Higher Total Costs Research Articles

TOTAL HIP ARTHROPLASTY IN THE PUBLIC HEALTH SYSTEM OF SÃO PAULO: COMPARING TYPES OF FIXATION.

(i) to describe the demographic profile of patients who underwent THA in the public health system of the municipality of São Paulo during the last 12 years and (ii) to compare fixation methods regarding costs, hospital stay length, and death rates. This is an ecological study conducted with data available on TabNet, a platform belonging to DATASUS. Public data (from the government health system) on THA procedures performed in São Paulo from 2008 to 2019 were extracted. Gender, age, city region, THA fixation method, number of surgeries, costs, hospital stay length, and death rates were analyzed. We analyzed 7,673 THA, of which 6220 (81%) were performed via cementless/hybrid fixation and 1453 (19%), via the cemented technique. Cementless/hybrid fixation had a higher cost (US$ 495.27) than the cemented one (p < 0.001). Nevertheless, hospital stay length was 0.87 days longer for cemented fixation than the cementless/hybrid one. We found no significant difference in death rates between THA fixation methods. THA cementless/hybrid fixation is prevalent in the municipality of São Paulo, which had higher total costs and shorter hospitalizations than cemented fixation. We found no difference between THA fixation methods and death rates. Level of Evidence IV, Case Series.

679. Infective Endocarditis and Septic Emboli-Related Complications; Epidemiology and Impacts on Hospital Outcomes

BackgroundInfectious endocarditis (IE) remains a disease of high mortality, complications and a severe burden to the healthcare system despite advances in diagnostic techniques and treatments. There are several investigations of IE using a nation-based population cohort, however, with limited focus on septic emboli-related complications.Figure 1. Flowchart of the study cohort. IE=Infective Endocarditis MethodsWe used the 2016 to 2018 National Readmission Database (NRD) to identify a primary diagnosis of admissions among adults (Age≥18) with IE. International Statistical Classification (ICD-10) codes were used to identify patients with a primary diagnosis of IE who experienced in-hospital septic emboli-related complications. Primary outcomes were mortality, length of stay, total cost and 30-day all-cause readmission. Uni- and Multivariate Linear, Logistic and Cox regression were used to assess statistical significance and a two-sided p-value less than 0.05 was considered significant. ResultsA total of 30,870 patients were admitted with a primary diagnosis of IE from 2016 to 2018 (December admissions were omitted). After excluding the patients with omitted information, 30,289 patients went into analysis. Baseline characteristics are shown in Table 1. Septic emboli-related complications were seen in 42.6% of the patients; about 10% had central nervous system (CNS) complications, 7% had cardiac complications and 20.2% had respiratory complications. Embolic complications of any kind were associated with higher mortality (Odds Ratio = 2.11 [1.74 – 2.54]), a longer length of stay (5.72 days [5.17 – 6.27]) and higher total costs (21,812 dollars [19,856 – 23,769]) while adjusted for baseline characteristics. Multivariate Cox regression to assess the risk of 30-day readmission was not statistically significant. Predictors of 30-day all-cause readmission among baseline characteristics and subgroups of embolic complications are shown in table 4 and table 5, respectively. ConclusionThe prevalence of septic emboli-related complications was up to 42.6% of patients admitted with the primary diagnosis of IE. These complications significantly impact hospital outcomes; including mortality, length of stay and total cost. Further studies are required to clarify the relationship between 30-day all-cause readmissions and embolic complications.Disclosures All Authors: No reported disclosures

Stability of blood eosinophils in acute exacerbation of chronic obstructive pulmonary disease and its relationship to clinical outcomes: a prospective cohort study

BackgroundThe clinical value of blood eosinophils and their stability in chronic obstructive pulmonary disease (COPD) remains controversial. There are limited studies on association between the stability of blood eosinophils in acute exacerbation of COPD (AECOPD) and clinical outcomes. This study aimed to evaluate the stability of blood eosinophils in hospitalized AECOPD and its relationship to clinical outcomes.MethodsThis prospective observational study recruited patients hospitalized with AECOPD from November 2016 to July 2020. The eligible patients were divided into four groups according to their blood eosinophil counts at admission and discharge: persistently < 300 cells/μl (LL), < 300 cells/μl at admission but ≥ 300 cells/µl at discharge (LH), ≥ 300 cells/μl at admission but < 300 cells/µl at discharge (HL), and persistently ≥ 300 cells/μl (HH). Cox hazard analyses were used to study the association between eosinophil changes and exacerbations or mortality.ResultsIn 530 patients included, 90 (17.0%) had a high blood eosinophil count (BEC) ≥ 300 cells/µl at admission but 32 (35.6%) of them showed a decreased BEC at discharge. The proportions and distribution for group LL, LH, HL, and HH were 381 (71.9%), 59 (11.1%), 32 (6.0%), and 58 (10.9%), respectively. During hospitalization, the LH group had a higher C-reactive protein level, higher rate of intensive care unit (ICU) admission, and higher total cost. The length of hospital stay of the LH group was longer compared with group LL, HL, or HH (P = 0.002, 0.017, and 0.001, respectively). During a follow-up of 12 months, the HH group was associated with a higher risk of moderate-to-severe exacerbations compared to the LL group (hazard ratio 2.00, 95% confidence interval 1.30–3.08, P = 0.002). Eosinophil changes had no significant association with mortality at 12 months. Sensitivity analyses in patients without asthma and without use of systemic corticosteroids prior to admission did not alter the results.ConclusionsMore attention should be paid to the LH group when evaluating the short-term prognosis of AECOPD. A persistently high BEC was a risk factor for long-term exacerbations. Eosinophil changes during hospitalization could help to predict outcomes.

