p = 0.03). Conclusion: Persistent hyperglycemia (MBG > 140 mg/dL), but not admission glucose, was associated with increased LOS, total cost and readmission rates independent of diabetes status. Our study emphasizes the need to further examine the role of glycemic control in patients admitted with CHF.

Economic Implications of Rasburicase Treatment in Adult Patients with Tumour Lysis Syndrome

Rasburicase is a recombinant urate-oxidase enzyme used to reduce high levels of plasma uric acid (PUA) resulting from tumour lysis syndrome (TLS). Rasburicase reduces PUA levels within 4 hours of administration, thereby minimizing the risk of serious complications from TLS. Treatment pattern analyses indicate rasburicase is often used in combination with allopurinol; however, no studies have evaluated the clinical and economic consequences of this pattern of care. The purpose of this study was to compare hospitalization costs, overall length of stay (LOS), and critical-care LOS in patients receiving rasburicase with or without allopurinol. Hospital claims data from the Premier Perspective Database™ were used to conduct this retrospective analysis. Patients in the Premier hospital database who were administered rasburicase or combination therapy (rasburicase + allopurinol) within 2 days of hospital admission were eligible for study inclusion. Patients were excluded if they were <18 years of age or received haemodialysis (or any other renal replacement therapy support) on admission. Rasburicase patients were propensity-score-matched to combination therapy patients based on gender, race, hospital type (urban/rural, teaching), provider type, payer type, admission source, use of electrolyte modification therapy, critical-care admission and presence of a cancer diagnosis. Differences in healthcare costs, overall LOS and critical-care LOS were assessed using γ-distributed generalized linear models with a log-link function. The study population comprised 66 patients receiving rasburicase monotherapy matched to 66 patients receiving combination therapy. Mean age was 62.9 years, and 29% were female. Patients initiated on combination therapy had a shorter mean duration of rasburicase administration than patients initiated on monotherapy (2.1 vs 2.7 days) [p = 0.0059]. Additionally, rasburicase monotherapy incurred an average total cost of $US35 843 per hospitalization, compared with $US46 672 for those receiving combination therapy (p = 0.0820). Rasburicase monotherapy patients also had a shorter mean overall LOS (10.0 days vs 15.4 days; p = 0.0067). The mean critical-care LOS was similar in both cohorts (2.4 days rasburicase vs 2.9 days combination therapy; p = 0.3389). Examination of claims data showed that combination therapy (rasburicase + allopurinol) trended toward higher total hospitalization costs than rasburicase monotherapy. In addition, combination therapy was associated with significantly longer overall LOS compared with upfront rasburicase monotherapy in patients at risk for developing TLS.

Abstracts for Canadian Stroke Conference

Specogna, AV; Patten, SB; Hill, MD; University of Calgary, Calgary, AB Background: Previous studies have examined predictors of treatment costs after Spontaneous Intracerebral Hemorrhage (ICH) in various countries and healthcare systems. Currently however, there is no clear understanding of which factors are associated with cost in any Canadian setting and thus no way of understanding how to plan ICH healthcare spending. Methods: We used a retrospective case series study design and adjusted linear regression to investigate if an association existed between the total cost of ICH hospital care in a Canadian health centre and age (years), gender (female vs. male), Charlson Comorbidity Index (0 vs. ≥1), in-hospital mortality (alive vs. dead), and having surgery (no vs. yes). Economic, treatment, and patient data were obtained from administrative sources. Total inflation-adjusted hospital cost per discharge was estimated in Canadian Dollars and log transformed for all analyses. Results: Analyses were performed using 987 consecutive ICH discharges from 1999 to 2008. The total cost of ICH hospital care was highly variable (mean cost per discharge=$25,613.96±$36,116.33; min $446.81 to max $326,275.10). Older age (β=–0.0057; 95% CI: –0.0103 to –0.0011) and death in hospital (β=–0.4859; 95% CI: –0.6357 to –0.3342) were significantly associated with lower total hospital cost per discharge. Whereas Charlson Comorbidity Index of ≥1 (β=0.6489; 95% CI: 0.5063 to 0.7916) and having surgery (β=1.3552; 95% CI: 1.1893 to 1.5210) were significantly associated with higher total hospital cost per discharge. Gender was not significantly associated with cost (β=0.0727; 95% CI: –0.0679 to 0.2134). Conclusions: To our knowledge this is the first study to examine predictors of ICH treatment costs in Canada. In a Canadian health centre, ICH treatment costs were significantly associated with patient age, level of comorbidity, in-hospital mortality, and surgical treatment. This study provides evidence that it may be reasonable to consider …

