Mean Cost Of Care Research Articles

Evolving etiologies, comorbidities, survival, and costs of care in adult encephalitis.

Encephalitis is a central nervous system disorder, often caused by infectious agents or aberrant immune responses. We investigated causes, comorbidities, costs, and outcomes of encephalitis in a population-based cohort. ICD-10 codes corresponding to encephalitis were used to identify health services records for all adults from 2004 to 2019. Data were cross-validated for identified diagnoses based on laboratory confirmation using univariate and multivariate statistical analyses. We identified persons with a diagnosis of encephalitis and abnormal cerebrospinal fluid (CSF) results (n = 581) in whom viral genome was detected (n = 315) in a population of 3.2 million adults from 2004 to 2019. Viral genome-positive CSF samples included HSV-1 (n = 133), VZV (n = 116), HSV-2 (n = 34), enterovirus (n = 4), EBV (n = 5), and CMV (n = 3) with the remaining viruses included JCV (n = 12) and HHV-6 (n = 1). The mean Charlson Comorbidity Index (2.0) and mortality rate (37.6%) were significantly higher in the CSF viral genome-negative encephalitis group although the mean costs of care were significantly higher for the CSF viral genome-positive group. Cumulative incidence rates showed increased CSF VZV detection in persons with encephalitis, which predominated in persons over 65years with a higher mean Charlson index. We detected HSV-2 and VZV more frequently in CSF from encephalitis cases with greater material-social deprivation. The mean costs of care were significantly greater for HSV-1 encephalitis group. Encephalitis remains an important cause of neurological disability and death with a viral etiology in 54.2% of affected adults accompanied by substantial costs of care and mortality. Virus-associated encephalitis is evolving with increased VZV detection, especially in older persons.

A value-based comparison of the management of respiratory diseases in walk-in clinics and emergency departments.

Our aim was to compare some of the health outcomes and costs associated with value of care in emergency departments (ED) and walk-in clinics for ambulatory patients presenting with an acute respiratory disease. A health records review was conducted from April 2016 through March 2017 in one ED and one walk-in clinic. Inclusion criteria were: (i) ambulatory patients at least 18years old, (ii) discharged home with a diagnosis of upper respiratory tract infection (URTI), pneumonia, acute asthma, or acute exacerbation of chronic obstructive pulmonary disease. Primary outcome was the proportion of patients returning to any ED or walk-in clinic within three and seven days of the index visit. Secondary outcomes were the mean cost of care and the incidence of antibiotic prescription for URTI patients. The cost of care was estimated from the Ministry of Health's perspectives using time-driven activity-based costing. The ED group included 170 patients and the walk-in clinic group 326 patients. The return visit incidences at three and seven days were, respectively, 25.9% and 38.2% in the ED vs. 4.9% and 14.7% in the walk-in clinic (adjusted relative risk (arr) of 4.7 (95% CI 2.6-8.6) and 2.7 (1.9-3.9)). The mean cost ($Cdn) of the index visit care was 116.0 (106.3-125.7) in the ED vs. 62.5 (57.7-67.3) in the walk-in clinic (mean difference of 56.4 (45.7-67.1)). Antibiotic prescription for URTI was 5.6% in the ED vs. 24.7% in the walk-in clinic (arr 0.2, 0.01-0.6). This study is the first in a larger research program to compare the value of care between walk-in clinics and the ED. The potential advantages of walk-in clinics over EDs (lower costs, lower incidence of return visits) for ambulatory patients with respiratory diseases should be considered in healthcare planning.

A single-patient-use ECG system for cardiothoracic surgery admissions in the UK: A cost-consequence analysis.

Deep sternal wound infections (DSWI) are severe complications in up to 1.36% of coronary artery bypass grafting (CABG) procedures in the United Kingdom. Each event adds between £4,000 and £11,000 in healthcare costs, owing primarily to prolonged hospitalisations. ECG devices have been shown to convey infection throughout perioperative CABG. On the other hand, single-patient ECG devices (spECG) can effectively reduce the incidence of surgical site infections (SSI), including DSWI, but no assessment of spECG impact in NHS cardiac units has been conducted. To estimate the impact of spECG on NHS cardiac units, we conducted a cost-consequence analysis modeling the CABG care pathway in the United Kingdom using Simul8 software for a probabilistic, individual-patient simulation. The simulation time was 1 year, with each patient followed from admission through 30 days post-discharge. The base case simulation mirrors the cardiac unit of Bart Health NHS Trust, London. A total of 2,183 patients are generated with demographic and clinical attributes from probabilistic distributions informed by hospital-specific inputs from NHS Digital Data. The Brompton Harefield Infection Score (BHIS) is allocated to gauge the risk of SSI. Results are averaged across 50 independent and randomly seeded iterations. Simulation results indicate a base-case savings of £388 per patient, determined by the incidence of infections rather than the number of CABG procedures. In the base-case simulation, the mean cost of care with rECG was £13,096, whereas the mean cost with spECG was £12,708, resulting in a cost saving of £388 (2021 GBP). The simulation yielded an overall 8.6% SSI incidence rECG, whereas the incidence of SSIs with spECG was 6.9%. The model was most sensitive to changes in general ward and ICU costs, and infection incidence was a stronger predictor of potential per-patient savings than annual CABG volume. Single-patient ECG is a sustainable and effective alternative to reusable ECG cables and lead wires in terms of patient safety and resource allocation.