The economic burden of NIPC and BOS following allogeneic HSCT in patients with commercial insurance in the United States

AbstractNoninfectious pulmonary complications (NIPC) after allogeneic hematopoietic stem cell transplantation (alloHSCT), including bronchiolitis obliterans syndrome (BOS), cause significant morbidity and mortality, but their impact on health care resource utilization (HRU) and costs is unknown. This longitudinal retrospective study quantified the economic burden of NIPC and BOS in alloHSCT patients using commercial claims data from the IQVIA PharMetrics Plus database. Study patients were aged 0 to 64 years and underwent alloHSCT between 1 January 2006 and 30 September 2018, and were observable 12 months before and up to 5 years after index alloHSCT. NIPC patients were identified using International Classification of Disease (ICD) diagnosis codes. Outcomes were mean per patient HRU (inpatient admissions, outpatient office, hospital visits, and prescription medications) and costs paid by insurers in each post-transplant year. Among 2162 alloHSCT patients, 254 developed NIPCs, and 155 were propensity score (PS)-matched to non-NIPC patients. The year following transplantation, NIPC patients had significantly higher inpatient admission rates (3.8 ± 3.2 vs non-NIPC: 2.6 ± 2.4; P < .001) and higher total costs ($567 870 vs $412 400; P = .07), reflecting higher costs for inpatient admissions ($452 475 vs $300 202; P = .06). Among those observable for more years, costs remained higher for NIPC patients, reflecting significantly higher inpatient admission rates in the first 3 years following transplant. Subanalysis of patients with diagnoses likely reflective of BOS were consistent with these findings. AlloHSCT patients who developed NIPC had higher health care resource utilization and incurred higher costs compared with alloHSCT patients who did not develop NIPC following transplant.

Abstract 12911: Outcomes of Transcatheter Aortic Valve Replacement at Teaching versus Non Teaching Hospitals in the United States

Introduction: Transcatheter aortic valve replacement (TAVR) has become widely available across the United States; however, national trends have not been evaluated by hospital teaching status. Hypothesis: There will be no differences in outcomes between teaching hospitals (TH) versus non teaching hospitals. Methods: This was an observational study of patients undergoing TAVR from 2012-2017, utilizing the Nationwide Readmissions Database with appropriate trend weights to generate national estimates. Codes from the International Classification of Diseases were used to identify patients with a primary procedure code for TAVR. TAVRs were stratified by hospital teaching status, while in-hospital mortality, complications, costs, and 30- and 90-day readmissions were compared between the groups. Results: During the study’s timeframe, 123,557 patients underwent TAVR, of which 90% occurred at a TH. The number of TAVRs increased by 744% from 2012 to 2017 (Cochrane-Armitage test, p&lt;0.001), with a larger increase for non-TH. Median age [IQR] was 82.0 [76.0-87.0] and 46.2% were women. Patients undergoing TAVR at a teaching hospital were more likely to have diabetes, dyslipidemia, hypertension, coronary artery disease, congestive heart failure, peripheral vascular disease, and cerebrovascular disease. In-hospital mortality was higher for patients undergoing TAVR at a TH (2.6% vs. 2.2%, p&lt;0.001). After TAVR, there was more stroke (1.5% vs. 0.9%), acute kidney injury (14.6% vs. 11.3%), and myocardial infarction (4.2% vs. 2.8%) in the TH group. TAVR at a TH was associated with higher total cost of care during their index admission (47.9 [37.5-61.9] vs. 44.3 [34.7-58.7] x $1000) and longer length of hospital stay (4.0 [2.0-7.0] vs. 3.0 [2.0-6.0] days). Moreover, patients undergoing TAVR at a TH were more likely to have been discharged to an intermediate care facility or home health care (50.0% vs. 40.9%). 30-day readmissions were higher for the TH group (18.7% vs. 18.0%), while 90-day readmissions were similar across each group (28.4% for the entire cohort). Conclusions: While patients undergoing TAVR at a teaching hospital had more comorbidities, they also had higher in-hospital mortality, more postoperative complications, and greater healthcare costs.

