Hospital Expenditures Research Articles

Racial disparities in hospitalization expenditures of older adults in Singapore

Caring for persons with dementia places a significant physical, emotional, and financial burden on caregivers. Although dementia caregivers may be exposed to more challenging caregiving environment than caregivers of those with other chronic conditions, little is known about how specific factors related to respite service use differ between dementia and nondementia caregivers. Thus, this study first examined factors related to respite service use among caregivers and further tested the moderating effect of dementia caregiver status in these relationships using nationally representative U.S. data. Logistic regression analyses were conducted among 1,203 caregivers (276 dementia and 927 nondementia caregivers) from the national Caregiving in the U.S. 2015 data. Caregivers’ race and ethnicity as a predisposing factor, caregivers’ self-rated health as an enabling factor, and care recipients’ living arrangement and functional limitations as need factors were significantly related to respite service use among caregivers. Moreover, dementia caregiver status moderated the association between enabling factors (i.e., household income, work status, and self-rated health) and respite service use. Our findings imply that dementia caregivers may be more in need of respite service use than nondementia caregivers when they have limited enabling factors (e.g., lower household income, nonworking status, poorer health). Policy and practice efforts that specifically support enabling factors are suggested to promote more respite service use among dementia caregivers.

Adherence to and persistence with antidiabetic medications and associations with clinical and economic outcomes in people with type 2 diabetes mellitus: A systematic literature review.

We designed a systematic literature review to identify available evidence on adherence to and persistence with antidiabetic medication in people with type 2 diabetes (T2D). Electronic screening and congress searches identified real‐world noninterventional studies (published between 2010 and October 2020) reporting estimates of adherence to and persistence with antidiabetic medication in adults with T2D, and associations with glycaemic control, microvascular and/or macrovascular complications, hospitalizations and healthcare costs. Ninety‐two relevant studies were identified, the majority of which were retrospective and reported US data. The proportions of patients considered adherent (median [range] 51.2% [9.4%‐84.3%]) or persistent (median [range] 47.7% [16.9%‐94.0%]) varied widely across studies. Multiple studies reported an association between greater adherence/persistence and greater reductions in glycated haemoglobin levels. Better adherence/persistence was associated with fewer microvascular and/or macrovascular outcomes, although there was little consistency across studies in terms of which outcomes were improved. More adherent and more persistent patients were typically less likely to be hospitalized or to have emergency department visits/admissions and spent fewer days in hospital annually than less adherent/persistent patients. Greater adherence and persistence were generally associated with lower hospitalization costs, higher pharmacy costs and lower or budget‐neutral total healthcare costs compared with lower adherence/persistence. In conclusion, better adherence and persistence in people with T2D is associated with lower rates of microvascular and/or macrovascular outcomes and inpatient hospitalization, and lower or budget‐neutral total healthcare expenditure. Education and treatment strategies to address suboptimal adherence and persistence are needed to improve clinical and economic outcomes.

How can the association between PRM and nutritional therapy protocol improve health outcomes and what is the impact on reducing expenditure in a public hospital?

Rationale: To minimise T2DM noncompliance, Patient Relationship Management (PRM) is the goal, enhancing decision making, as well as delegation and control of tasks. Many hospitals have already recognised the use of the best practice in PRM practices, which has enabled them to deal more effectively and efficiently with the entire healthcare process by responding directly to patients' needs and experiences throughout the assistance process. Our goals were find strategies that support the Win-Win model (patient, institution) to understand the importance of PRM with a nutritional protocol in adherence to therapy, and health gains.

Burns in India: a call for health policy action

Burns in India: a call for health policy action

Cost-Effectiveness of Combination of Baricitinib and Remdesivir in Hospitalized Patients with COVID-19 in the United States: A Modelling Study.