Complications and costs associated with adhesiolysis at the time of repeat cesarean delivery

OBJECTIVE: To calculate the proportion of women with adhesiolysis at primary or repeat Cesarean delivery (CD) and to compare rates of bleeding complications, postoperative length of stay (LOS), and total hospital costs in patients with and without adhesiolysis at repeat CD.DESIGN: A propensity score–matched cohort study.MATERIALS AND METHODS: Data from a sample of 609 US hospitals were used to identify women with either primary or repeat CD. We included women ≥15 years old, with singleton gestation, and discharged in calendar years 2007 or 2008. Adhesiolysis rates were calculated for primary and repeat CD. For repeat CD, propensity score matching was used to achieve comparability on patient, hospital, and physician characteristics between adhesiolysis and control groups. We evaluated risk for bleeding complications and mean postoperative LOS and total hospital costs between groups.RESULTS: Of 223,129 primary and 166,980 repeat CD women included, adhesiolysis was performed in 0.5% (n=1,056) and 6.1% (n=10,262), respectively. Using propensity scores, 10,261 repeat CD women with adhesiolysis were matched to 10,261 controls without adhesiolysis; cohorts were comparable. Hemorrhage occurred in 1.7% (n=178) of the adhesiolysis group and 1.2% (n=121) of controls; relative risk (RR) =1.47, 95% CI = 1.17-1.85. Transfusion was required in 1.9% (n=194) of the adhesiolysis group and 1.1% (n=108) of controls; RR = 1.80, (1.42-2.27). The adhesiolysis group had greater LOS (3.0 ± 0.9 vs. 2.9 ± 0.8 days; P<0.001) and higher total hospital costs ($5,739 ± 3,368 vs. $5,448 ± 3,031; P <0.001) compared with controls.CONCLUSION: Adhesiolysis rates were significantly higher at the time of repeat compared with primary CD. At repeat CD, the risk of complications was higher in patients who had adhesiolysis than in those who did not. Measures to prevent adhesions taken during first CD may reduce complications and overall hospital costs at the time of repeat CD. OBJECTIVE: To calculate the proportion of women with adhesiolysis at primary or repeat Cesarean delivery (CD) and to compare rates of bleeding complications, postoperative length of stay (LOS), and total hospital costs in patients with and without adhesiolysis at repeat CD. DESIGN: A propensity score–matched cohort study. MATERIALS AND METHODS: Data from a sample of 609 US hospitals were used to identify women with either primary or repeat CD. We included women ≥15 years old, with singleton gestation, and discharged in calendar years 2007 or 2008. Adhesiolysis rates were calculated for primary and repeat CD. For repeat CD, propensity score matching was used to achieve comparability on patient, hospital, and physician characteristics between adhesiolysis and control groups. We evaluated risk for bleeding complications and mean postoperative LOS and total hospital costs between groups. RESULTS: Of 223,129 primary and 166,980 repeat CD women included, adhesiolysis was performed in 0.5% (n=1,056) and 6.1% (n=10,262), respectively. Using propensity scores, 10,261 repeat CD women with adhesiolysis were matched to 10,261 controls without adhesiolysis; cohorts were comparable. Hemorrhage occurred in 1.7% (n=178) of the adhesiolysis group and 1.2% (n=121) of controls; relative risk (RR) =1.47, 95% CI = 1.17-1.85. Transfusion was required in 1.9% (n=194) of the adhesiolysis group and 1.1% (n=108) of controls; RR = 1.80, (1.42-2.27). The adhesiolysis group had greater LOS (3.0 ± 0.9 vs. 2.9 ± 0.8 days; P<0.001) and higher total hospital costs ($5,739 ± 3,368 vs. $5,448 ± 3,031; P <0.001) compared with controls. CONCLUSION: Adhesiolysis rates were significantly higher at the time of repeat compared with primary CD. At repeat CD, the risk of complications was higher in patients who had adhesiolysis than in those who did not. Measures to prevent adhesions taken during first CD may reduce complications and overall hospital costs at the time of repeat CD.