Impact of Atrial Fibrillation on Cardiovascular and Economic Outcomes in Patients with Chronic Lymphocytic Leukemia

Introduction: Chronic lymphocytic leukemia (CLL) is the most frequently diagnosed hematologic cancer, with many patients diagnosed at a later stage in life and typically with comorbidities that often complicate CLL management. Atrial fibrillation (AF) is the most common arrhythmia in the United States and is associated with high hospitalization and mortality rates. While the relationship between CLL and AF has been reported, there is limited real-world evidence on the clinical and economic impact of AF in CLL patients. The objectives of this study were to examine the impact of AF on cardiovascular (stroke, bleeding events, heart failure) and economic (costs and healthcare resource utilization [HRU]) outcomes among patients with CLL.Methods: This retrospective observational study used the IBM MarketScan Research Databases in Treatment Pathways that includes at least a 10-million sample of the commercial and Medicare supplemental claims database. Patients who were at least 18 years, diagnosed with CLL (identified by ICD-9/ICD-10) and continuously enrolled from January 2009 to July 2020 were included. CLL patients were followed up for one year after their first CLL diagnosis date to examine the incidence of AF. Cardiovascular outcomes were evaluated as the incidence of stroke, bleeding events, and heart failure among the CLL patients with and without AF. Costs and HRU were assessed following up until 1 year after the first date of AF, stroke, bleeding events, and heart failure. HRU was evaluated for outpatient, emergency room (ER), inpatient, and pharmacy visits, and by length of stay (LOS) for hospitalizations. Costs were evaluated in overall population and by HRU type. Statistical differences in clinical outcomes between patients with and without AF were compared using chi-square tests. The Mann Whitney Wilcoxon test was used to compare the medians for the HRU and cost outcomes. The associations between AF and hospitalizations as well as costs were evaluated by multivariable logistic regression and generalized linear model, respectively. Statistical significance was determined at a P-value of less than 0.05.Results: Among the total of 23,756 newly diagnosed CLL patients (median age 68 years, 57.83% male) included in the study, 11% had AF within 1 year of the CLL diagnosis. CLL patients who had AF were significantly older (median age: 67 vs 82 years) and had more male patients (56.9% vs 65.1%) compared to CLL patients without AF. Significantly higher rates of stroke (12.67% vs. 4.97%), bleeding events (17.45% vs. 8.53%), and heart failure (31.14% vs. 4.70%) were observed in CLL patients with AF than those without (Figure 1). Compared to the CLL cohort without AF, adjusted regression analysis indicated that overall, CLL cohort with AF was twice as likely to be hospitalized (odds ratio [OR]=2.03) and incurred 44% higher total costs (cost ratio [CR]=1.44). Further examining the impact of AF-related cardiovascular outcomes, we observed that CLL patients with AF who developed stroke, bleeding events, and heart failure had statistically significant higher HRU (outpatient, ER, inpatient, and pharmacy visits), longer LOS, and costs (total, outpatient, pharmacy) than CLL patients without AF. After adjusting for demographic and clinical confounders, significantly higher hospitalization rates and costs were also reported in the CLL cohort who had AF with further stroke (OR=2.59; CR=1.36), bleeding events (OR=3.27; CR=2.03), and heart failure (OR=5.47; CR=2.07) compared to the CLL cohort without AF.Conclusions: The findings of this real-world study demonstrated significantly higher hospitalizations, cardiovascular events, and economic burden incurred by CLL patients who had AF than those without. The presence of stroke, bleeding events, heart failure among CLL patients with AF further increased the HRU and costs. This study highlighted the importance of better disease management, more intentional monitoring for AF and improved CLL therapeutics with a lower risk of AF or cardiovascular toxicity to prevent or minimize the incidence of AF in CLL patients. [Display omitted] DisclosuresMohan: BeiGene, Ltd.: Current Employment. Yang: BeiGene, Ltd.: Current Employment. Liu: BeiGene, Ltd.: Current Employment. Dick: IBM Watson Health: Current Employment. Tang: BeiGene, Ltd.: Current Employment. Chanan-Khan: Ascentage: Research Funding; Alpha2 Pharmaceuticals, NonoDev, Starton: Current holder of stock options in a privately-held company; Cellectar: Current equity holder in publicly-traded company; Alpha2 Pharmaceuticals: Patents & Royalties: Tabi; Ascentage, Starton, Cellectar, NonoDev, Alpha2 Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees; BeiGene, Jansen, Ascentage: Honoraria; BieGene, Jansen, Ascentage: Consultancy.

Economic Evaluation of Umeclidinium/Vilanterol versus Umeclidinium or Salmeterol in Symptomatic Non-Exacerbating Patients with COPD from a UK Perspective Using the GALAXY Model.