IntroductionBaricitinib–remdesivir (BARI-REM) combination is superior to remdesivir (REM) in reducing recovery time and accelerating clinical improvement among hospitalized patients with coronavirus disease 2019 (COVID-19), specifically those receiving high-flow oxygen/noninvasive ventilation. Here we assessed the cost-effectiveness of BARI-REM versus REM in hospitalized patients with COVID-19 in the USA.MethodsA three-state model was developed addressing costs and patient utility associated with COVID-19 hospitalization, immediate post hospital care, and subsequent lifetime medical care. Analysis was performed from the perspective of a payer and a hospital. Both perspectives evaluated two subgroups: all patients and patients who required oxygen. The primary measures of benefit in the model were patient quality-adjusted life years (QALYs) accrued during and after hospitalization, cost per life years gained, cost per death avoided, and cost per use of mechanical ventilation avoided.ResultsIn the base-case payer perspective with a lifetime horizon, treatment with BARI-REM versus REM resulted in an incremental total cost of $7962, a gain of 0.446 life years and gain of 0.3565 QALYs over REM. The incremental cost-effectiveness ratios of using BARI-REM were estimated as $22,334 per QALY and $17,858 per life year. The base-case and sensitivity analyses showed that the total incremental cost per QALY falls within the reduced willingness-to-pay threshold of $50,000/QALY applied under health emergencies. In all hospitalized patients, treatment with BARI-REM versus REM reduced total hospital expenditures per patient by $1778 and total reimbursement payments by $1526, resulting in a $252 reduction in net costs per patient; it also resulted in a net gain of 0.0018 QALYs and increased survival of COVID-19 hospitalizations by 2.7%.ConclusionOur study showed that BARI-REM is cost-effective compared to using REM for hospitalized patients with COVID-19. The base-case results of this cost-effectiveness model were most sensitive to average annual medical costs for recovered patients.Supplementary InformationThe online version contains supplementary material available at 10.1007/s12325-021-01982-6.

Projected private hospital expenditure in Ireland, 2018-2035: What role for demographics, cost, and Sláintecare?

Despite private hospitals occupying an important role in the delivery of acute hospital care in Ireland, an understanding of future spending pressures on these services is limited. Particularly, a key dimension of Ireland's ambitious roadmap for healthcare reform (Sláintecare) seeks to remove private practice from public hospitals. However, to date, there has been no examination of how this reform could impact private hospital demand and expenditure, and ultimately, the capacity to treat public patients. Using previously unavailable administrative health insurer data and a healthcare macro-simulation projection model, we project real (volume-based) and nominal expenditure on private hospital services over the medium-term (2018-2035). We develop a number of projection scenarios that vary assumptions in relation to population growth and ageing, healthy ageing, and the future cost of care delivery. Additionally, by developing profiles of private activity in public hospitals, we examine how the removal of private practice from public hospitals could impact on demand and expenditure in private hospitals over time. Findings from this analysis have implications for capital investment and workforce planning in private hospitals, and failure to meet future demand could have implications for access to care in public hospitals. Moreover, should private practice be ended in public hospitals, most complex private in-patient and emergency care is likely to remain within the public hospitals with limited capacity benefits for the public system.

Developing Standardized Peer Review Guidelines For Adverse Events

Introduction: Adverse events (AE) are common in medical practice and are associated with poor patient outcomes, including prolonged hospitalizations, increased readmission rates, and reduced quality of life, which lead to increased hospital expenditures. Peer review is a cornerstone to evaluating AEs in the hospital setting and contributes valuable information to root-cause analyses. When executed effectively, peer review programs help identify system-based failures contributing to adverse clinical outcomes which can then be used to prevent patient harm on an institutional scale. Many hospitals utilize standard forms when an AE review is required to establish standard of care. However, no evidence-based guidance exists describing what case data should be presented or what types of case assessments should be made to highlight system versus human factors that can inform root-cause analyses and systems safety solution development. The purpose of this study is to develop a consensus guideline for a standardized, health system-wide AE peer review tool as part of an AE analysis process. Methods: The consensus guidelines were developed using a two-step modified Delphi method. This method uses successive rounds of questionnaires to obtain consensus from an expert panel and is frequently used in healthcare settings to develop guidelines for defined clinical problems where little definitive evidence exists. Participants: Our expert panel included 30 Mount Sinai Health System faculty and staff. There were 6 nurse leaders, 4 participants from community hospitals, and 4 system leaders. All were required to have a background in AE peer review and a stake in the outcomes. Survey Construction: Our study incorporated two rounds of email surveys. The initial survey was developed through a systematic literature review for existing peer review structure and design. Results from our review were used in conjunction with Mount Sinai’s existing peer review forms to develop a list of 15 multiple-choice survey questions organized into three content domains: peer review process/procedure (n = 3), relevant case details/information (n = 6), and event evaluation criteria (n = 6). Survey Implementation: Surveys were disseminated via email. In round 1, panelists could provide written feedback to questions. Round 1 responses were collected and answer frequencies were calculated for each question. Question consensus was defined by answer choice agreement of ≥51%. Questions that were below this threshold were recirculated on round 2. In round 2, survey questions were presented alongside the panelist’s initial response and majority group response. Questions without round 2 consensus were excluded from the final consensus tool. Results: The group agreed to the inclusion of 16 items for a peer review. Reviewers overwhelmingly agreed that both system and individual factors should be assessed during the review process. Some of the system factors that received high levels of consensus included workplace culture (87% agreement), workflow process (90% agreement), resource management (93% agreement), and work environment (77% agreement). The individual and team factors that were commonly favored included communication (100% agreement), supervisory availability (93% agreement) and quality (87% agreement). There was also a strong consensus among reviewers that peer review should include a summary assessment of the standard of care (96.7% agreement). The experts concurred that assessments should evaluate for delays in diagnosis or intervention, lapses in documentation, and failure to perform necessary testing or treatment. Conclusion: Despite the recognized importance of peer-review, there are currently no evidence-based guidelines describing elements of a successful review process. This study provides a unique, consensus-derived peer review tool that incorporates input from multiple clinical and administrative stakeholders across the Mount Sinai Health System. When implemented, this tool will help standardize peer review, facilitate objective AE case assessments and root-cause analyses, and generate targeted solutions.

