Increased Care Costs Research Articles

Conversion Total Knee Arthroplasty: Prior Fracture or Osteotomy Around the Knee Leads to Increased Resource Utilization

BackgroundPrior knee surgery before total knee arthroplasty (TKA) puts patients at higher risk of inferior outcomes and increased care cost. This study compares intraoperative and postoperative variables including procedure duration, components, length of stay, readmission, complications, and reoperations among patients undergoing conversion TKA. MethodsPrimary TKA from a single-surgeon database identified 130 patients with prior knee surgery to form a “conversion” cohort. One-to-one matching identified 130 patients of similar age, American Society of Anesthesiologists score, body mass index, and gender without prior knee surgery for comparison. Perioperative and 90-day postoperative variables were compared between patients with and without prior surgery, within the conversion group based on the type of prior surgery, and whether the prior surgery was bony or soft tissue. ResultsThe conversion group had longer mean operative time (96.1 vs 90.0 minutes, P = .01), higher revision component utilization (8.5% vs 0.8%, P = .005), and higher calculated blood loss (1440 vs 1249 mL, P = .004). Thirty-eight patients with prior fracture or osteotomy were compared to the remaining 92 patients in the conversion group and showed longer operative time (107.1 vs 91.3 minutes, P < .001), higher 90-day readmissions (18.4% vs 3.3%, P = .003), more complications (23.7% vs 8.7%, P = .021), and greater utilization of revision components (26.3% vs 1.1%, P < .001). ConclusionPatients undergoing conversion TKA required increased resource utilization, particularly patients with a prior osteotomy or fracture. Policymakers should consider these variables, as they did in conversion THA, in adding a code to account for increased case complexity and resource utilization.

Analysis of Diabetes Mellitus-Related Amputations in the State of Espírito Santo, Brazil.

Background and objectives: Diabetes mellitus (DM) stands out among the most important public health problems worldwide since it represents a high burden on health systems and is associated with higher hospitalization rates, and a higher incidence of cardiovascular diseases. Amputations are among the most common complications, leading to disability and increasing care costs. This research aims to analyze the prevalence of DM-related amputations, comorbidities and associated risk factors in the diabetic population residing in the State of Espírito Santo, Brazil. Materials and Methods: This is a quantitative, exploratory, cross-sectional study with a time series design and the use of secondary data registered and followed by the system of Registration and Monitoring of Hypertension and Diabetes—SisHiperdia. Results: The sample consisted of 64,196 diabetic patients, out of them, 3.9% had type 1 DM, 10.9% with type 2 DM, and 85.2% with DM coexisting with hypertension. Most were female (66.6%), aged 40 to 59 years (45.6%), and 60 years and older (45.2%). The prevalence of DM-related amputations in the analyzed sample was 1.2% in type 1 DM, 1.5% in type 2 DM, and 2.2% in concomitant DM and hypertension. Higher amputation rates were observed in males in the age group above 60 years in type 1 DM and type 2 DM and were slightly higher in the age groups up to 29 years in DM with hypertension. A higher prevalence of amputation was related to smoking, physical inactivity, acute myocardial infarction (AMI), stroke, chronic kidney disease (CKD), and diabetic foot (DF) in all types of DM. Conclusions: The present study showed a significant prevalence of DM-related amputations. An increased prevalence was evidenced when correlated with smoking, physical inactivity, AMI, stroke, CKD, and DF with significant statistical associations, except for a sedentary lifestyle in type 1 DM.

Association Between Steroid-Sparing Therapy and the Risk of Perianal Fistulizing Complications Among Young Patients With Crohn Disease