IntroductionDual bronchodilators are recommended as maintenance treatment for patients with symptomatic COPD in the UK; further evidence is needed to evaluate cost-effectiveness versus monotherapy. Cost-effectiveness of umeclidinium/vilanterol versus umeclidinium and salmeterol from a UK healthcare perspective in patients without exacerbations in the previous year was assessed using post hoc EMAX trial data.MethodsThe validated GALAXY model was populated with baseline characteristics and treatment effects from the non-exacerbating subgroup of the symptomatic EMAX population (COPD assessment test score ≥10) and 2020 UK healthcare and drug costs. Outputs included estimated exacerbation rates, costs, life-years (LYs), and quality-adjusted LYs (QALYs); incremental cost-effectiveness ratio (ICER) was calculated as incremental cost/QALY gained. The base case (probabilistic model) used a 10-year time horizon, assumed no treatment discontinuation, and discounted future costs and QALYs by 3.5% annually. Sensitivity and scenario analyses assessed robustness of model results.ResultsUmeclidinium/vilanterol treatment was dominant versus umeclidinium and salmeterol, providing an additional 0.090 LYs (95% range: 0.035, 0.158) and 0.055 QALYs (−0.059, 0.168) with total cost savings of £690 (£231, £1306) versus umeclidinium, and 0.174 LYs (0.076, 0.286) and 0.204 QALYs (0.079, 0.326) with savings of £1336 (£1006, £2032) versus salmeterol. In scenario and sensitivity analyses, umeclidinium/vilanterol was dominant versus umeclidinium except over a 5-year time horizon (more QALYs at higher total cost; ICER=£4/QALY gained) and at the lowest estimate of the St George’s Respiratory Questionnaire treatment effect (fewer QALYs at lower total cost; ICER=£12,284/QALY gained); umeclidinium/vilanterol was consistently dominant versus salmeterol. At willingness-to-pay threshold of £20,000/QALY, probability that umeclidinium/vilanterol was cost-effective in this non-exacerbating subgroup was 95% versus umeclidinium and 100% versus salmeterol.ConclusionBased on model predictions from a UK perspective, symptomatic patients with COPD and no exacerbations in the prior year receiving umeclidinium/vilanterol are expected to have better outcomes at lower costs versus umeclidinium and salmeterol.

Optimization of Inventory Level Using Fuzzy Probabilistic Exponential Two Parameters Model

Inventory control is an important factor in trading activities. Inventory control aims to ensure product availability. Several factors affect the level of inventory including the level of demand factor, maximum inventory, and the level of deterioration. If the influencing factors cannot be defined with certainty and follow a certain statistic distribution then the fuzzy probabilistic approach can be applied. This research discusses the problem of optimizing the inventory of red chillies at the retail level. The level of deterioration is assumed to follow an exponential distribution and demand follows a Pareto distribution. Statistical parameters are estimated using the Maximum likelihood method and cost parameters are expressed by triangular fuzzy numbers. Based on the calculation results for several beta values, the highest total cost is 405143.6 rupiah, a maximum inventory level of 15 kg, and an order cycle time of 0.923 days.

Inpatient mortality and healthcare resource utilization of nontraumatic intracerebral hemorrhage complications in the US.

Nontraumatic, primary intracerebral hemorrhage (ICH) accounts for 2 million strokes worldwide annually and has a 1-year survival rate of 50%. Recent studies examining functional outcomes from ICH evacuation have been performed, but limited work has been done quantifying the incidence of subsequent complications and their healthcare economic impact. The purpose of this study was to quantify the incidence and healthcare resource utilization (HCRU) for major complications that can arise from ICH. The IBM MarketScan Research databases were used to retrospectively identify patients with ICH from 2010 to 2015. Complications examined included cerebral edema, hydrocephalus, venous thromboembolic events (VTEs), pneumonia, urinary tract infections (UTIs), and seizures. For each complication, inpatient mortality and HCRU were assessed. Of 25,322 adult patients included, 10,619 (42%) developed complications during the initial admission of ICH: 22% had cerebral edema, 11% hydrocephalus, 10% pneumonia, 6% UTIs, 5% seizures, and 5% VTEs. The inpatient mortality rates at 7 and 30 days for each complication of ICH ranked from highest to lowest were hydrocephalus (24% and 32%), cerebral edema (15% and 20%), pneumonia (8% and 18%), seizure (7% and 13%), VTE (4% and 11%), and UTI (4% and 8%). Hydrocephalus had the highest total cost (median $92,776, IQR $39,308-$180,716) at 7 days post-ICH diagnosis and the highest cumulative total cost (median $170,839, IQR $91,462-$330,673) at 1 year post-ICH diagnosis. This study characterizes one of the largest cohorts of patients with nontraumatic ICH in the US. More than 42% of the patients with ICH developed complications during initial admission, which resulted in high inpatient mortality and considerable HCRU.

Trends in end-of- life (EOL) systemic oncologic treatment in contemporary clinical practice: Insights from real-world data.