Hospitalization budget impact during the COVID-19 pandemic in Spain

ObjectivesThe aim was to determine the direct impact of the COVID-19 pandemic on Spain’s health budget.MethodsBudget impact analyses based on retrospective data from patients with suspected severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) admitted to a Spanish hospital between February 26 and May 21, 2020. Direct medical costs from the perspective of the hospital were calculated. We analyzed diagnostic tests, drugs, medical and nursing care, and isolation ward and ICU stays for three cohorts: patients seen in the emergency room only, hospitalized patients who tested positive for SARS-CoV-2, and patients who tested negative.ResultsThe impact on the hospital’s budget for the 3 months was calculated at €15,633,180, 97.4% of which was related to health care and hospitalization. ICU stays accounted for 5.3% of the total costs. The mean cost per patient was €10,744. The main costs were staffing costs (10,131 to 11,357 €/patient for physicians and 10,274 to 11,215 €/patient for nurses). Scenario analysis showed that the range of hospital expenditure was between €14,693,256 and €16,524,924. The median impact of the pandemic on the Spanish health budget in the sensitivity analysis using bootstrapped individual data was €9357 million (interquartile range [IQR], 9071 to 9689) for the conservative scenario (113,588 hospital admissions and 11,664 ICU admissions) and €10,385 million (IQR, 110,030 to 10,758) for the worst-case scenario (including suspected cases).ConclusionThe impact of COVID-19 on the Spanish public health budget (12.3% of total public health expenditure) is greater than multiple sclerosis, cancer and diabetes cost.

Temporal and spatial distribution of health, labor, and crop benefits of climate change mitigation in the United States

Societal benefits from climate change mitigation accrue via multiple pathways. We examine the US impacts of emission changes on several factors that are affected by both climate and air quality responses. Nationwide benefits through midcentury stem primarily from air quality improvements, which are realized rapidly, and include human health, labor productivity, and crop yield benefits. Benefits from reduced heat exposure become large around 2060, thereafter often dominating over those from improved air quality. Monetized benefits are in the tens of trillions of dollars for avoided deaths and tens of billions for labor productivity and crop yield increases and reduced hospital expenditures. Total monetized benefits this century are dominated by health and are much larger than in previous analyses due to improved understanding of the human health impacts of exposure to both heat and air pollution. Benefit-cost ratios are therefore much larger than in prior studies, especially those that neglected clean air benefits. Specifically, benefits from clean air exceed costs in the first decade, whereas benefits from climate alone exceed costs in the latter half of the century. Furthermore, monetized US benefits largely stem from US emissions reductions. Increased emphasis on the localized, near-term air quality-related impacts would better align policies with societal benefits and, by reducing the mismatch between perception of climate as a risk distant in space and time and the need for rapid action to mitigate long-term climate change, might help increase acceptance of mitigation policies.

Comparison of Clinical Characteristics and Outcomes Between Positive and Negative Blood Culture Septic Patients: A Retrospective Cohort Study.