Acute kidney injury in non-critically ill children treated with aminoglycoside antibiotics in a tertiary healthcare centre: a retrospective cohort study

Aminoglycosides (AG) cause acute kidney injury (AKI), but the incidence and severity distribution are unclear, particularly in non-critically ill children. We determined the incidence, severity and risk factors of AG-associated AKI and assessed for associations with longer hospitalization and higher costs. At Texas Children's Hospital, we conducted a retrospective cohort study of children treated with AG for ≥ 5 days in 2005, excluding children with admission primary renal diagnoses. AKI was defined by the paediatric Risk, Injury, Failure, Loss, End Stage Kidney Disease (pRIFLE) and Acute Kidney Injury Network (AKIN) definitions. Multiple logistic and linear regression analyses were used to assess independence of associations with outcomes. Five hundred and fifty-seven children [mean ± SD age = 8.0 ± 5.9 years, 286 (51%) male, 489 (88%) gentamicin] were studied. The AKI rate was 33% and 20% by pRIFLE and AKIN definitions, respectively. Longer treatment, higher baseline estimated glomerular filtration rate, being on a medicine (versus surgical) treatment service and prior AG treatment were independent risk factors for AKI development. AKI by pRIFLE or AKIN was independently associated with longer hospital stay and higher total hospital costs. The pRIFLE definition was more sensitive for AKI detection, but the AKIN definition was more strongly related to outcomes. AKI is common and associated with poorer outcomes in non-critically ill children treated with AG. Future research should attempt to understand how to best define AKI in the non-critical illness paediatric setting.

The economic implications of rasburicase treatment in adult tumor lysis syndrome patients

e17503 Background: Rasburicase is a recombinant urate-oxidase enzyme used to reduce high levels of plasma uric acid (UA) resulting from tumor lysis syndrome (TLS). Rasburicase reduces UA levels within 4 hours of administration, minimizing risk of serious complications from TLS. Treatment pattern analyses indicate rasburicase is often used in combination with allopurinol; however, no studies have evaluated clinical and economic consequences of this pattern of care. The purpose of the study was to compare hospitalization costs, length of stay (LOS), and duration of critical care in patients receiving rasburicase with or without allopurinol. Methods: Patients in the Premier hospital database administered rasburicase or combination therapy within 2 days of hospital admission were eligible for study inclusion. Patients were excluded if they were &lt;18 years of age or received hemodialysis on admission. Patients were propensity score matched to rasburicase patients based on gender, race, hospital type, provider type, payer type, admission source, use of electrolyte modification therapy, critical care admission, and comorbid diagnoses. Differences in health care costs, LOS, and duration of subsequent critical care were assessed using exponentially distributed generalized linear models with a log link function. Projection weights are used to produce national projected patient counts. Results: There were 280 rasburicase and 310 combination patients matched in the analysis. Mean age of the sample was 65.2, with 31% being female. There were no statistical differences in matched covariates across the cohorts. Rasburicase patients incurred an average total cost of $39,474 per hospitalization compared to $52,047 for combination patients (p = 0.0029). Rasburicase patients also had a lower LOS (10.5 days) compared to combination therapy (16.4 days, p &lt; 0.0001). Duration of critical care was similar in both cohorts (rasburicase = 1.4 days vs 1.8 days, p = 0.1222). Conclusions: Combination therapy of rasburicase and allopurinol resulted in higher total hospitalization costs and longer LOS compared to rasburicase monotherapy. [Table: see text]