Abstract P4-07-46: The Out-of-Pocket Cost of Breast Cancer Care in Nigeria: A Prospective Analysis

Abstract Introduction A major barrier to timely breast cancer diagnosis and care in Nigeria is attributable to the out-of-pocket cost of accessing healthcare services, despite the presence of a National Health Insurance Scheme (NHIS). Excessive out-of-pocket payments are often associated with a catastrophic health care expenditure (CHE). Despite the rising incidence of breast cancer in Nigeria, there is a paucity of economic data on the cost of care and the impact healthcare expenditure may have on a household. This study provides a comprehensive, prospective analysis of out-of-pocket spending for breast cancer care at a single tertiary care institution in South West Nigeria. Methods Consecutive patients undergoing curative intent surgery for a new diagnosis of breast cancer at Obafemi Awolowo University Teaching Hospital (OAUTH) between August 2019-April 2022 were approached for enrolment. A novel, context specific questionnaire was developed for this study and administered by trained personnel. The questionnaire was delivered to patients and caregivers during hospital admission and again during six-month follow-up. Participants were asked to estimate monthly household income and expenditures. Out-of-pocket direct and indirect expenses for breast cancer diagnosis and care were elicited. Where feasible, hospital accounting records and individual receipts were used to minimize recall bias. Sequelae of the out-of-pocket costs were also elicited, such as the use of debt financing and important forgone expenditures, such as childhood education. Capacity-to-pay was calculated for each household from the provided data as the sum of annual non-food expenditures. A CHE was defined as an aggregate healthcare expenditure that exceeded 40% of a household’s capacity-to-pay. All monetary figures were collected in the local currency (Naira) and converted to USD using the Nigerian Central Bank conversion rate of 415.83N to 1USD. Research ethics board approval was obtained for this study from OAUTH. Results Data were collected from 57 eligible patients with a mean age of 49.8 years (SD 12). The median household size was five (range 1-10) and the majority (75.4%) had completed at least secondary education. Seventy four percent (73.6%) of patients had ≥ Stage III disease at presentation and 89.5% received systemic chemotherapy. Only seven percent (4/received adjuvant radiotherapy. The mean annual capacity-to-pay for the cohort was $2,840.8 ($2,913.6). The mean cost of care, including direct and indirect expenditure was $3,379.7 (SD $3032.2). Excluding indirect costs, such as the cost of travel and self-reported lost income, the mean cost of direct expenditures associated with diagnosis and treatment was $1,705.3 (SD $1,236.6). Out of the 57 patients enrolled in the study 52 (91.2%) experienced a CHE as a result of their breast cancer treatment. As a result, 56% of households had to borrow money and seven percent withdrew children from school. Sixty-three percent of patients had no form of health insurance. Conclusions Over 90% of breast cancer patients at a tertiary care facility in Nigeria experience a CHE as a result of out-of-pocket costs associated with accessing care. This limits access to costly evidence-based adjuncts (i.e. radiotherapy) and has a negative impact on the wellbeing of the broader household. There is a need for national and global initiatives to ensure financial protection from the cost of breast cancer care. Citation Format: Funmilola Wuraola, Chloe Blackman, Israel Adeyemi Owoade, Adeoluwa Oluwaseyi Adeleye, Peter Kingham, Olusegun Alatise, Gregory Knapp. The Out-of-Pocket Cost of Breast Cancer Care in Nigeria: A Prospective Analysis [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P4-07-46.

Dying with Parkinson's Disease: Healthcare Utilization and Costs in the Last Year of Life.

The end-of-life period is associated with disproportionately higher health care utilization and cost at the population level but there is little data in Parkinson's disease (PD). The goals of this study were to 1) compare health care use and associated cost in the last year of life between decedents with and without PD, and 2) identify factors associated with palliative care consultation and death in hospital. Using linked administrative datasets held at ICES, we conducted a retrospective, population-based cohort study of all Ontario, Canada decedents from 2015 to 2017. We examined demographic data, rate of utilization across healthcare sectors, and cost of health care services in the last year of life. We identified 291,276 decedents of whom 12,440 (4.3%) had a diagnosis of PD. Compared to decedents without PD, decedents with PD were more likely to be admitted to long-term care (52% vs. 23%, p < 0.001) and received more home care (69.0 vs. 41.8 days, p < 0.001). Receipt of palliative homecare or physician palliative home consultation were associated with lower odds of dying in hospital (OR: 0.24, 95% CI: 0.19- 0.30, and OR: 0.38, 95% CI: 0.33- 0.43, respectively). Mean cost of care in the last year of life was greater for decedents with PD ($68,391 vs. $59,244, p < 0.001). Compared to individuals without PD, individuals with PD have higher rates of long-term care, home care and higher health care costs in the last year of life. Palliative care is associated with a lower rate of hospital death.