BackgroundFew studies have studied the relationship between blood culture and mortality in sepsis patients. The aim of this study was to compare the characteristics and outcomes of positive and negative blood culture sepsis.MethodsWe performed a study on 640 patients suffering from sepsis in Beijing Chao-Yang Hospital from October 2017 to December 2019. The primary findings revolved around length and expenditure of hospital stay, the possibility of suffering from acute respiratory distress syndrome (ARDS), and any requirements for mechanical ventilation. The secondary findings revolved around whether the patient died early (28-day) or late (28-to-90-day).ResultsA total of 592 of the 640 patients met the inclusion criteria for sepsis, with 274 of them having culture-positive results. The culture-positive patients were mostly elderly suffering from diabetes and at risk of cancer, with a higher white blood cell count, and higher procalcitonin. Additionally, they scored higher in their acute physiology and chronic health evaluation II score (15 vs.11, P=0.010), as well as in their predisposition, infection, response, and organ dysfunction (17 vs 11, P<0.001) than the individuals in the culture-negative group. Culture-positive patients had a longer duration of hospital stay (14 vs 6, P<0.001) and higher in-hospital mortality (14.6% vs 8.5%, P=0.019) than culture-negative ones. No significant difference in intensive care unit (ICU) mortality (45.7% vs.36.4%, P=0.254) or early mortality (9.5% vs 7.2%, P=0.321) was noted between the two groups. However, the culture-positive patients had increased late mortality (15.7% vs.6.9%, P=0.001), when compared with those with culture-negative results in the cohort. Furthermore, the culture-positive patients who received the appropriate antibiotics early had a lower mortality rate than the culture-negative patients (7.3% vs.14.2%, P=0.008).ConclusionCulture-positive patients had higher in-hospital mortality, comparable early mortality, and worse late mortality than the culture-negative patients. Early appropriate use of antibiotics might reduce mortality and improve clinical prognosis.

Assessment of Costs and Care Quality Associated With Major Surgical Procedures After Implementation of Maryland’s Capitated Budget Model

In 2014, Maryland implemented the all-payer model, a distinct hospital funding policy that applied caps on annual hospital expenditures and mandated reductions in avoidable complications. Expansion of this model to other states is currently being considered; therefore, it is important to evaluate whether Maryland's all-payer model is achieving the desired goals among surgical patients, who are an at-risk population for most potentially preventable complications. To examine the association between the implementation of Maryland's all-payer model and the incidence of avoidable complications and resource use among adult surgical patients. This comparative effectiveness study used hospital discharge records from the Healthcare Cost and Utilization Project state inpatient databases to conduct a difference-in-differences analysis comparing the incidence of avoidable complications and the intensity of health resource use before and after implementation of the all-payer model in Maryland. The analytical sample included 2 983 411 adult patients who received coronary artery bypass grafting (CABG), carotid endarterectomy (CEA), spinal fusion, hip or knee arthroplasty, hysterectomy, or cesarean delivery between January 1, 2008, and December 31, 2016, at acute care hospitals in Maryland (intervention state) and New York, New Jersey, and Rhode Island (control states). Data analysis was conducted from July 2019 to July 2021. All-payer model. Complications (infectious, cardiovascular, respiratory, kidney, coagulation, and wound) and health resource use (ie, hospital charges). Of 2 983 411 total patients in the analytical sample, 525 262 patients were from Maryland and 2 458 149 were from control states. Across Maryland and the control states, there were statistically significant but not clinically relevant differences in the preintervention period with regard to patient age (mean [SD], 49.7 [19.0] years vs 48.9 [19.3] years, respectively; P < .001), sex (22.7% male vs 21.4% male; P < .001), and race (0.3% vs 0.4% American Indian, 2.8% vs 4.5% Asian or Pacific Islander, 25.9% vs 12.7% Black, 4.7% vs 11.9% Hispanic, and 63.5% vs 63.4% White; P < .001). After implementation of the all-payer model in Maryland, significantly lower rates of avoidable complications were found among patients who underwent CABG (-11.3%; 95% CI, -13.8% to -8.7%; P < .001), CEA (-1.6%; 95% CI, -2.9% to -0.3%; P = .02), hip arthroplasty (-0.8%; 95% CI, -1.0% to -0.5%; P < .001), knee arthroplasty (-0.4%; 95% CI, -0.7% to -0.1%; P = .01), and cesarean delivery (-1.0%; 95% CI, -1.3% to -0.7%; P < .001). In addition, there were significantly lower increases in index hospital costs in Maryland among patients who underwent CABG (-$6236; 95% CI, -$7320 to -$5151; P < .001), CEA (-$730; 95% CI, -$1367 to -$94; P = .03), spinal fusion (-$3253; 95% CI, -$3879 to -$2627; P < .001), hip arthroplasty (-$328; 95% CI, -$634 to -$21; P = .04), knee arthroplasty (-$415; 95% CI, -$643 to -$187; P < .001), cesarean delivery (-$300; 95% CI, -$380 to -$220; P < .001), and hysterectomy (-$745; 95% CI, -$974 to -$517; P < .001). Significant changes in patient mix consistent with a younger population (eg, a shift toward private/commercial insurance for orthopedic procedures, such as spinal fusion [4.3%; 95% CI, 3.4%-5.2%; P < .001] and knee arthroplasty [1.6%; 95% CI, 1.0%-2.3%; P < .001]) and a lower comorbidity burden across surgical procedures (eg, CABG: -0.7% [95% CI, -0.1% to -0.5%; P < .001]; hip arthroplasty: -3.0% [95% CI, -3.6% to -2.3%; P < .001]) were also observed. In this study, patients who underwent common surgical procedures had significantly fewer avoidable complications and lower hospital costs, as measured against the rate of increase throughout the study, after implementation of the all-payer model in Maryland. These findings may be associated with changes in the patient mix.