253 Background: Among patients with cancer, receipt of systemic oncolytic therapy near the end-of-life (EOL) does not improve outcomes and worsens patient and caregiver experience. Accordingly, the ASCO/NQF measure, Proportion Receiving Chemotherapy in the Last 14 Days of Life, was published in 2012. Over the last decade there has been exponential growth in high cost targeted and immune therapies which may be perceived as less toxic than traditional chemotherapy. In this study, we identified rates and types of EOL systemic therapy in today’s real-world practice; these can serve as benchmarks for cancer care organizations to drive improvement efforts. Methods: Using data from the nationwide Flatiron Health electronic health record (EHR)-derived de-identified database we included patients who died during 2015 through 2019, were diagnosed after 2011, and who had documented cancer treatment. We identified the use of aggressive EOL systemic treatment (including, chemotherapy, immunotherapy, and combinations thereof) at both 30 days and 14 days prior to death. We estimated standardized EOL rates using mixed-level logistic regression models adjusting for patient and practice-level factors. Year-specific adjusted rates were estimated in annualized stratified analysis. Results: We included 57,127 patients, 38% of whom had documentation of having received any type of systemic cancer treatment within 30 days of death (SD: 5%; range: 25% - 56%), and 17% within 14 days of death (SD: 3%; range: 10% - 30%). Chemotherapy alone was the most common EOL treatment received (18% at 30 days, 8% at 14 days), followed by immunotherapy (± other treatment) (11% at 30 days, 4% at 14 days). Overall rates of EOL treatment did not change over the study period: treatment within 30 days (39% in 2015 to 37% in 2019) and within 14 days (17% in 2015 to 17% in 2019) of death. However, the rates of chemotherapy alone within 30 days of death decreased from 24% to 14%, and within 14 days, from 10% to 6% during the study period. In comparison, rates for immunotherapy with chemotherapy (0%-6% for 30 days, 0% -2% for 14 days), and immunotherapy alone or with other treatment types (4%-13% for 30 days, 1%-4% for 14 days) increased over time for both 30 and 14 days. Conclusions: End of life systemic cancer treatment rates have not substantively changed over time despite national efforts and expert guidance. While rates of traditional chemotherapy have decreased, rates of costly immunotherapy and targeted therapy have increased, which has been associated with higher total cost of care and overall healthcare utilization. Future work should examine the drivers of end-of-life care in the era of immune-oncology.

Green Inventory Routing Problem using Hybrid Genetic Algorithm

Carbon dioxide (CO2) is known as one of the largest sources of global warming. One of the ways to curb CO2 emissions is by considering the environmental aspect in the supply chain management. This paper analyses the influence of carbon emissions on the Inventory Routing Problem (IRP). The IRP network consists of a depot, an assembly plant and multiple suppliers. The deterministic demands vary and are determined by the assembly plant. Fixed transportation cost, fuel consumption cost and inventory holding cost are used to evaluate the system’s total cost in which fuel consumption cost is determined by fuel consumption rate, distance, and fuel price. Backordering and split pick-up are not allowed. The main purpose of this study is to analyze the distribution network especially the overall costs of the supply chain by considering the CO2 emissions as well. The problem is known as Green Inventory Routing Problem (GIRP). The mixed-integer linear programming of this problem is adopted from Cheng et al. wherein this study a different Hybrid Genetic Algorithm is proposed at mutation operator. As predicted, GIRP has a higher total cost as it considered fuel consumption cost together with the transportation and inventory costs. The results showed the algorithm led to different sequences of routings considering the carbon dioxide emission in the objective function.

Comparison of two regional citrate anticoagulation modalities for continuous renal replacement therapy by a prospective analysis of safety, workload, effectiveness, and cost.

Currently, regional citrate anticoagulation (RCA) is the preferred approach for continuous renal replacement therapy (CRRT), and several RCA protocols are commercially available. This study was aimed at comparing two RCA modalities for CRRT in terms of safety, workload, effectiveness, and costs. We prospectively evaluated two different RCA approaches in patients admitted to our intensive care unit (ICU) who needed CRRT. Patients with acute liver failure were excluded. We compared a hypertonic sodium-citrate solution 136 mmol/L added before the filter as anticoagulant during bicarbonate continuous hemodialysis (RCA-CVVHD) versus citrate-buffered replacement fluid 13.3 mmol/L infused by predilution setting in continuous venovenous hemofiltration (RCA-CVVH). Alkalosis, calcium homeostasis, nursing workload, filter lifespan, urea-creatinine metabolic control, and costs were recorded. Forty-five and 31 patients who underwent RCA-CVVH and RCA-CVVHD, respectively, were included. Alkalosis-free time distributions were significantly different in favor of a higher alkalosis incidence in the RCA-CVVHD group (log-rank test χ2(1)=8.18, P=0.004). Multivariable analysis showed that RCA-CVVHD was associated with a longer filter lifespan (HR=0.47; 95% CI: 0.28-0.78), higher total cost (1362 CHF [782-1901] vs. 976 CHF [671-1353], P<0.001), and higher number of anticoagulation adjustments (9 [IQR, 4-14] vs. 2 [IQR, 1-4]). The mean urea and creatinine reduction ratios at the first 24 hours were significantly higher in the RCA-CVVHD group. Calcium homeostasis and filter downtime were similar in the two groups. Pre-filter hypertonic sodium-citrate solution (136 mmol/L) results in longer filter patency and improves depuration effectiveness. However, compared to RCA-CVVHF, it causes metabolic alkalosis and increases nursing interventions and cost.