The length of stay and inpatient burden in inpatients with different psoriasis subtypes.

Background: Heavy disease burden of psoriasis has been indicated by previous studies. However, the cost of care and length of stay (LOS) in inpatients with different psoriasis subtypes were rarely addressed. This study aimed to investigate the cost of care and LOS in Chinese patients with different psoriasis types and to clarify the independent factors affecting LOS.Methods: We conducted a cross-sectional study by enrolling patients with psoriasis who were hospitalized between 13 Feb 2017 and 29 Mar 2021. Demographic and clinical characteristics of the patients were collected by reviewing their Electronic Medical Records. Multivariate linear regression was used to estimate the associations with adjustments.Results: A total of 310 adult patients with psoriasis were included (mean cost of care: 13.0±22.3 kCNY; mean LOS: 7.9±4.3 days). Statistically significant differences were found among patients with different psoriasis subtypes in LOS (P<0.001) but not in the cost of care (P=0.530). Relative to psoriasis vulgaris, pustular psoriasis (Adjusted coefficient: 2.37, 95% confidence interval (CI): 0.87-3.87) and erythrodermic psoriasis (Adjusted coefficient: 2.92, 95%CI: 1.38-4.47) were significantly associated with an increased LOS. Meanwhile, respiratory tract infections (Adjusted coefficient: 1.60, 95%CI: 0.11-3.10) also significantly increased the LOS. On the contrary, a decreased LOS was found in psoriatic arthritis patients treated with TNF-alpha inhibitors (Adjusted coefficient: -2.21, 95%CI: -4.37 to -0.05).Conclusions: LOS differed significantly among different psoriasis subtypes while the inpatient burden for a single hospitalization was alike. Infection is an important factor associated with a longer LOS. TNF-alpha inhibitors evidently reduced the total hospital stay period for patients with psoriatic arthritis.

Cost and Cost Driver Analysis of Anterior Cruciate Ligament Reconstruction Using Time-Driven Activity-Based Costing: Bone-Tendon-Bone Autograft Versus Hamstring Autograft.

Background:As health care transitions toward value-based care, orthopaedics has started to implement time-driven activity-based costing (TDABC) to understand costs and cost drivers. TDABC has not previously been used to study cost drivers in anterior cruciate ligament reconstruction (ACLR). The purpose of this study was to use TDABC to (1) calculate bone-tendon-bone (BTB) and hamstring ACLR total costs of care and (2) evaluate the impact of graft choice and other factors on ACLR costs.Methods:Data were collected from electronic medical records for primary ACLR from the institutional patient-reported outcome registry between 2009 and 2016 in 1 ambulatory surgery center. Patients receiving allograft, revision ACLR, or concomitant meniscal repair or ligament reconstruction were excluded. The total cost of care was determined using TDABC. Multivariate regression analysis was conducted between ACLR cost and group characteristics.Results:A total of 328 patients were included; 211 (64.3%) received BTB autograft and 117 (35.7%) received hamstring autograft. The mean cost was $2,865.01 ± $263.45 (95% confidence interval: $2,829.26, $2,900.77) for BTB ACLR versus $3,377.44 ± $320.12 ($3,318.82, $3,436.05) for hamstring ACLR (p < 0.001). Operative time was 103.1 ± 25.1 (99.7, 106.5) minutes for BTB ACLR versus 113.1 ± 27.9 (108.0, 118.2) minutes for hamstring ACLR (p = 0.001). The total implant cost was $270.32 ± $97.08 ($257.15, $283.50) for BTB ACLR versus $587.36 ± $108.78 ($567.44, $607.28) for hamstring ACLR (p < 0.001). Hamstring graft (p = 0.006) and suspensory fixation on the femoral side (p = 0.011) were associated with increased costs.Conclusions:The mean cost of care and operative time for BTB autograft ACLR are less than those for hamstring autograft ACLR. Operative time, implant choice, and graft choice were identified as modifiable cost drivers that can empower surgeons to manage primary ACLR costs while maximizing the value of the procedure.Level of Evidence:Economic and Decision Analysis Level IV. See Instructions for Authors for a complete description of levels of evidence.