Omitting nasogastric tube placement after gastrectomy does not enhance postoperative recovery: a propensity score matched analysis.

Enhanced recovery after surgery (ERAS) program has become the main trend in gastrointestinal surgery. This study aims to investigate factors influencing the decision-making of nasogastric tube (NGT) placement and its safety and efficacy after gastrectomy. We analyzed our prospectively maintained database including 287 patients who underwent elective gastrectomy in our department from January 1 to December 31, 2017. All cases were divided into two groups, namely, the no-NGT group and the NGT group. Logistic regression was used to analyze factors that affected the decision of NGT placement, and propensity score matching (PSM) was later applied to balance those factors for the analysis of safety outcomes between groups. Multivariate analysis showed resection range (p = 0.004, proximal gastrectomy: OR = 4.555, 95%CI = 1.392-14.905, p = 0.016; total gastrectomy: OR = 1.990, 95%CI = 1.205-3.287, p = 0.009) was the only independent risk factor of NGT placement. NGT was omitted in the majority (58.8%) of distal gastrectomy but only in 42.5% and 25% in total and proximal gastrectomy. After PSM, we found no significant differences between patients with or without NGT in postoperative hospital stay, time to first flatus and defecation, time to fluid and semi-fluid diet, rate of reinsertion, or hospitalization expenditure (p > 0.05, respectively). The incidence of postoperative complications in the two groups were 21.7% and 23.5%, respectively (p = 0.753), and the incidence of major complications was 7.0% and 9.6% (p = 0.472). The decision-making of NGT placement is mainly influenced by the resection range. Omitting NGT is a safe approach in all types of gastrectomy but was not able to enhance the recovery in our practice.

Systemic anticoagulation is associated with decreased mortality and morbidity in acute pancreatitis

Background/objectivesAcute pancreatitis (AP) is a procoagulant state, and markers of coagulopathy are associated with AP severity. We aimed to explore the association of systemic anticoagulation therapy before AP onset with the inpatient outcomes of patients with acute pancreatitis. MethodsThis case-control, retrospective study used data from the Nationwide Inpatient Sample (Jan 2014–Dec 2016). We used medical coding data to identify patients with a principal diagnosis of AP who were receiving systemic anticoagulation therapy. Patients with anticoagulation were matched to those without it on the propensity for having anticoagulation. The propensity for having anticoagulation was estimated using a logistic regression model, matching for age, gender, race, median household income for patients' zip code, Charlson comorbidity score, region of hospital, location of hospital (urban/rural), teaching status of hospital, if admission day was on a weekend, pancreatic cancer class, obesity, tobacco usage. Secondary outcomes were inpatient outcomes and hospital expenditures. ResultsA total of 190,474 patients admitted for acute pancreatitis were identified, out of which 7827 patients were on anticoagulation. After propensity matching, 5776 matched pairs were successfully identified. Patients with AP on anticoagulation tended to have lower risk for ICU admission, acute kidney injury, organ failure or inpatient mortality. However, the group with anticoagulation had longer hospital length of stay and higher hospital costs. ConclusionsAnticoagulation therapy may have a pivotal role in the pathogenesis and progression of AP. These data suggest a potential therapeutic role for anticoagulants in AP. Further studies are needed to better understand these observations.