A Retrospective Study of Clinical and Economic Burden of Focal Segmental Glomerulosclerosis (FSGS) in the United States

IntroductionInformation on the economic burden of focal segmental glomerulosclerosis (FSGS) is sparse. This study characterized health care resource utilization (HCRU) and costs in patients with FSGS, and evaluated the impact of nephrotic range proteinuria on these outcomes.MethodsThis retrospective, observational cohort study used administrative claims data from the Optum Clinformatics Data Mart Database from October 2015 to December 2019. Patients with FSGS (n = 844; first claim = index event) between April 2016 and December 2018 were matched on index date, age, sex, and race to non-FSGS controls (n = 1688). FSGS nephrotic range (urine protein/creatinine ratio >3000 mg/g or albumin/creatinine ratio >2000 mg/g) and non-nephrotic subpopulations were identified. Baseline comorbidities, 12-month post-index all-cause HCRU and costs (per patient per year [PPPY]), and immunosuppressant prescriptions were compared between matched cohorts and between FSGS subpopulations.ResultsComorbidity burden was higher in FSGS. Of 308 patients with available urine protein/creatinine ratio/albumin/creatinine ratio results, 36.4% were in nephrotic range. All-cause HCRU was higher in FSGS across resource categories (all P < 0.0001); 50.6% of FSGS and 23.3% of controls were prescribed glucocorticoids (P < 0.0001). Mean total medical costs were higher in FSGS ($59,753 vs. $8431 PPPY; P < 0.0001), driven by outpatient costs. Nephrotic range proteinuria was associated with higher all-cause inpatient, outpatient, and prescription costs versus nonnephrotic patients (all P < 0.0001), resulting in higher total costs ($70,481 vs. $36,099 PPPY; P < 0.0001).ConclusionsFSGS is associated with significant clinical and economic burdens; the presence of nephrotic range proteinuria increased the economic burden. New treatment modalities are needed to reduce proteinuria, help improve patient outcomes, and reduce HCRU and associated costs.

Robotic total gastrectomy for carcinoma in the remnant stomach: a comparison with laparoscopic total gastrectomy.

BackgroundTotal gastrectomy for carcinoma in the remnant stomach (CRS) remains a technically demanding procedure. Whether robotic surgery is superior, equal, or inferior to laparoscopic surgery in patients with CRS is unclear. This study was designed to compare the efficacy and safety of robotic total gastrectomy (RTG) and laparoscopic total gastrectomy (LTG) for the treatment of CRS.MethodsIn this cohort study, we retrospectively analysed the data from patients who underwent RTG or LTG for CRS at Southwest Hospital (Chongqing, China) between May 2006 and October 2019. The surgical outcomes, post-operative complications, and survival outcomes between the two groups were compared.ResultsCompared with LTG, RTG was associated with similar effective operation time (272.0 vs 297.9 min, P = 0.170), higher total costs (105,967.2 vs 81,629.5 RMB, P < 0.001), and less estimated blood loss (229.2 vs 288.8 mL, P = 0.031). No significant differences were found between the robotic and laparoscopic groups in terms of conversion rate, time to first flatus, time to first soft diet, post-operative hospital stay, post-operative complications, R0 resection rate, and number of retrieved lymph nodes (all P > 0.05). The 3-year disease-free survival and 3-year overall survival rates were comparable between the two groups (65.5% vs 57.5%, P = 0.918; 69.0% vs 60.0%, P = 0.850, respectively).ConclusionsRTG is a safe and feasible procedure for the treatment of CRS and could serve as an optimal treatment for CRS.

Cost analysis of utilising wound edge protector in open appendicectomy to prevent surgical site infection

BackgroundThe rate of surgical site infection (SSI) differ with variable nature with appendicitis with a global incidence of up to 11%. Several randomised trials describe a significant reduction in incisional SSI using wound edge protectors (WEP), mainly in elective procedures. This study was designed to analyse WEP use in emergency open appendicectomy. MethodThis randomised controlled trial enrolled 200 patients who underwent emergency open appendicectomy. Permuted block randomisation was used to assign subjects to either mechanical retraction or double ring WEP. The primary endpoints were SSI rates and cost analysis between the methods. ResultsThe incidence of SSI was similar, n = 7 (7.4%) in the control group and n = 8 (8.4%) in the WEP group, and demonstrates no statistically significant difference (p > 0.05). Cost analysis showed a statistically significant (p < 0.001) higher total cost in the WEP group, MYR 456.00 (414.75, 520.00) as compared to the control group, MYR 296.00 (296.00, 300.00). However, the median cost of managing patients complicated with SSI was significantly lower at MYR 750.50 (558.75, 946.50) in the WEP group when compared to the control group MYR 1453.00 (1119.00, 2592.00) (p = 0.008). ConclusionThe use of WEP does not reduce the incisional SSI rate, and it is not cost-effective for application in all open appendicectomies. However, when faced with incisional SSI, the use of WEP had a significantly lower cost in incisional SSI management. Selective WEP use is economical in clinically suspected perforated appendicitis when laparoscopic appendicectomy approach is unsuitable.