Perianal fistulizing complications (PFCs) develop in 15% to 30% of patients with Crohn disease (CD), are difficult to treat, worsen quality of life, increase cost of care, and commonly recur. Evidence-based strategies to prevent PFCs are lacking. To investigate the effectiveness of medical therapy for reducing risk of PFCs among young people with CD and to test the hypothesis that steroid-sparing therapy (SST) use would be associated with reduced risk of PFC development. In this comparative effectiveness analysis of commercial administrative claims from January 1, 2001, through June 30, 2016, patients who did or did not initiate SST were matched via propensity score to adjust for all available confounders. Using Optum's Clinformatics Data Mart, a deidentified database of US commercial administrative claims, all patients aged 5 to 24 years with CD (January 1, 2001, through June 30, 2016) were identified. The index date was the CD diagnosis date. Patients with PFCs or SST use at or before CD diagnosis were excluded. The dates of analysis were October 2017 to February 2020. The primary exposure of interest was SST initiation, including immunomodulators and/or anti-tumor necrosis factor α (anti-TNFα) medications, initiated before either PFC development or the end of the study period. The primary outcome was PFC development. Propensity score matching was used to balance baseline characteristics. Cox proportional hazards multivariable regression analyses were used to estimate hazard ratios (HRs) with 95% CIs for PFC development. Among 2214 young people with CD without PFCs identified, the mean (SD) age at CD diagnosis was 17.0 (4.5) years, and 1151 (52.0%) were male. Among the cohort, 1242 patients (56.1%) initiated SST before PFC development or the end of 24-month follow-up. After propensity score matching, 972 patients remained in each treatment group. Overall, 384 of 1944 (19.8%) developed PFCs within 2 years of the index date. The use of SST was associated with a 59% decreased risk of PFC development (hazard ratio [HR], 0.41; 95% CI, 0.33-0.52; P < .001) in 2 years compared with no SST use. Among those who developed PFCs, 55% fewer SST users underwent ostomy than SST nonusers. The use of immunomodulators alone, anti-TNFα alone, and combination therapy was associated with 52% (HR, 0.48; 95% CI, 0.37-0.62; P < .001), 47% (HR, 0.53; 95% CI, 0.36-0.78; P = .001), and 83% (HR, 0.17; 95% CI, 0.09-0.30; P < .001) reductions in the risk of 2-year PFC development, respectively, compared with no SST use. In this study, PFC development was common among young patients with CD. The use of SST was lower than expected. Compared with no SST, patients who initiated SST were 59% less likely to develop PFCs and fewer underwent ostomy. These results indicate that PFCs may be preventable and emphasize the importance of considering SST for all patients with CD.

Sentinel Lymph Node Biopsy for T1b Melanoma: Balancing Prognostic Value and Cost.

The purpose of this study is to report the additional prognostic information and cost associated with sentinel lymph node biopsy (SLNB) for patients with T1b melanoma. An institutional database was queried for patients with T1b melanoma (0.8-1.0mm or < 0.8mm with ulceration) with at least 5years of follow-up. Results of SLNB, completion lymphadenectomy (CLND), recurrence, and melanoma-specific survival (MSS) were assessed. Institutional costs of melanoma care were converted to Medicare proportional dollars. A Markov model was created to estimate long-term costs. Among the total 392 patients, 238 underwent SLNB. Median follow-up was 10.5years. SLNB was positive in 19 patients (8.0%). Patients who underwent SLNB had higher 10-year nodal recurrence-free survival (98.6% vs. 91.2%, p < 0.001) but not MSS (94.4% vs. 93.2%, p = 0.55). Ulceration (HR 4.7, p = 0.022) and positive sentinel node (HR 11.5, p < 0.001) were associated with worse MSS. Estimates for 5-year costs reflect a fourfold increase in total costs of care associated with SLNB. However, a treatment plan that forgoes adjuvant therapy for resected stage IIIA melanoma but offers systemic therapy for a node-basin recurrence would nullify the additional cost of SLNB. SLNB is prognostic for T1b melanoma. Its impact on the overall cost of melanoma care is intimately tied to systemic therapy in the adjuvant and recurrent settings.

Update on immune-mediated therapies for myasthenia gravis.

With the exception of thymectomy, immune modulatory treatment strategies and clinical trials in myasthenia gravis over the past 50 y were mainly borrowed from experience in other nonneurologic autoimmune disorders. The current experimental therapy paradigm has significantly changed such that treatments directed against the pathological mechanisms specific to myasthenia gravis are being tested, in some cases as the initial disease indication. Key advances have been made in three areas: (i) the expanded role and long-term benefits of thymectomy, (ii) complement inhibition to prevent antibody-mediated postsynaptic membrane damage, and (iii) neonatal Fc receptor (FcRn) inhibition as in vivo apheresis, removing pathogenic antibodies. Herein, we discuss these advances and the potential for these newer therapies to significantly influence the current treatment paradigms. While these therapies provide exciting new options with rapid efficacy, there are anticipated challenges to their use, especially in terms of a dramatic increase in cost of care for some patients with myasthenia gravis.