Clinical Outcomes and Resource Utilization Associated With Laparoscopic and Open Colectomy Using a Large National Database

To clarify national clinical and economic laparoscopic colectomy outcomes, we conducted a study of patients who underwent colectomy by laparoscopic or open approaches. Laparoscopy is becoming the preferred approach for colectomy in benign and malignant diseases. Although it is associated with significant clinical benefits, economic outcomes have varied. We analyzed cohorts of patient-level data from Premier Inc.'s Perspective Rx Comparative Database, which collects data from more than 500 hospitals throughout the United States. By reviewing hospital charge data, patients who underwent elective colectomies from July 1, 2004, through June 30, 2006, were identified using International Classification of Diseases, 9th Revision, Clinical Modification procedure codes. The colectomy had to be listed as the primary or secondary procedure of the hospitalization. Primary outcomes included transfusion rates, in-hospital complications, readmissions within 30 days, reoperations, length of stay, total hospitalization costs, and discharge dispositions and services. We identified 32,733 patients who had elective colectomies throughout 402 hospitals; 11,044 (33.7%) were laparoscopic and 21,689 (66.3%) were open colectomies. The mean age was 64.2 +/- 13.9 years and 53.8% were women. Laparoscopic colectomy patients had a longer mean operative time (195 +/- 76 vs. 178 +/- 80 minutes; P < 0.0001) and higher total hospital costs ($8076 vs. $7678; P = 0.0002). Laparoscopic patients had shorter mean length of stay (7.0 vs. 8.1; P < 0.0001) and fewer mean intensive care unit days (0.7 +/- 3.8 vs. 1.3 +/- 5.2 days; P < 0.0001). The laparoscopic cohort also had lower rates of transfusions (odds ratio [OR] = 0.68; P < 0.0001), in-hospital complications (OR = 0.89; P < 0.0001), and readmissions within 30 days (OR = 0.89; P = 0.0051), although reoperation rates were slightly, but significantly increased (OR = 1.78; P = 0.002). Laparoscopic colectomy patients were more likely to be discharged home without nursing care (OR = 0.70; P < 0.0001). Evaluation of a national administrative data set showed that patients who underwent laparoscopic colectomy had shorter intensive care unit and total hospital stays, fewer complications, lower mortality, fewer readmissions, and less use of skilled nursing facilities after discharge. There was a small but significant increase in reoperation rates and in-hospital costs with laparoscopic colectomy. Improved application of enhanced recovery programs and operative efficiencies may further improve resource utilization associated with laparoscopic colectomy.

Clinical outcomes and cost comparison of carotid artery angioplasty with stenting versus carotid endarterectomy