Cost of Pediatric Acute Lymphoblastic Leukemia Care in the Current Treatment Era

Introduction: Acute lymphoblastic leukemia (ALL) is the most common malignancy of childhood, with a current incidence of 3,000 cases annually. Incremental alterations in treatment over time have resulted in overall survival rates that now exceed 90%. Although minor differences exist between ALL treatment protocols from different cooperative groups, risk-stratified treatment for ALL is generally standard across the country. As more has been understood about ALL biology and outcomes, treatments have been further risk stratified to optimize outcomes for higher risk individuals while minimizing toxicities for those with more favorable disease characteristics. With the improvements in outcome for ALL, cost of care is a critical component and financial toxicity for patients and society requires evaluation.Methods: Using commercial insurance data from the OptumLabs ® Data Warehouse, a cohort of 1941 ALL patients was identified, aged 1-30 years and diagnosed between 2000 and 2017 in the United States. ALL diagnosis was confirmed based on ICD-9 and ICD-10 diagnostic codes, in combination with bone marrow and lumbar puncture procedure codes within 14 days of diagnosis. Individuals were followed up to 36 months from diagnosis. Mean monthly and cumulative costs were computed for the initial 8 months of therapy and for 36 months from diagnosis, as were mean number of inpatient and outpatient days. Costs were further broken down by the types of services provided. All results were stratified by age group (1-9 years, 10-12 years, ≥13 years) as a proxy for risk group, with the younger group most consistent with standard risk disease and the older groups indicating high risk and very high risk disease, respectively.Results: Among the 1941 identified ALL patients (1-9 years, 1233; 10-12 years, 162; ≥13 years, 546), 44% were female, 51% were white, median age at diagnosis was 6 years (interquartile range 3-14 years) and 941 of enrolled patients had continuous data through 36 months. Mean cost of care over the approximate 3 years of therapy was $537,000, with approximately 58% of costs incurred within the initial intensive 8 months of therapy. Mean cost was highest among the ≥13 year age group, both for the initial 8 months of therapy ($487,000, 95% CI $449,300-530,400)), as well as over the 36 months following diagnosis ($850,000, 95% CI $778,400-937,100) (Figure). This was reflective of the highest mean number of inpatient days among the ≥13 year age group (88.1 days over 36 months, 95% CI 82.1-94.9) compared to the 10-12 year group (73.2 days, 95% CI 64.3-85.1) and the 1-9 year group (47.5 days, 95% CI 45.2-50.9). Mean number of outpatient visits over 36 months was not significantly different between 1-9 and 10-12 year age groups but was significantly higher among the ≥13 year age group compared with the 1-9 year group. Thirty-six month survival varied by age group and was highest among the 1-9 year group (95.9%, 95% CI 94.6-97.2) compared with the 10-12 year group (90.5%, 95% CI 85-4-95.8) and the ≥13 year group (79.6%, 95% CI 75.8-83.6).Conclusions: This robust real-world cost analysis shows for the first time that the average cost of ALL care in the current treatment era, including inpatient and outpatient data, is more than $500,000. We showed that the cost of care is highest among the oldest pediatric age group, indicating increasing cost with increased therapeutic intensity. This study provides a valuable benchmark that can be used to analyze the financial toxicity of ALL therapy on patients and families and can be re-assessed over time as novel therapeutics are introduced into ALL therapy. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

A Value-Based Comparison of the Management of Ambulatory Respiratory Diseases in Walk-in Clinics, Primary Care Practices, and Emergency Departments: Protocol for a Multicenter Prospective Cohort Study.

BackgroundIn Canada, 30%-60% of patients presenting to emergency departments are ambulatory. This category has been labeled as a source of emergency department overuse. Acting on the presumption that primary care practices and walk-in clinics offer equivalent care at a lower cost, governments have invested massively in improving access to these alternative settings in the hope that patients would present there instead when possible, thereby reducing the load on emergency departments. Data in support of this approach remain scarce and equivocal.ObjectiveThe aim of this study is to compare the value of care received in emergency departments, walk-in clinics, and primary care practices by ambulatory patients with upper respiratory tract infection, sinusitis, otitis media, tonsillitis, pharyngitis, bronchitis, influenza-like illness, pneumonia, acute asthma, or acute exacerbation of chronic obstructive pulmonary disease.MethodsA multicenter prospective cohort study will be performed in Ontario and Québec. In phase 1, a time-driven activity-based costing method will be applied at each of the 15 study sites. This method uses time as a cost driver to allocate direct costs (eg, medication), consumable expenditures (eg, needles), overhead costs (eg, building maintenance), and physician charges to patient care. Thus, the cost of a care episode will be proportional to the time spent receiving the care. At the end of this phase, a list of care process costs will be generated and used to calculate the cost of each consultation during phase 2, in which a prospective cohort of patients will be monitored to compare the care received in each setting. Patients aged 18 years and older, ambulatory throughout the care episode, and discharged to home with one of the aforementioned targeted diagnoses will be considered. The estimated sample size is 1485 patients. The 3 types of care settings will be compared on the basis of primary outcomes in terms of the proportion of return visits to any site 3 and 7 days after the initial visit and the mean cost of care. The secondary outcomes measured will include scores on patient-reported outcome and experience measures and mean costs borne wholly by patients. We will use multilevel generalized linear models to compare the care settings and an overlap weights approach to adjust for confounding factors related to age, sex, gender, ethnicity, comorbidities, registration with a family physician, socioeconomic status, and severity of illness.ResultsPhase 1 will begin in 2021 and phase 2, in 2023. The results will be available in 2025.ConclusionsThe end point of our program will be for deciders, patients, and care providers to be able to determine the most appropriate care setting for the management of ambulatory emergency respiratory conditions, based on the quality and cost of care associated with each alternative.International Registered Report Identifier (IRRID)PRR1-10.2196/25619