Evaluation of an Electronic Health Record System With a Disease Management Program and Health Care Treatment Costs for Danish Patients With Type 2 Diabetes

Electronic health record (EHR) systems and disease management programs (DMP) are often promoted, but associated health care cost changes are not well understood. To evaluate the association between annual health care costs of patients with type 2 diabetes and the use of an electronic health record system with a disease management program (EHR/DMP) in general practice. This retrospective cohort study examined patients with type 2 diabetes in Denmark between January 1, 2008, and December 31, 2014, who attended practices that either used an EHR/DMP at a high level or never used the disease management system. An EHR/DMP system was rolled out across general practices in Denmark beginning in 2011 and was discontinued in 2014. Data were analyzed between March 2019 and March 2020. The main outcome was total health care costs, and the secondary outcomes were primary care, medication, nonhospital specialist, and hospital (total, outpatient, inpatient, and emergency) costs. Regression models were used to estimate EHR/DMP-associated percentage differences in patients' annual health care treatment costs across health care treatment categories. All models included general practice-level fixed effects and patient-level controls. Two-part models examined robustness of estimated associations for hospital cost categories. Of 33 970 patients included in the analysis, 15 953 (8016 [50.2%] male; mean [SD] age, 59.9 [13.3] years) attended 244 general practices that used the system at a high level, and 18 017 (9291 [51.6%] male; mean [SD] age, 60.0 [12.9] years) attended 344 general practices that had never used the system. Use of the EHR/DMP was associated with 3.2% higher (95% CI, 0.9%-5.6%) annual general practice treatment costs and with 6.4% lower (95% CI, -11.6% to -1.2%) annual hospital emergency visit costs. The associations between EHR/DMP use and annual total hospital (percentage difference, -0.8%; 95% CI, -7.5% to 5.7%) and total health care (percentage difference, -0.1%; 95% CI, -2.1% to 1.9%) cost changes were not statistically significant. Among patients with type 2 diabetes, attendance at general practices that used an EHR/DMP was associated with a moderate increase in primary care costs and a reduction in emergency hospital visit costs but no significant change in total health care costs. Large health care cost savings associated with improved use of EHR-based disease management systems should not be expected to be realized in the short term.

PCN221 OCM TO OCF: IMPLICATIONS FOR TOTAL COST OF CARE

To map the limitations of the Oncology Care Model (OCM) to the proposed features of the 2021 Oncology Care First (OCF) model in order to evaluate whether the OCF is more likely to successfully reduce total cost of care. The study employed a pragmatic literature review to identify key shortcomings of the current OCM model with respect to lowering total cost of care. Interviews with thought leaders in the field of value-based payment models helped to then shed light on whether the OCF would address these gaps. These findings were mapped to specific features (e.g., two-sided risk, tumor-specific adjustments) proposed for the OCF. Several elements within the OCM have led to participants achieving subpar improvements on total cost and quality of care. These include insufficient consideration of tumor-specific care differences, challenges with accurate patient attribution, diminishing returns from self-benchmarked price targets, and insufficient timely feedback on performance metrics. The OCF attempts to address the first two issues by including new tumor-specific calculation methods and providing prospective payments to any oncology patient managed by a participating practice. However, the partially capitated prospective payment, the requirement for electronic Patient Reported Outcomes (ePRO), and the faster trajectory towards two-sided risk will likely drive a bias in OCF participation towards innovative practices. These practices will continue to suffer from diminishing benefits of further improvement, and with an updated novel therapies adjustment, they may experience an increase in drug-related total cost of care. While the OCF model builds upon the OCM, there are still several components that have been critiqued under OCM and remain unaddressed. Given past OCM experiences, the OCF may ultimately follow a similar trajectory and have limited impact on the total cost of care unless solutions to these issues are included in the final program design.