Association of preoperative frailty with postoperative delirium after elective brain tumor resection: Retrospective analysis of a prospective cohort

BackgroundPreoperative frailty is associated with poor outcomes in major surgery. Postoperative delirium is common after neurosurgery. To date, the association of preoperative frailty with postoperative delirium after neurosurgery has not been established. We aimed to determine the association between preoperative frailty and postoperative delirium in patients undergoing elective brain tumor resection. MethodsWe retrospectively analyzed the data of a prospective cohort, consecutively enrolling adult patients admitted to the intensive care unit after elective craniotomy for brain tumor resection under general anesthesia in a tertiary hospital in China from March 1, 2017 to February 2, 2018. Preoperative frailty was evaluated using the modified frailty index. The primary outcome was postoperative delirium, assessed using the Confusion Assessment Method for the Intensive Care Unit. Univariate and multivariable regression analyses were performed to examine the association. Results659 patients met inclusion criteria for our analysis. There were 398 (60.4%) non-frail (modified frailty index = 0), 237 (36.0%) pre-frail (modified frailty index = 1–2), and 24 (3.6%) frail (modified frailty index ≥ 3) patients. Of these, 124 (18.8%) developed postoperative delirium. In adjusted analyses, frailty was independently associated with postoperative delirium (odds ratio 1.7, 95% confidence interval 1.0–2.7, P = .032). Frail patients had longer length of hospital stay and higher total costs than non-frail patients. ConclusionPreoperative frailty is associated with postoperative delirium, length of hospital stay, and total costs in patients undergoing elective brain tumor resection. Preoperative frailty assessment and appropriate management strategies should be involved in the perioperative management of postoperative delirium.

Racial Disparities in Treatment Patterns and Outcomes Among Patients with Multiple Myeloma: A SEER-Medicare Analysis

Introduction: Recent advances in novel therapies and autologous stem cell transplants (ASCT) have increased treatment options for multiple myeloma (MM) and improved overall survival (OS). Previous studies suggest that racial disparities may exist in patient access to these treatments. The present study aimed to assess racial disparities in treatment patterns and clinical and economic outcomes among patients with MM. The study focused on the comparison between Caucasians (CAU) vs African Americans (AA) and Hispanics (HISP). Other racial/ethnic groups were not included due to small sample size. Methods: Patients with a confirmed MM diagnosis (dx) from the SEER-Medicare (2007-2013) database were included. Continuous enrollment for six months before (baseline) and at least six months after the initial MM dx date was required, unless the patient died prior to that. Treatment patterns (including time from initial MM dx to first-line (1L) therapy initiation, novel therapy [i.e., lenalidomide, pomalidomide, bortezomib, carfilzomib] initiation, and ASCT), time to first hospitalization or emergency department (ED) admission after MM dx, and healthcare costs (up to one year after MM dx), OS, and MM-specific survival (MSS) among the three racial/ethnic cohorts were evaluated. Unadjusted statistical comparisons were conducted for AA vs CAU and HISP vs CAU. In addition, multivariable regression models were used to adjust for baseline characteristics, including age, gender, marital status, region, poverty indicator, MM dx year, select comorbidities, and baseline healthcare costs. Trends in novel treatment utilization and OS across MM dx years were assessed using linear regression models. Results: The study included 4,830 patients (3,504 CAU, 858 AA, and 468 HISP). CAU were significantly older (mean age 76 years) than AA (72) and HISP (73). The average follow-up time was 2.2 years. Median time from MM dx to 1L therapy initiation was significantly longer for AA compared to CAU (1.9 vs 1.5 months, p In terms of resource utilization, AA had a significantly higher risk of ED admission compared to CAU (3-month ED admission rate: 31.2% [AA], 23.8% [CAU]; adjusted HR = 1.2, p Conclusions: Significant variations in terms of treatment patterns and outcomes were observed among different racial/ethnic groups. While OS was similar across cohorts, both AA and HISP may not be reaping the full benefits from the introduction of novel therapies, as they receive them later than CAU. Use of novel therapy increased over time, but the increase was more pronounced in CAU than AA. Healthcare costs were similar between AA and CAU, while HISP had higher total costs than CAU, mainly driven by higher hospitalization costs. These disparities must be addressed for equitable healthcare utilization and universal benefit. Disclosures Ailawadhi: Takeda: Consultancy, Honoraria; Amgen: Consultancy, Honoraria; Pharmacyclics: Research Funding; Novartis: Consultancy, Honoraria. Parikh: Celgene Corporation: Employment. Zhou: Analysis Group, Inc.: Employment; Celgene Corporation: Other: I am an employee of Analysis Group, which received consulting fees from Celgene for this study. Tang: Analysis Group, Inc.: Employment; Celgene Corporation: Other: I am an employee of Analysis Group, which received consulting fees from Celgene for this study. Clancy: Celgene Corporation: Employment. Cheung: Analysis Group, Inc.: Employment; Celgene Corporation: Other: I am an employee of Analysis Group, which received consulting fees from Celgene for this study. Zhou: Analysis Group, Inc.: Employment; Celgene Corporation: Other: I am an employee of Analysis Group, which received consulting fees from Celgene for this study. Xie: Analysis Group, Inc.: Employment; Celgene Corporation: Other: I am an employee of Analysis Group, which received consulting fees from Celgene for this study. Abouzaid: Celgene Corporation: Employment, Equity Ownership, Research Funding.