Cost of hospital care of women with postpartum haemorrhage in India, Kenya, Nigeria and Uganda: a financial case for improved prevention

ObjectiveAccess to quality, effective lifesaving uterotonics in low and middle-income countries (LMICs) remains a major barrier to reducing maternal deaths from postpartum haemorrhage (PPH). Our objective was to assess the costs of care for women who receive different preventative uterotonics, and with PPH and no-PPH so that the differences, if significant, can inform better resource allocation for maternal health care.MethodsThe costs of direct hospital care of women who received oxytocin or heat-stable carbetocin for prevention of PPH in selected tertiary care facilities in India, Kenya, Nigeria, and Uganda were assessed. We collected data from all women who had PPH, as well as a random sample of women without PPH. Cost data was collected for the cost of stay, PPH interventions, transfusions and medications for 2966 women. We analyzed the difference in cost of care at a facility level between women who experienced a PPH event and those who did not.Key findingsThe mean cost of care of a woman experiencing PPH in the study sites in India, Kenya, Nigeria, and Uganda exceeded the cost of care of a woman who did not experience PPH by between 21% and 309%. There was a large variation in cost across hospitals within a country and across countries.ConclusionOur results quantify the increased cost of PPH of up to 4.1 times that for a birth without PPH. PPH cost information can help countries to evaluate options across different conditions and in the formulation of appropriate guidelines for intrapartum care, including rational selection of quality-assured, effective medicines. This information can be applied to national assessment and adaptation of international recommendations such as the World Health Organization’s recommendations on uterotonics for the prevention of PPH or other interventions used to treat PPH. Trial registration HRP Trial A65870; UTN U1111-1162-8519; ACTRN12614000870651; CTRI/2016/05/006969, EUDRACT 2014–004445-26. Date of registration 14 August 2014Plain English summaryAccess to quality, effective lifesaving medicines in low and middle-income countries remains a major barrier to reducing maternal deaths from bleeding after childbirth. Information on to what extent treatments for bleeding increases the cost of care of women after childbirth is important for informed resource allocation.We collected data from all women who had bleeding after childbirth, as well as a random sample of women without bleeding in selected hospitals in India, Kenya, Nigeria, and Uganda. Cost data was collected for the cost of stay and interventions to manage bleeding for 2966 women. We compared the difference in cost of care between women who experienced a bleeding event and those who did not.The mean cost of care of a woman with bleeding in the study sites exceeded the cost of care of a woman who did not experience PPH by between 21% and 309%. There was a large variation in cost across hospitals within a country and across countries.Our results indicate an increased cost of bleeding of up to 4.1 times that for birth without bleeding. Effective prevention reduces the cost of care. Cost information can help countries to evaluate options across different conditions and in the formulation of appropriate guidelines for intrapartum care, including rational selection of quality-assured, effective medicines. This information can be applied to national assessment and adaptation of international recommendations such as the World Health Organization’s recommendations on medications for the prevention of bleeding after childbirth or other interventions used to treat bleeding.

Restorative surgery for ulcerative colitis in the elderly: an analysis of ileal pouch-anal anastomosis procedures from the American College of Surgeons National Surgical Quality Improvement Program.

Ileal pouch-anal anastomosis (IPAA) for ulcerative colitis(UC) can be performed as either 2- or 3-stage procedure. IPAA in the elderly has been reported as safe and feasible, but little work to date has assessed outcomes by procedure. The aim of our study was to assess use and short-term outcomes of 2- and 3-stage IPAA in older adults. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was searched for ≥ 65-year-old patients who underwent IPAA for UC in 2- or 3-stage from 2012 to 2016. The primary endpoint was the rate and trends of the two approaches over time. Secondary endpoints included 30-day adverse events and complication-associated costs. Overall, 123 patients were included: 77.5% (n = 83) 2-stage and 40 (32.5%) 3-stage IPAA. Mean age was 68.7 ± 3.9years, with 43 (34.9%) women. The use of the 3-stage IPAA increased over time (18.8% in 2012 vs. 33.3% in 2016), with decreasing use of 2-stage IPAA(81.3% vs. 66.7%, p < 0.001). The morbidity associated with the procedures decreased over time, overall (81.3% in 2012 and 51.5% in 2016, p < 0.001) and in each group individually. No differences were observed in postoperative complications across groups (45.8% 2-stage, 32.5% 3-stage). The overall mean costs of care when no postoperative complications occurred was $25,910, vs. $38,577 when any complication occurred (p < 0.001), but no differences were observed between groups. In a national analysis, there was a trend of increasing 3-stage vs. 2-stage IPAA for UC in older Americans. Complications and complication-associated costs were comparable across approaches, suggesting that the choice of procedure type should be based on the specific patient comorbidities and surgeon preferences.