Costs of Post–Renal Transplant Care in the Final Period of Graft Function

IntroductionExcept for benefits in survival and quality of life, renal transplantation is considered a method that is cheaper compared to alternative modalities of renal replacement therapy; it is thought that, after the first post-transplant year, costs of care decrease and then remain relatively low. However, over time, health problems accumulate in transplant recipients, which may be connected to increased costs of care. In this study, we attempted to verify whether costs of care actually remain low until the graft loss. Material and MethodsThis study included 20 renal transplant recipients with grafts functioning at least 5 years post transplant who were managed in our transplant center and who lost their transplants in 2017 or 2018. Costs of post–renal transplant care in consecutive years post transplant were retrospectively assessed in these cases. Direct costs of inpatient as well as outpatient care, from the perspective of a transplant center, were considered. ResultsThis study included 8 (40%) men and 12 (60%) women. A significant increase in costs of care was observed in the final period of graft function at least in the year of graft loss. It was observed both in those who lost the transplant because of the graft failure and in those who died with a functioning graft. However, despite this increase, mean costs of post-transplant care in the last 6 years of graft function remained lower compared to hemodialysis. ConclusionsDespite the increase in costs of post–renal transplant care observed in the final period of graft function, treatment with renal transplantation remains cheaper compared with hemodialysis.

Abstract WP344: Total Healthcare Costs Before and After Stroke in Non-Valvular Atrial Fibrillation (NVAF) Patients Who Initiated Treatment With Rivaroxaban or Warfarin

Introduction: Healthcare expenditures remain unclear in NVAF patients initiating anticoagulation therapy. Objective: To compare total healthcare cost in pre- and post-stroke periods between rivaroxaban- and warfarin-treated NVAF patients. Methods: This retrospective study using de-identified IBM MarketScan Commercial and Medicare databases (2011-2019) included patients initiating rivaroxaban or warfarin within 30 days after a 1 st observed NVAF diagnosis who later developed ischemic or hemorrhage stroke. Patients had ≥6 months continuous health plan enrollment, CHA 2 DS 2 -VASc score ≥2 and no history of stroke or anticoagulation therapy. Inpatient stroke diagnosis was identified by ICD-9/-10 code, and stroke severity status was defined by National Institutes of Health Stroke Scale (NIHSS) score, imputed by a random forest method. Total per-patient per-year (PPPY) cost of care was calculated pre- and post-stroke (from treatment initiation to time of stroke and from stroke until end of study enrollment, respectively). Cost increases pre-/post-stroke were compared within each treatment cohort. Results: During a mean follow up of 25 and 30 months for rivaroxaban and warfarin respectively, 272 (2.0%) and 1,303 (3.3%) patients, respectively, developed stroke. For the rivaroxaban cohort, the pre-/post-stroke cost increase was lower than that for warfarin (1.79-fold vs 3.08-fold, respectively); for more severe stroke (NIHSS ≥6), the cost increase for rivaroxaban was half that of warfarin (3.19-fold increase vs 6.37-fold increase, respectively). Conclusions: The study showed a substantial increase in total cost of care following stroke, especially among patients with severe strokes. Warfarin patients had a much higher increase in post-stroke costs relative to rivaroxaban patients, suggesting a benefit of rivaroxaban in preventing strokes with poor outcomes that are costly.

Clinical and Economic Impact of Ibalizumab for People With Multidrug-Resistant HIV in the United States.

We projected the clinical outcomes, cost-effectiveness, and budget impact of ibalizumab plus an optimized background regimen (OBR) for people with multidrug-resistant (MDR) HIV in the United States. Using the Cost-Effectiveness of Preventing AIDS Complications microsimulation model and a health care sector perspective, we compared 2 treatment strategies for MDR HIV: (1) IBA + OBR-ibalizumab plus OBR and (2) OBR-OBR alone. Ibalizumab efficacy and cohort characteristics were from trial data: mean age 49 years, 85% male, and mean CD4 150/µL. Six-month viral suppression was 50% with IBA + OBR and 0% with OBR. The ibalizumab loading dose cost $10,500, and subsequent ibalizumab injections cost $8400/month; OBR cost $4500/month. Incremental cost-effectiveness ratios (ICERs) were calculated using discounted (3%/year) quality-adjusted life years (QALYs) and costs. ICERs ≤$100,000/QALY were considered cost-effective. We performed sensitivity analysis on key parameters and examined budget impact. In the base case, 5-year survival increased from 38% with OBR to 47% with IBA + OBR. Lifetime costs were $301,700/person with OBR and $661,800/person with IBA + OBR; the ICER for IBA + OBR compared with OBR was $260,900/QALY. IBA + OBR was not cost-effective even with 100% efficacy. IBA + OBR became cost-effective at base case efficacy if ibalizumab cost was reduced by ≥88%. For an estimated 12,000 people with MDR HIV in the United States, IBA + OBR increased care costs by $1.8 billion (1.5% of total treatment budget) over 5 years. For people with MDR HIV lacking other treatment options, ibalizumab will substantially increase survival when effective. Although adding ibalizumab to OBR is not cost-effective, the low number of eligible patients in the United States makes the budget impact relatively small.