Recently, carotid angioplasty with stenting (CAS) has evolved as an alternative to carotid endarterectomy (CEA) for the treatment of carotid occlusive disease. Some concerns have arisen regarding the high cost of stents and neuroprotection devices, which may inflate the overall procedural costs relative to CEA. We report here a review and analysis contrasting the clinical outcomes and associated hospital costs incurred for patients treated with either CAS or CEA. Ninety-four consecutive patients with surgically amenable carotid stenosis were offered CAS or CEA. Forty-six patients elected CAS, and 48 patients underwent CEA. CAS was performed with the Smart Precise or Acculink stents, and all procedures included neuroprotection (Filter Wire or Accunet). CEA was performed with patients under general anesthesia with routine shunting and with Dacron or bovine pericardium patches. Clinical outcomes such as perioperative mortality, major adverse events (myocardial infarction, stroke, and death), length of stay, and the incidence of hemodynamic instability were analyzed. Total costs, indirect costs, and direct procedural costs associated with hospitalization were also reviewed. CAS was associated with a shorter length of stay compared with CEA (1.2 vs 2.1 days; P = .02). Differences in perioperative mortality (0% vs 2%; P = NS), major adverse events (2% vs 10%; P = .36), strokes (2% vs 4%; P = NS), myocardial infarctions (0% vs 4%; P = .49), and hypotension necessitating pressor support (21% vs 18%; P = NS) were not statistically significant. By using cost to charge ratio methodology according to the Medicare report, CAS was associated with higher total procedural costs (US dollars 17,402 vs US dollars 12,112; P = .029) and direct costs (US dollars 10,522 vs US dollars 7227; P = .017). The differences in indirect costs were not significant (US dollars 6879 vs US dollars 4885; P = .063). CAS with neuroprotection was associated with clinical outcomes equivalent to those with CEA but had higher total hospital costs. These higher costs reflect the addition of expensive devices that have improved the technical success and the clinical outcomes associated with CAS.

Utilization of Intensive Care Resources in Bariatric Surgery

Obese patients occasionally require either elective or emergency critical care services following bariatric surgery. We describe this subgroup of patients. From July 1, 1991 to July 31, 2004, we performed 1,279 bariatric operations; 241 (19%) required admission to the surgical critical care service. We retrospectively reviewed medical records for gender, body mass index (BMI), age, whether the operation was initial or revisional, and whether critical care admission was elective or emergent. 3 complication clusters (thromboembolic, pulmonary, and anastomotic) were identified using discharge ICD-9 codes. The costs and length of stay of these subpopulations was calculated. Patients were on average 46+/-10 years old, with BMI 59+/-13. Critical care admission was emergent in 52.7% (n=127) of cases. Revisional cases did not differ from the initial cases in BMI (56.4 vs 59.2, P=0.42) and they were no more likely to require emergent critical care admission than initial cases (P=0.16). Revisional cases were hospitalized longer (27.2+/-25.6 vs 12.5+/-18.7 days, P=0.003); had higher total hospital costs (US$ 60,631+/-78,337 vs 27,697+/-52,351, P=0.025); and were more likely to die from their complications (revisional surgery mortality 6.5% vs 1.9% for initial surgery [P=0.002]). An increasing number of surgical revisions will likely accompany the recent increase in popularity of bariatric surgery. In our experience, these patients require significant critical care services, and have longer, complicated, and more costly hospitalizations.

Clinical findings associated with prairie rattlesnake bites in dogs: 100 cases (1989-1998).

To identify clinically relevant variables and treatments for dogs bitten by prairie rattlesnakes (Crotalus viridis viridis). Retrospective study. 100 client-owned dogs. Records of dogs evaluated for rattlesnake envenomation from 1989 to 1998 were reviewed. Analysis was performed to test for significant associations among clinical variables or treatments and cell counts, costs, and duration of hospitalization. Most prairie rattlesnake bites occurred between May and September. Dogs were 3 months to 12 years old (median, 3.7 years); most were bitten on the head in the late afternoon. There was no sex predilection. Median time to evaluation was 1 hour (range, 15 minutes to 13 hours). Swelling in the area of the bite was the primary physical abnormality. Principal initial laboratory findings were echinocytosis, thrombocytopenia, leukocytosis, and prolonged activated clotting time. Ninety-four dogs were hospitalized; 48 were discharged the following day. Antimicrobials and crystalloid fluids, glucocorticoids, antihistamines, and antivenin administered i.v. were the most commonly used treatments. One dog died, and small dogs were hospitalized longer than large dogs. Antivenin administration was not significantly associated with duration of hospitalization but was associated with higher platelet counts after treatment and higher total hospital costs. Prairie rattlesnake envenomation in dogs is associated with high morbidity rate but low mortality rate. The efficacy of administration of antivenin for dogs with bites from this snake species is questionable.