Restorative surgery for ulcerative colitis in the elderly: an analysis of ileal pouch-anal anastomosis procedures from the American College of Surgeons National Surgical Quality Improvement Program.

Ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) can be performed as either 2- or 3-stage procedure. IPAA in the elderly has been reported as safe and feasible, but little work to date has assessed outcomes by procedure. The aim of our study was to assess use and short-term outcomes of 2- and 3-stage IPAA in older adults. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Database was searched for ≥ 65-year-old patients who underwent IPAA for UC in 2- or 3-stage from 2012 to 2016. The primary endpoint was the rate and trends of the two approaches over time. Secondary endpoints included 30-day adverse events and complication-associated costs. Overall, 123 patients were included: 77.5% (n = 83) 2-stage and 40 (32.5%) 3-stage IPAA. Mean age was 68.7 ± 3.9years, with 43 (34.9%) women. The use of the 3-stage IPAA increased over time (18.8% in 2012 vs. 33.3% in 2016), with decreasing use of 2-stage IPAA (81.3% vs. 66.7%, p < 0.001). The morbidity associated with the procedures decreased over time, overall (81.3% in 2012 and 51.5% in 2016, p < 0.001) and in each group individually. No differences were observed in postoperative complications across groups (45.8% 2-stage, 32.5% 3-stage). The overall mean costs of care when no postoperative complications occurred was $25,910, vs. $38,577 when any complication occurred (p < 0.001), but no differences were observed between groups. In a national analysis, there was a trend of increasing 3-stage vs. 2-stage IPAA for UC in older Americans. Complications and complication-associated costs were comparable across approaches, suggesting that the choice of procedure type should be based on the specific patient comorbidities and surgeon preferences.

Influence of Influenza Infection on In-Hospital Acute Myocardial Infarction Outcomes

Influenza is associated with significant morbidity in the United States but its influence on in-hospital outcomes in patients with AMI has not been well studied. The Nationwide Readmission Database (NRD) from 2010 to 2014 was queried using the International Classification of Diseases-Ninth edition, Clinical Modification (ICD-9-CM) codes to identify all patients ≥18 years who were admitted for AMI with and without concurrent influenza. Propensity score matching was used to adjust patients' baseline characteristics and co-morbidities. In-hospital mortality, 30-day readmission rates, in-hospital complications, and resource utilization were analyzed. We identified a total of 2,428,361 patients admitted with AMI, of whom 3,006 (0.12%) had coexisting influenza. We noted significantly higher in-hospital mortality (7.7% vs 5.6%, p <0.01) and 30-day readmission rates (15.8% vs 14.1%, p <0.01) in patients with influenza compared with those without it. After propensity matching, the differences in in-hospital mortality and 30-day readmission were no longer statistically significant between the groups. Patients with influenza had a higher incidence of acute kidney injury (30.9% vs 24.6%, p <0.01), acute respiratory failure (50.2% vs 32.2%, p <0.01), need for mechanical ventilation (13.9% vs 9.2%, p <0.01), and sepsis (10% vs 3.8%, p <0.01) in the matched cohort. Patients with influenza had longer hospital stays (8.4 days vs 6.4 days, p <0.01) and mean costs of care (26,200USD vs 23,400USD, p <0.01). In conclusion, AMI patients with concomitant influenza infection had higher in-hospital mortality, 30-day readmission, in-hospital complications, and higher resource utilization compared with those without influenza.

Preoperative Risk Factor Screening Protocols in Total Joint Arthroplasty: A Systematic Review

BackgroundPreoperative optimization protocols targeting potentially modifiable risk factors could prove beneficial in reducing the rate of complications in lower extremity total joint arthroplasty (LE-TJA). We aimed to summarize the evidence on preoperative screening protocols targeting modifiable risk factors to assess their effect on postoperative outcomes following primary LE-TJA. MethodsA literature search of MEDLINE, EMBASE, CINAHL, and Cochrane Library databases was performed in August 2019. The bibliographies of relevant publications were searched for further applicable studies. Included studies were required to report at least one outcome including prosthetic joint infection/surgical site infection (PJI/SSI), hospital length of stay (LOS), disposition, 90-day emergency department visits, or hospital readmissions after implementation of an evidence-based preoperative optimization protocol targeting modifiable risk factors. Methodological quality of included studies was assessed using the methodological index for non-randomized studies (MINORS) criteria. ResultsA total of 8 retrospective cohort studies including 9915 patients were reviewed. Implementation of preoperative optimization protocols were associated with reductions in SSI (0.56% vs. 2.60%; RR 0.21 [95% CI 0.12 to 0.37]; P < .00001), hospital LOS, mean cost of care, and hospital readmission rates. The mean MINORS score for comparative studies was 16.285. ConclusionsImplementation and compliance with evidence-based preoperative protocols for optimization of modifiable risk factors is associated with overall improved outcomes following LE-TJA. SSI, hospital LOS, average total cost of care, and hospital readmission rates were favorable in those cohorts subjected to a preoperative intervention protocol. Future prospective studies are necessary for further refinement of preoperative optimization protocols and referral algorithms, without compromising patients’ access to surgery. Level of EvidenceIII, Systematic Review;