The Policy Effect of China’s Medical and Health System Reform：Based on the Investigation of Pilot Comprehensive Medical Reform

Comprehensive medical reform is important to explore the medical and health system reform. It is the main direction of deepening medical reform, which is a powerful driving force for building a healthy China. This paper uses the data of the China Family Panel Studies （CFPS） 2010, 2012, 2014 and 2018, and treats the provinces in the pilot comprehensive medical reform as the treatment group and the remaining provinces as the control group. The DID method is used to examine the impact of comprehensive health care reform on residents’ medical treatment satisfaction, medical level acceptance and medical expenditures.Firstly, this paper cuts from the two perspectives of residents’ medical treatment satisfaction and medical level acceptance. It is more authentic and purposeful to investigate from the individual’s intuitive perception of medical conditions and medical services. Secondly, this paper cuts from the perspective of medical expenditures, and examines the annual medical expenditures of residents （absolute medical expenditures）, annual medical expenditures excluding reimbursements （absolute out-of-pocket medical expenditures）, the ratio of medical expenditures to family expenditures （relative medical expenditures）, the ratio of out-of-pocket medical expenditures to family expenditures （relative out-of-pocket medical expenditures）, and the ratio of out-of-pocket medical expenditures to medical expenditures （the ratio of out-of-pocket expenditures）, among which residents’ personal medical expenditures include hospitalization expenditures and injury and illness expenditures （non-hospital expenditures）.It is found that the comprehensive medical reform has significantly increased residents’ medical treatment satisfaction and medical level acceptance. Although the comprehensive medical reform fails to reduce residents’ absolute medical expenditures and absolute out-of-pocket medical expenditures, it significantly reduces relative medical expenditures and relative out-of-pocket medical expenditures. Further research finds that the comprehensive medical reform mainly reduces hospitalization expenditures, but it fails to reduce injury and illness expenditures in medical expenditures; from the perspective of self-paid ratio, the comprehensive medical reform significantly reduces the proportion of residents’ out-of-pocket expenditures; compared with rural areas, the policy effect of comprehensive medical reform in urban areas is more obvious. In general, the comprehensive medical reform has significant policy effects in many aspects, which has relatively reduced the burden of residents’ medical expenditures, but it has failed to directly reduce residents’ medical expenditures.

Assessment of Medical Expenditure for Patients With Breast Cancer in China: Evidence From Current Curative Expenditure by System of Health Accounts 2011

ObjectivesThe incidence and mortality of breast cancer have been increasing in China and bring heavy economic burdens to patients, families, and society. This study aimed to analyze the structure and influencing factors of inpatient expenditures of patients with breast cancer and put forward suggestions for insurance management. MethodsA multistage stratified random sampling method was used to investigate 379 medical institutions and 7366 pieces of inpatient records of patients with breast cancer in Dalian in 2018. Under the framework of “System of Health Accounts 2011,” the current curative expenditure (CCE) and its distribution were calculated. The relationships between hospitalization expenditure and factors were analyzed by multiple stepwise regression and structural equation modeling. ResultsThe CCE of patients with breast cancer in Dalian in 2018 was ¥273.38 million, accounting for 10.66% of the total expenditure on cancer. The majority of the CCE flowed to large general hospitals. The CCE was concentrated in patients aged 40 to 69 years (23.46%). The hospitalization expenditure correlated positively with length of stay, surgery, and drug expenses (rs = 0.586-0.754, P < .01) and negatively associated with age (rs = −0.074, P < .01). The length of stay mediated the relationship between surgery and hospitalization expenses for patients with breast cancer. The factors that affected the hospitalization expenditure were the drug expenses, surgery, length of stay, insurance status, and institution level. ConclusionsThe cost control for CCE of breast cancer inpatient treatment is crucial in China. Promoting hierarchical diagnosis and treatment, reducing the length of stay, and improving medical insurance depth would be effective measures to reduce the financial burden of patients.

Worse Outcomes Associated With Liver Transplants: An Increasing Trend.