Occult hypoperfusion is associated with increased morbidity in patients undergoing early femur fracture fixation.

The presence of persistent occult hypoperfusion (OH) is associated with higher morbidity and mortality rates after trauma. Early femur fracture fixation in trauma patients with multiple injuries is associated with decreased morbidity and mortality. Association of OH and incidence of postoperative complications after intramedullary (IM) fixation in patients with femur fractures was investigated. A retrospective study design was used. All patients with femur fractures admitted to the trauma service of a Level I trauma center between January 1, 1995, and August 1, 1998, who were older than 18 years of age and who had IM fracture fixation within 24 hours of admission and serum lactate determinations on admission and at proscribed intervals, were included in the study. Patients with lactic acid levels > or = 2.5 mmol/L were determined to have OH. No patients had clinical signs of shock (hypotension, tachycardia, decreased urine output) on transfer to the operating room. Complete resuscitation was defined as a lactic acid level < 2.5 mmol/L. Patients were divided into two groups based on presence/absence of OH determined from the lactic acid level immediately before surgery. The incidence of all postoperative organ complications was recorded, and complication rates were compared between groups. Total hospital costs were also compared. One hundred seventy-seven patients with femur fractures were admitted to the trauma service during this period. Seventy-nine patients met initial criteria for inclusion in the study. Further review excluded 32 patients. Occult hypoperfusion was present in 20 patients before early IM fixation (group 2). Twenty-seven patients were completely resuscitated before early IM fixation (group 1). Injury Severity Scores were similar in both groups. Group 2 had 35 complications in 20 patients, and group 1 had 11 complications in 27 patients. A significant difference was found in incidence of postoperative complications in group 1 (20%) versus group 2 (50%). Group 2 also had a significantly higher proportion of postoperative infections than group 1 (72% vs. 28%, respectively) and higher total hospital costs ($46,469 vs. $23,139). The presence of OH in trauma patients undergoing early IM fixation of a femur fracture is associated with a twofold higher incidence of postoperative complications. Clinical judgment, not surgical dogma, should guide the timing of IM fixation in these patients. Identifying and correcting OH through relatively simple resuscitative measures may be advantageous in reducing morbidity in the patient with multiple injuries.

Pediatric patients, DRG hospital payment, and comorbidities

To determine whether the diagnosis related group (DRG) hospital payment system is causing financial pressure on pediatric hospitals similar to that shown in our previous work in other settings, we analyzed resource consumption for pediatric patients in any of the 251 DRGs not stratified by comorbidities. The new DRG prospective "all payor system" is in effect at our hospital. Analysis of 12,771 pediatric patients by payer (Medicaid and commercial insurance such as Blue Cross) in these DRGs for a 3-year period demonstrated that, as a group, pediatric patients with more comorbidities generated higher total hospital costs, a longer hospital length of stay, a greater percentage of procedures per patient, financial risk under DRG payment, more outliers (expensive patients), and a higher mortality rate than pediatric patients in the same DRGs with fewer comorbidities. This study confirms major inequities in DRG prospective hospital payment for many pediatric patients.

Hospital costs, cancer patients, and gynecology diagnostic related groups

This study of 115 Medicare gynecology patients in five noncancer-designated gynecology diagnostic related groups (DRGs) demonstrated that patients with a diagnosis of a malignancy ( N = 52) had significantly higher hospital resource utilization compared to patients without a malignancy ( N = 63) in these gynecology DRGs. Cancer patients had higher total hospital costs ( P < 0.001), longer hospital length of stay ( P < 0.01), significant financial losses under DRGs ( P < 0.01), greater percentage of outliers ( P < 0.05), greater severity of illness, and greater mortality ( P < 0.001) compared to noncancer patients in these same gynecology DRGs. These findings raise the question of whether hospitals will be adequately reimbursed by DRGs for many gynecology cancer patients. Disincentives for hospitals to treat gynecology cancer patients under the current DRG reimbursement system may affect both the access to and the quality of care.