Clinical Decision Support for Recognizing and Managing Hypertensive Blood Pressure in Youth: No Significant Impact on Medical Costs.

To evaluate economic costs from the health system perspective of an electronic health record-based clinical decision support (CDS) tool, TeenBP, designed to assist in the recognition and management of hypertension in youth. Twenty primary care clinics within an integrated health system were randomized to the TeenBP CDS or usual care (UC), with patient enrollment from 4/15/14 to 4/14/16. The 12-month change in standardized medical care costs for insured patients aged 10 to 17 years without prior hypertension were calculated for each study arm. The primary analysis compared patients with ≥1 visit with blood pressure (BP) ≥95th percentile (isolated hypertensive BP), and secondary analyses compared patients with ≥3 visits within one year with BP ≥95th percentile (incident hypertension). Generalized estimating equation models estimated the difference-in-differences in costs between groups over time. Among 925 insured patients with an isolated hypertensive BP, the pre-to-post change in overall costs averaged $22 more for TeenBP CDS versus UC patients over 12 months, but this difference was not statistically significant (P=.723). Among 159 insured patients with incident hypertension, the pre-to-post change in overall costs over 12 months was higher by $227 per person on average for TeenBP CDS versus UC patients, but this difference also was not statistically significant (P=.313). The TeenBP CDS intervention was previously found to significantly improve identification and management of hypertensive BP in youth, and in this study, we find that this tool did not significantly increase care costs in its first 12 months of clinical use.

Evaluation of a bundle of care to reduce incisional surgical site infection after gastrointestinal surgery.

Surgical site infection (SSI) is associated with morbidity, mortality and increased care costs; many SSIs are considered preventable. The aim of the present study was to test implementation of a pragmatic, evidence-based bundle designed to reduce incisional SSI after emergency laparotomy and elective major lower gastrointestinal surgery. This was a prospective before-and-after study. Data were collected before the intervention and for two separate subsequent time periods. An evidence-based bundle of care (BOC) was implemented; the primary outcome measure was incisional SSI at 30 days. The secondary outcome measure was 30-day unplanned readmissions. The initial post-intervention group, Group 2, assessed a variable number of potential impacting factors; however, due to funding and staffing levels the second post-bundle group, Group 3, focused on the core aspects of the BOC and rates of incisional SSI and readmission. In total, 99 patients were included in the 'before' group; and 71 in Group 2 and 92 in Group 3, the post-intervention groups. The incisional SSI rate was 29.3% (29/99) before and 28.2% (20/71) in Group 2 (P=0.873) and 21.7% (20/92) in Group 3 (P=0.234) after the intervention. After adjustment for confounders, the care bundle was associated with a non-significant reduction in SSI (Group 2: odds ratio [OR] = 0.93, 95% confidence interval [CI] = 0.45-1.93, P=0.0843). However, it was associated with significantly reduced readmissions 18.1% (18/99) before versus 5.6% (4/71) in Group 2 (OR = 0.236, 95% CI = 0.077-0.72, P=0.012) and 8.7% (8/92) in Group 3 (OR = 0.38, 95% CI = 0.16-0.9, P=0.029). Comparing the pre-bundle group to the post-bundle groups, there was an overall significant reduction in readmissions (P=0.003). This implies a number needed to treat of 8-11 patients to prevent one readmission. Adherence to antibiotic prophylaxis with the Trust guidelines increased from 91% to 99% (1 vs. 2, P=0.047). Introduction of the bundle was associated with a reduction in the observed rate of incisional SSI from 29.3% to 21.7%; significantly fewer patients required unplanned readmission. Use of the bundle was associated with significantly improved compliance with appropriate antimicrobial prophylaxis.