Background and aimSince individuals in the early stages of liver cirrhosis are typically asymptomatic, the prevalence of liver cirrhosis may be underestimated. Liver cirrhosis has a significant morbidity and mortality rate, with 1.03 million deaths worldwide each year. For end-stage liver disease, liver transplantation is a potential therapeutic option. The goal of our research was to examine the current trend in liver transplants using data from a national database.MethodsUsing the International Classification of Diseases (ICD)-9 codes, we identified individuals who had a liver transplant during the index hospital admission in the Nationwide Inpatient Sample from 2007 to 2011. This national sample of patients is from the United States. We looked at the yearly trend in liver transplants and related outcomes, such as duration of hospitalization (DOH), hospital expenses, and mortality in the hospital. In order to find determinants of mortality, we used a multivariate analysis.ResultsThere were 25,331 patients hospitalized (weighted for national estimate). Between 2007 and 2011, the number of transplants grew by 1.2%. The majority of transplant recipients were Caucasian (57%), with an average age of 54 years, had a private healthcare plan (53%), and had average earnings in the upper quartile by zip code (26%). Patients with a higher Charlson Comorbidity Index (79% had a score of four) were more likely to be admitted to a southern hospital (33%), an academic hospital (>99%), and a large capacity hospital (90%). Seventy percent of liver transplant recipients received cadaver donors. Hepatitis C was the most prevalent reason for transplant (30%), followed by hepatocellular carcinoma (HCC) (29%) and alcoholic liver disease (25%). In 2011, compared to 2007, there was an upward rise in fatality (from 3.8% to 5.1%), average hospital expenditures (from $335,504 to $498,369), and DOH (from 17.4 to 22.7 days). The cost of hospitalization was two billion dollars per year. The independent variables related to an increased mortality on multivariate analysis were African American race (OR: 2.0, 95%, CI: 1.2-3.2; p=0.005) and large capacity hospitals (OR: 2.5, 95% CI: 1.6-4.1; p=0.0002). Predictors linked to lower mortality included private healthcare coverage (vs. Medicare: OR: 0.7, 95%, CI: 0.51-0.97; p=0.03), academic hospital (OR: 0.6, 95% CI: 0.4-0.8; p=0.005), cadaver donor (OR: 0.6, 95% CI: 0.5-0.8; p=0.002), HCC (OR: 0.6, 95% CI: 0.4-0.9; p=0.01), and non-alcoholic steatohepatitis (NASH) cirrhosis (OR: 0.4, 95% CI: 0.2-0.9; p=0.02).ConclusionOur study found an increasing trend in worse outcomes (increased mortality, average hospital costs, and average DOH) after a liver transplant. Patients of the African American race and large capacity hospitals were associated with a higher risk of death, whereas private healthcare plans, academic hospitals, cadaver donors, HCC, and NASH cirrhosis were associated with a lower risk.

Paradigm shift in gastrointestinal surgery - combating sarcopenia with prehabilitation: Multimodal review of clinical and scientific data.

A growing body of evidence has demonstrated the prognostic significance of sarcopenia in surgical patients as an independent predictor of postoperative complications and outcomes. These included an increased risk of total complications, major complications, re-admissions, infections, severe infections, 30 d mortality, longer hospital stay and increased hospitalization expenditures. A program to enhance recovery after surgery was meant to address these complications; however, compliance to the program since its introduction has been less than ideal. Over the last decade, the concept of prehabilitation, or “pre-surgery rehabilitation”, has been discussed. The presurgical period represents a window of opportunity to boost and optimize the health of an individual, providing a compensatory “buffer” for the imminent reduction in physiological reserve post-surgery. Initial results have been promising. We review the literature to critically review the utility of prehabilitation, not just in the clinical realm, but also in the scientific realm, with a resource management point-of-view.

Impacts of Ambient Carbon Monoxide on Hospital Admissions and Hospitalization Expenditures for Three Cardiorespiratory Diseases in 74 Cities of China

BACKGROUND AND AIM: Evidence about health burden and economic loss of cardiorespiratory diseases (CRDs) caused by ambient carbon monoxide (CO) is sparse. We aimed to assess health burden as well as economic loss caused by coronary heart disease (CHD), stroke and lower respiratory infections (LRI) attributed to ambient CO in multiple cities in China. METHODS: Hospital admission and expenditures data were obtained from urban employee-based basic medical insurance scheme (UEBMI) of the national health insurance system in China. We performed a three-stage time-series analysis approach based on Generalized Linear Model controlling for potential confounding factors to examine the association between ambient CO and hospitalization data of CHD, stroke and LRI in 74 cities of China from January 1, 2015 to December 31, 2017. We conducted subgroup analyses by geographical region, gender and age (15-64 and ≥65), and tested the robustness of the results in two-pollutant models and sensitive analyses. RESULTS:We found that the average daily concentration of ambient CO across 74 cities from 2015 to 2017 was 1.10 mg/m³ (SD: 0.62). For a 1 mg/m³ increase in CO concentrations, the largest excess risks (ERs) were 3.82% (95% CI: 1.27% to 6.44%) at lag04 for CHD, 3.14% (95% CI: 1.90% to 4.38%) at lag0 for stroke and 2.71% (95% CI: 1.21% to 4.23%) at lag01 for LRI. Moreover, we observed that 4.50%, 3.33% and 2.97% of CHD, stroke and LRI related hospital admissions during 2015 to 2017 could be attributed to ambient CO in included cities, and the annualized attributable numbers of hospitalization expenditures were enormous, with 490 million CNY (US$ 73 M), 371 million CNY (US$ 55 M) and 217 million CNY (US$ 32 M) for CHD, stroke and LRI, respectively. CONCLUSIONS:Our study provides robust evidence for substantial excess hospitalization burden of CHD, stroke and LRI attributable to ambient CO based on multi-city analyses. KEYWORDS: Air pollution, Cardiovascular diseases, Environmental epidemiology, Traffic-related, Respiratory outcomes