Financial risk and hospital cost for elderly patients in non-age stratified urology DRGS

The Diagnostic Related Group (DRG) hospital payment system may be inequitable for certain groups of Medicare patients. This study of 216 Medicare urology patients in the ten nonage stratified urology DRGS demonstrated that patients seventy years of age and older (70+) had higher resource consumption than patients under seventy years of age (70 − ). Findings were: (1) older patients (70 + ) had higher total hospital costs ($12,022 per patient) than younger patients (70 − ) ($9,872 per patient); (2) a longer hospital length of stay (14.2 days vs 11.6 days); (3) financial risk of $1, 756 loss per (70 + ) patient vs $1,309 profit per (70 − ) patient (p < 0.05); (4) more diagnoses and procedures per patient, and (5) a higher mortality (4.0 % vs 3.3 %). These findings suggest that the current DRG scheme may be inequitable vis-a-vis the older urology patient in nonage stratified DR Gs, and thus could limit access and quality of care for these patients in the future.

Financial Risk and Hospital Cost in Stratified, Peripheral Vascular Surgical DRGs Without Complications and Comorbidities

The purpose of this study was to analyze hospital resource consumption in any of the nine non-complicating conditions covered under stratified, peripheral vascular surgical Diagnosis-Related Groups (DRGs) using the new DRG prospective All Payer System in effect in New York. There is significant health policy debate at the level of the United States Congress regarding the improvement of the equity of DRG hospital payment. Although there have been a number of recommendations by federal advisory bodies to further stratify DRGs by complications and comorbidities, no major revision of DRGs along these lines has been implemented. The all payer system uses the DRG format to pay for all patients. We analyzed 788 peripheral vascular surgical patients by payer (Medicare, Medicaid, Blue Cross and commercial insurance) in these stratified, peripheral vascular surgical DRGs with no complications or comorbidities for a three year period. Our study demonstrated that patients within each DRG with more complications and comorbidities generated higher total hospital costs, a longer hospital length of stay, a greater percentage of procedures per patient, financial risk under DRG payment, more outliers, and a higher mortality, compared to patients in these same DRGs with fewer complications and comorbidities. These findings suggest that new, prospective DRG all payer systems may be inequitable to certain groups of patients or types of hospitals in these stratified peripheral vascular surgical DRGs with no complication or comorbidities. This analysis suggests that these peripheral vascular surgical DRGs should be stratified by the numbers and types of complications and comorbidities to more equitably reimburse hospitals under DRGs.(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnosis Related Group 'All Payor' Hospital Payment and Medical Diseases

There are many health policy issues related to diagnosis-related group (DRG) hospital payment. Previous work by our group had suggested that some DRGs did not adequately comorbidities. Despite recommendations by federal advisory committees, the secretary of Health and Human Services has proposed no major changes to DRGs along these lines. We analyze resource consumption in any of the 88 non-complicating condition (CC)-stratified medical DRGs using the DRG prospective "all payor system" in effect at our hospital. Analysis of 12,340 medical patients by payor (Medicare, Medicaid, Blue Cross, and commercial insurance) in these non-CC-stratified medical DRGs for a three-year period demonstrated that patients with more CCs per DRG for each payor generated higher total hospital costs, a longer hospital length of stay, a greater percentage of procedures per patient, higher financial risk under DRG payment, and a higher mortality, compared with patients in these same DRGs with fewer CCs. These findings suggest that new prospective DRG all payor systems may be inequitable to certain groups of patients or types of hospitals vis-à-vis the non-CC-stratified medical DRGs. Health policy leaders should be encouraged to stratify many medical DRGs by the numbers and types of CCs to more equitably reimburse hospitals under DRG all payor systems.