Healthcare Cost Impact of Continued Anticoagulation Therapy with Rivaroxaban Versus Aspirin for Prevention of Recurrent Symptomatic Venous Thromboembolism in the Einstein Choice Trial Population

Healthcare Cost Impact of Continued Anticoagulation Therapy with Rivaroxaban Versus Aspirin for Prevention of Recurrent Symptomatic Venous Thromboembolism in the Einstein Choice Trial Population

Time-efficiency and hospital costs of open compared with laparoscopic groin hernia repair in a teaching hospital.

Time efficiency and hospital costs may influence the preferred method of groin hernia repair. Despite growing expertise in laparoscopic hernia repair, knowledge on the actual costs and the potential financial advantages over open hernia repair are limited. A single-center retrospective cohort study comparing hospital costs and time-efficiency of open-mesh (Lichtenstein) and laparoscopic groin hernia repair between 2010 and 2015, including a comparison of surgeons and residents, was conducted. Secondary outcomes were length of hospital stay, complication and recurrence rates. Nine hundred forty-seven open and 449 laparoscopic groin hernia repairs were included. Unilateral open repair showed a shorter operation theatre occupancy (63.5 min±17.2 vs. 71.9 min±19.9, P<0.001) and lower total costs (€ 974.51±266.67 vs. € 1165.32±285.94, P<0.001) compared with laparoscopic repair. Residents had longer operative times compared with surgeons in the unilateral open procedure (43.8±13.4 min vs. 34.5±16.3 min, P<0.001), in the unilateral laparoscopic procedure (46.9±16.6 min vs. 41.7±18.7 min, P<0.001) and higher total costs in the unilateral open procedure (€ 1007.47±238.58 vs. € 909.35±305.00, P<0.001). There were no significant differences in complication and recurrence rates between residents and surgeons. Open-mesh hernia repair appears to be superior in costs for both uni- and bilateral groin hernias when performed by surgeons as well as residents. Residents had higher total costs and longer operation times in the unilateral open groin hernia group when compared with surgeons, yet overall complications and recurrence rates were similar in all groups suggesting that residents are sometimes more expensive and slower, but just as safe.

Patient-incurred costs in a differentiated service delivery club intervention compared to standard clinical care in Northwest Tanzania.

IntroductionPlacing all clients with a positive diagnosis for HIV on antiretroviral therapy (ART) has cost implications both for patients and health systems, which could, in turn, affect feasibility, sustainability and uptake of new services. Patient‐incurred costs are recognized barriers to healthcare access. Differentiated service delivery (DSD) models in general and community‐based care in particular, could reduce these costs. We aimed to assess patient‐incurred costs of a community‐based DSD intervention (clubs) compared to clinic‐based care in the Shinyanga region, Tanzania.MethodsCross‐sectional survey among stable ART patients (n = 390, clinic‐based; n = 251, club‐based). For each group, we collected socio‐demographic, income and expenditure data between May and August 2019. We estimated direct and indirect patient‐incurred costs. Direct costs included out‐of‐pocket expenditures. Indirect costs included income loss due to time spent during transport, accessing services and off work during illness. Cost drivers were assessed in multivariate regression models.ResultsOverall, costs were significantly higher among clinic participants. Costs (USD) per year for clinic versus club were as follows: 11.7 versus 4.17 (p < 0.001) for direct costs, 20.9 versus 8.23 (p < 0.001) for indirect costs and 32.2 versus 12.4 (p < 0.001) for total costs. Time spent accessing care and time spent in illness (hours/year) were 38.3 versus 13.8 (p < 0.001) and 16.0 versus 6.69 (p < 0.001) respectively. The main cost drivers included transportation (clinic vs. club: 67.7% vs. 44.1%) for direct costs and income loss due to time spent accessing care (clinic vs. club: 60.4% vs. 56.7%) for indirect costs. Factors associated with higher total costs among patients attending clinic services were higher education level (coefficient [95% confidence interval]) 20.9 [5.47 to 36.3]) and formal employment (44.2 [20.0 to 68.5). Differences in mean total costs remained significantly higher with formal employment, rural residence, in addition to more frequent visits among clinic participants. The percentage of households classified as having had catastrophic expenditures in the last year was low but significantly higher among clinic participants (10.8% vs. 5.18%, p = 0.014).ConclusionsCosts incurred by patients accessing DSD in the community are significantly lower compared to those accessing standard clinic‐based care. DSD models could improve access, especially in resource‐limited settings.