Public expenditure on hospitalizations for COVID-19 treatment in 2020, in Brazil.

ABSTRACTOBJECTIVE Describe the expenditure resulting from hospitalizations for clinical treatment of users diagnosed with COVID-19 in the Unified Health System (SUS) between February and December 2020.METHODS This is a descriptive study based on data from the Hospital Information System about government expenditure on hospitalizations for clinical treatment of users diagnosed with COVID-19 and causes included in the ICD-10 chapters. We obtained the number of hospitalizations, average length of stay, lethality rate, and total expenditure considering hospital services, professional services and average expenditure per hospitalization.RESULTS In the period evaluated, SUS registered 462,149 hospitalizations, 4.9% of them for COVID-19 treatment. Total expenditure exceeded R$ 2.2 billion, with 85% allocated to hospital services and 15% to professional services. Expenditure for treating COVID-19 was distributed differently between the country’s regions. The Southeast region had the highest number of hospitalizations, highest total amount spent, highest average length of stay in days, and highest lethality rate; the South region, in turn, recorded the highest percentage of spending on non-profit hospitals (58%) and corporate hospitals (15%).CONCLUSIONS Hospitalizations for clinical treatment of coronavirus infection were more costly compared to those for treatment of acute respiratory failure and pneumonia or influenza. Our results show the disparities in hospitalization expenditure for similar procedures between the regions of Brazil, underlining the vulnerability and the need for strategies to reduce the differences in access, use, and distribution of SUS resources, ensuring equanimity, and considering the unfair inequalities between the country’s regions.

Patient Characteristics, Injury Types, and Costs Associated with Secondary Over-Triage of Isolated Cervical Spine Fractures.

Retrospective cohort. To aim of this study was to identify patient variables, injury characteristics, and costs associated with operative and non-operative treatment following inter-facility transfer of patients with isolated cervical spine fractures. Patients with isolated cervical spine fractures are subject to inter-facility transfer for surgical assessment, yet are often treated nonoperatively. The American College of Surgeons' benchmark rate of "secondary over-triage" is <50%. Identifying patient and injury characteristics as well as costs associated with treatment following transfer of patients with isolated cervical spine fractures may help reduce rates of secondary over-triage and healthcare expenditures. Patients transferred to a Level-1 trauma center with isolated cervical spine fractures between January 2015 and September 2020 were identified. Patient demographics, comorbidities, insurance data, injury characteristics, imaging workup, treatment, and financial data were collected for all patients. Multivariable logistic regression models were constructed to identify patient and injury characteristics associated with surgical treatment. Nearly 75% of patients were treated non-operatively. Over 97% of transfers were accepted by the general surgery trauma service. Multivariable modeling found that higher BMI, presence of any neurologic deficit including spinal cord or isolated spinal nerve root injuries, present smoking status, or cervical spine magnetic resonance imaging obtained post-transfer, were associated with surgical treatment for isolated cervical spine fractures. Among patients with type II dens fractures, increased fracture displacement was associated with surgical treatment. Median charges to patients treated operatively and nonoperatively were $380,890 and $90,734, respectively. Median hospital expenditures for patients treated operatively and nonoperatively were $55,115 and $12,131, respectively. A large proportion of patients with isolated cervical spine fractures are subject to over-triage. Injury characteristics are important for determining need for surgical treatment, and therefore interfacility transfer. Improving communication with spine surgeons when deciding to transfer patients may significantly reduce health care costs and resource use.Level of Evidence: 4.