Évolution des coûts et de la prise en charge du cancer pulmonaire entre 2004 et 2014

Given its morbidity and mortality, lung cancer is a major public health issue. In recent years, it has benefited from several therapeutic innovations. The objective of this study was to compare, over two distinct periods of ten years, the impact on survival and the costs of lung cancer management. The monocentric study assessed survival and the direct costs of lung cancer management of patients diagnosed in Brest University hospital in 2004 and in 2014. The analysis included 142 patients in 2004 and 156 in 2014. Most patients were smokers (72%), metastatic at diagnosis (60%) both in 2004 and in 2014. Median survival was not significantly improved between the 2 periods (9.7 versus 10.9 months), but there was a significant increase in the average cost of care per patient (€ 17,063 vs. € 29,264, P=<0.0001) between 2004 and 2014. The significant increase in treatment costs did not translate into an improvement in the survival of patients with lung cancer between 2004 and 2014.

Factors influencing the cost of care and admission to long-term care for people with dementia in Ireland

Objective To explore the factors associated with the cost of care and admission to long-term care (LTC) for people with dementia living at home in Ireland. Methods Data on formal and informal resource use for people with dementia, and their LTC admission, were obtained from a national study of spousal dementia caregivers. Functional status was measured using the Bristol Activities of Daily Living Scale, while behavioural and psychiatric symptoms were evaluated using the Neuropsychiatric Inventory. Multivariable regression analysis was used to model costs and the predictors of LTC admission. Results Physical and cognitive symptoms were significantly associated with costs. Severely impaired functional ability was associated with a €2,308 increase in mean total 30-day monthly costs. Psychosis was associated with a €335 increase in primary and community 30-day monthly care costs. These factors also make it more likely that a person with dementia is admitted to LTC. Having an older caregiver also increases the risk of admission to LTC, while living in a rural area and having a female caregiver reduce the likelihood of admission. Conclusions Dependency matters for the cost of care. Physical and cognitive symptoms, caregiver age and gender, and geographic location are significant predictors of admission to LTC.

Using smart-messaging to enhance mindfulness-based cognitive therapy for cancer patients: A mixed methods proof of concept evaluation.

ObjectiveDepression and anxiety lead to reduced treatment adherence, poorer quality of life, and increased care costs amongst cancer patients. Mindfulness‐based cognitive therapy (MBCT) is an effective treatment, but dropout reduces potential benefits. Smart‐message reminders can prevent dropout and improve effectiveness. However, smart‐messaging is untested for MBCT in cancer. This study evaluates smart‐messaging to reduce dropout and improve effectiveness in MBCT for cancer patients with depression or anxiety.MethodsFifty‐one cancer patients attending MBCT in a psycho‐oncology service were offered a smart‐messaging intervention, which reminded them of prescribed between‐session activities. Thirty patients accepted smart‐messaging and 21 did not. Assessments of depression and anxiety were taken at baseline, session‐by‐session, and one‐month follow‐up. Logistic regression and multilevel modelling compared the groups on treatment completion and clinical effectiveness. Fifteen post‐treatment patient interviews explored smart‐messaging use.ResultsThe odds of programme completion were eight times greater for patients using smart‐messaging compared with non‐users, controlling for age, gender, baseline depression, and baseline anxiety (OR = 7.79, 95% CI 1.75 to 34.58, p = .007). Smart‐messaging users also reported greater improvement in depression over the programme (B = ‐2.33, SEB = .78, p = .004) when controlling for baseline severity, change over time, age, and number of sessions attended. There was no difference between groups in anxiety improvement (B = ‐1.46, SEB = .86, p = .097). In interviews, smart‐messaging was described as a motivating reminder and source of personal connection.ConclusionsSmart‐messaging may be an easily integrated telehealth intervention to improve MBCT for cancer patients.

ESKAPE Pathogens in Bloodstream Infections Are Associated With Higher Cost and Mortality but Can Be Predicted Using Diagnoses Upon Admission.