Drivers of care costs and quality in the last 3 months of life among older people receiving palliative care: A multinational mortality follow-back survey across England, Ireland and the United States

Background: Care costs rise towards the end of life. International comparison of service use, costs and care experiences can inform quality and improve access. Aim: The aim of this study was to compare health and social care costs, quality and their drivers in the last 3 months of life for older adults across countries. Null hypothesis: no difference between countries. Design: Mortality follow-back survey. Costs were calculated from carers’ reported service use and unit costs. Setting: Palliative care services in England (London), Ireland (Dublin) and the United States (New York, San Francisco). Participants: Informal carers of decedents who had received palliative care participated in the study. Results: A total of 767 questionnaires were returned: 245 in England, 282 in Ireland and 240 in the United States. Mean care costs per person with cancer/non-cancer were US$37,250/US$37,376 (the United States), US$29,065/US$29,411 (Ireland), US$15,347/US$16,631 (England) and differed significantly (F = 25.79/14.27, p < 0.000). Cost distributions differed and were most homogeneous in England. In all countries, hospital care accounted for > 80% of total care costs; community care 6%–16%, palliative care 1%–15%; 10% of decedents used ~30% of total care costs. Being a high-cost user was associated with older age (>80 years), facing financial difficulties and poor experiences of home care, but not with having cancer or multimorbidity. Palliative care services consistently had the highest satisfaction. Conclusion: Poverty and poor home care drove high costs, suggesting that improving community palliative care may improve care value, especially as palliative care expenditure was low. Major diagnostic variables were not cost drivers. Care costs in the United States were high and highly variable, suggesting that high-cost low-value care may be prevalent.

Variation of the Inpatient Cost of Care in the Treatment of Isolated Geriatric Intertrochanteric Hip Fractures.

Introduction:Geriatric hip fractures are a major, costly public health issue, expected to increase in incidence and expense with the aging population. As healthcare transitions towards value-based care, understanding cost drivers of hip fracture treatment will be necessary to perform adequate risk adjustment. Historically, cost has been variable and difficult to determine. This study was purposed to identify variables that can predict the overall cost of care for geriatric intertrochanteric (IT) hip fractures and provide a better cost prediction to ensure the success of future bundled payment models.Methods:A retrospective review of operatively-managed geriatric hip fractures was performed at single urban level I academic trauma center between 2013 and 2017. Patient variables were collected via the electronic medical record (EMR) including CCI, ACCI, ASA, overall length of stay (LOS), AO/OTA fracture classification and demographics. Direct and indirect costs were calculated by activity-based costing by the hospital’s accounting software. Multivariable linear regression models evaluated which parameters predicted total inpatient cost of care.Results:The mean cost of care was $19,822, ranging from $9,128 to $64,211. Critical care comprised 16.9% of total costs, followed by implant costs (13.6%), and nursing costs (12.6%). Regression analysis identified both ASA (p < 0.01) and ACCI (p = 0.01) as statistically significant associative parameters, but only LOS (r 2 = 0.77) as a strong correlative measure for inpatient care cost.Conclusion:This study found no correlation between ACCI or ASA and the total inpatient cost of care in isolated intertrochanteric geriatric hip fractures, suggesting that the inpatient episode-of-care costs cannot be accurately predicted by the patient demographics/comorbidities alone. Future bundled care payment models would have to be adjusted to account for variables beyond just patient characteristics.Level of Evidence:Diagnostic Level IV.

Dying of amyotrophic lateral sclerosis: Health care use and cost in the last year of life.

To describe health care service utilization and cost for decedents with and without amyotrophic lateral sclerosis (ALS) in the last year of life. Using linked health administrative data, we conducted a retrospective, population-based cohort study of Ontario, Canada, decedents from 2013 to 2015. We examined demographic data, rate of utilization, and cost of health care services in the last year of life. We identified 283,096 decedents in Ontario, of whom 1,212 (0.42%) had ALS. Decedents with ALS spent 3 times as many days in an intensive care unit (ICU) (mean 6.3 vs 2.1, p < 0.001), and twice as many days using complex continuing care (mean 12.7 vs 6.0, p < 0.001) and home care (mean 99.1 vs 41.3, p < 0.001). A greater percentage of decedents with ALS received palliative home care (44% vs 20%, p < 0.001) and palliative physician home visits (40% vs 18%, p < 0.001) than decedents without ALS. Among decedents with ALS, a palliative physician home visit in the last year of life was associated with reduced adjusted odds of dying in hospital (odds ratio 0.65, 95% confidence interval 0.48-0.89) and fewer days spent in the ICU. Mean cost of care in the last year of life was greater for those with ALS ($68,311.98 vs $55,773.48, p < 0.001). In this large population-based cohort of decedents, individuals with ALS spent more days in the ICU, received more community-based services, and incurred higher costs of care in the last year of life. A palliative care physician home visit was associated with improved end of life outcomes; however, the majority of patients with ALS did not access such services.