BackgroundESKAPE bacteria are thought to be especially resistant to antibiotics, and their resistance and prevalence in bloodstream infections are rising. Large studies are needed to better characterize the clinical impact of these bacteria and to develop algorithms that alert clinicians when patients are at high risk of an ESKAPE infection.MethodsFrom a US data set of >1.1 M patient encounters, we evaluated if ESKAPE pathogens produced worse outcomes than non-ESKAPE pathogens and if an ESKAPE infection could be predicted using simple word group algorithms built from decision trees.ResultsWe found that ESKAPE pathogens represented 42.2% of species isolated from bloodstream infections and, compared with non-ESKAPE pathogens, were associated with a 3.3-day increase in length of stay, a $5500 increase in cost of care, and a 2.1% absolute increase in mortality (P < 1e-99). ESKAPE pathogens were not universally more resistant to antibiotics, but only to select antibiotics (P < 5e-6), particularly against common empiric therapies. In addition, simple word group algorithms predicted ESKAPE pathogens with a positive predictive value of 7.9% to 56.2%, exceeding 4.8% by random guessing (P < 1e-99).ConclusionsTaken together, these data highlight the pathogenicity of ESKAPE bacteria, potential mechanisms of their pathogenicity, and the potential to predict ESKAPE infections upon admission. Implementing word group algorithms could enable earlier and targeted therapies against ESKAPE bacteria and thus reduce their burden on the health care system.

Impact of Automated Digital Navigation Program on Bowel Preparation Quality and Patient Satisfaction for Colonoscopy: A Comparative Study Across Multiple Sites

Background Nearly 1 in 5 patients suffers from inadequate or poor bowel preparation in advance of a colonoscopy. Prior studies have shown that this leads to a decrease in adenoma detection rate, increased time spent in completing efficiency in endoscopy suite, as well as an overall increase in cost of care from 13-20%. With the shift to value-based care in the American healthcare system, there is an urgent need for solutions that can automate pre-procedure guidance and post-procedure follow up. Objective As part of the American Gastroenterology Association digital transformation network, we sought to automate and improve pre-procedure navigation for colonoscopy using connected health technologies (specifically digital navigation). At Arizona Center for Digestive Health (AZCDH), we assessed the impact of digital navigation on bowel preparation quality, patient engagement, and patient satisfaction. We also sought to assess the reproducibility of outcomes seen at AZCDH at additional sites that have implemented digital navigation for endoscopic procedures as part of the American Gastroenterology Association network, including Yale New Haven Hospital (YNHH) and three Mount Sinai Hospital locations. Methods At AZCDH, we compared two cohorts of patients (usual care versus digital navigation) scheduled for colonoscopy. The digital navigation cohort received usual care in addition to time based messages and education content pathways on smartphones and delivered through Rx.Health’s digital medicine platform. Bowel preparation quality was then assessed, as well as patient satisfaction with the digital navigation intervention. Patient engagement and satisfaction were then compared with initial data from other sites within the network. Results Of the 217 patients prescribed the digital navigation program at AZCDH, 93 completed the procedure to date and had bowel preparation results documented in the electronic endoscopic record system. After implementing the digital navigation program the rate of aborted procedures decreased from 2.2% at baseline to 1.07%. In a follow up survey, 93% of respondents “strongly agreed” or “agreed” that the digital navigation program was helpful in preparing for their colonoscopy. At other locations to date, 433 patients have been prescribed the pathway at YNHH along with 213 patients at Mount Sinai locations. One hundred percent and 94% of respondents “strongly agreed” or “agreed” that the digital navigation program was helpful in preparing for their procedure at YNHH and Mount Sinai locations, respectively. Conclusions Our single-site study at AZCDH paved the way to implementing digital navigation pathways at YNHH and Mount Sinai endoscopy locations by demonstrating that colonoscopy instructions are well received by patients, can reduce the rate of aborted procedures and can result in higher patient satisfaction as well as a higher quality of bowel preparation. Further, patient engagement rates and satisfaction with the program was consistent at all sites across the US where the digital navigation program has been implemented. In the future, we plan to report on patient outcomes (including reduction in no shows, poor bowel preparation) to allow benchmarking on a national scale.

Women at risk for hip fracture following decline in bisphosphonate use.

239 Background: Hip fractures in older adults are associated with increases in morbidity, mortality, and costs of care. Breast cancer treatment, including chemotherapy and endocrine treatment, interfere with bone health, increasing the risk of hip fracture for breast cancer survivors. Multiple studies report large and steady declines in hip fracture incidence coinciding with the availability of bisphosphonates to prevent osteoporosis, although black label warnings about side effects in 2011 steered physicians away from their widespread use. This study estimates trends in hip fracture incidence in a cohort of women with breast cancer before and after 2011. Methods: Retrospective observational study using 2007-2015 SEER-Medicare data for women aged 66 years or older continuously enrolled in fee-for-service Medicare with a first primary diagnosis of breast cancer. Primary outcome was an inpatient admission for a hip fracture within two years of cancer diagnosis. Monthly discrete time survival models were used to estimate the probability of hip fracture after diagnosis conditional on observable factors including demographic characteristics, comorbidities, and the concurrent use of bisphosphonates and cancer treatment. Results: A total of 67,577 patients met the inclusion criteria. The age adjusted incidence of hip fracture declined by 25.1% from 2007 to 2011; from 1093.662 (95% CI, 1027.9-1159.4) to 819.224 (95% CI, 762.1-876.4) per 100,000. However, the incidence of hip fractures stabilized after 2011, with a decline of only 4% from 2011 to 2014, when the incidence was 785.4 (95% CI, 728.6-842.1). The risk of hip fracture increases with age and the number of comorbid conditions. Although more women are prescribed bisphosphonates after a cancer diagnosis, prescription rates declined after 2011. Conclusions: The incidence of hip fractures in breast cancer survivors stabilized after years of steady declines. This significant change in incidence coincided with a large reduction in the use of bisphosphonates after warnings of rare but serious side effects were issued. More research is needed to prevent hip fracture in women with breast cancer and further consideration of available treatments is required for women at high risk for hip fracture.

Impact of mycotoxin contamination in the animal feed industry

Mycotoxin contamination generally affects a large number of raw materials and finished feed intended for animal production. The economic impact on livestock production encompasses both, the cost of eliminating contaminated feed and the reduction in animal productivity. Therefore, the increase in veterinary care costs and technical efforts aimed at reducing mycotoxins negative effects. Cereals and by-products constitute the main ingredients of finished feed in production animals. Food processing affects mycotoxin distribution and concentration. The mycotoxin distribution in cereal processing procedures is a worldwide problem due to the high economic and health impacts. The use of a safe diet in which the risk of mycotoxin contamination can be minimized and the cost/benefit is accurately quantified should allow the maximization of herd productivity. The present review intends to address the problem of animal feed contamination describing the impact on animal health and productivity. Moreover, the economic impact generated by mycotoxins and their control in the animal feed industry was considered.

Increase in direct social care costs of Alzheimer's disease in Japan depending on dementia severity.

With the aging population, costs of direct social support for patients with Alzheimer's disease have grown and will continue to increase. The purpose of the present study was to estimate the cost of direct social support for Alzheimer's disease under long-term care insurance in Japan. This cross-sectional study included 169 patients with Alzheimer's disease or mild cognitive impairment who visited a memory clinic and were followed over time. Dementia severity, use of care services and costs were analyzed. The use of direct social support and costs increased significantly between patients with mild, moderate and severe dementia (P < 0.001). In particular, the use of day services and short stay services increased with the severity of dementia (P < 0.001). Similar findings were obtained when participants were stratified by long-term care insurance care levels. Of 169 participants, 49 had not applied for long-term care insurance, although their dementia severity was not different from support-need level 1 and care-need level 1. Logistic regression analysis of "did not apply" and "applied and certified" groups showed significant differences not only in dementia severity, but also in age (odds ratio 1.112, 95% confidence interval 1.037-1.193, P = 0.003) and living arrangements (odds ratio 0.257, 95% confidence interval 0.076-0.862, P = 0.028). As the number of patients with Alzheimer's disease increases, direct social costs will increase. The findings of this study might help standardize the type of direct social support provided after diagnosis of Alzheimer's disease and contribute to the development of cost-effective care for these patients. Geriatr Gerontol Int 2019; 19: 1023-1029.