A growing challenge: The rise of femoral periprosthetic fractures – An 11-year observational study

IntroductionThe demand for joint arthroplasty has risen as our elderly population increases and ages. With this so to has the number of patients suffering periprosthetic fractures (PPF). The aim of our study was to quantify the burden of PPF and provide an up to date reference of the epidemiology of PPF in Ireland. We also sought to assess length of stay (LOS), resource utilisation and mortality associated with this cohort of patients. MethodsAn eleven-year retrospective observational study was conducted of a consecutive series of patients treated for a femoral PPF. Costs were obtained from activity based tariffs provided by the hospital inpatient enquiry system and mortality was confirmed using the national death events publication system. ResultsOver the 11-year study period 174 procedures for a femoral PPF were performed. Mean age of patients was 77.6 years (SD 11.1 years) with 44.7% male. Median ASA grade was 3 (range 1–4) and mean LOS was 19 days. There was a 700% increase in patients undergoing surgery for a PPF over the study period. The mean cost of care was €24,413 in 2017. Thirty-day mortality was 2.9% while one-year mortality was 12.4%. ConclusionsPPF occur in an elderly comorbid cohort of patients. Care of these patients now makes up a considerable part of the orthopaedic workload and consumes a significant portion of healthcare resources. Patients should be treated in tertiary referral centres with surgeons skilled in their management. Better access to rehabilitation is needed.

Quantifying the costs and profitability of care for diabetic foot ulcers treated in a multidisciplinary setting

ObjectiveIncreasing Wound, Ischemia, and foot Infection (WIfI) stage has previously been shown to be associated with prolonged wound healing time, higher number of surgical procedures, and increased cost of care in patients with diabetic foot ulcers (DFUs) treated in a multidisciplinary setting. However, the profitability of this care model is unknown. We aimed to quantify the hospital costs and net margins associated with multidisciplinary DFU care. MethodsAll patients presenting to our multidisciplinary diabetic limb preservation service (January 2012-June 2016) were enrolled in a prospective database. Inpatient and outpatient costs and net margin (U.S. dollars) were calculated for each wound episode (initial visit until complete wound healing) overall and per day of care according to WIfI classification. ResultsA total of 319 wound episodes in 248 patients were captured. Patients required an average of 2.6 ± 0.2 inpatient admissions and 0.9 ± 0.1 outpatient procedures to achieve complete healing. Limb salvage at 1 year was 95.0% ± 2.4%. The overall mean cost of care per wound episode was $24,226 ± $2176, including $41,420 ± $3318 for inpatient admissions and $11,265 ± $1038 for outpatient procedures. The mean net margin was $2412 ± $375 per wound episode, including $5128 ± $622 for inpatient admissions and a net loss ($−3730 ± $596) for outpatient procedures. Mean time to wound healing was 136.3 ± 7.9 days, ranging from 106.5 ± 13.1 days for WIfI stage 1 wounds to 229.5 ± 20.0 days for WIfI stage 4 wounds (P < .001). When adjusted for days of care, the net margin ranged from $2.6 ± $1.3 per day (WIfI stage 1) to $23.6 ± $18.8 (WIfI stage 4). ConclusionsThe costs associated with multidisciplinary DFU care are substantial, especially with advanced-stage wounds. Whereas hospitals can operate at a profit overall, the net margins associated with outpatient procedures performed in a hospital-based facility are prohibitive, and the overall net margins are relatively low, given the labor required to achieve good outcomes. Thus, reimbursement for the multidisciplinary care of DFUs should be re-examined.

The estimated cost of surgically managed isolated traumatic head injury secondary to road traffic accidents.

OBJECTIVE Traumatic brain injury due to road traffic accidents occurs mainly in the younger age group in which injury-related disability leads to long-term impact on employment and economic and social consequences across the lifespan. This study was designed to assign a monetary cost (in Malaysian ringgits [RM]) to the treatment of patients with surgically treated isolated traumatic head injury as determined up to 1 year after injury. METHODS Relevant resource items used were identified and valued using the direct measurement of costs method, cost accounting methods, standard unit costs method, fees, charges and/or market prices method. These values were then tabulated to generate the total costs for each patient, via a combination of macro-costing and micro-costing methods. Malaysian currency values were converted to US dollars according to the average conversion rate for the period from January to May 2016: RM1 = US$0.2452. RESULTS This costing study analyzed data from 49 patients. The estimated cost for the 1st year of care for all patients was RM1,471,919.80 (US$360,914.735), with a mean (± SD) cost per case of RM30,039.18 ± 22,986.25 or $7365.61 ± $5636.23. The mean cost of care per case was RM11,041.35 ± 10,936.88 or $2707.34 ± $2681.72 for mild head injury, RM32,550.00 ± 20,998.76 or $7981.26 ± $5148.90 for moderate head injury, and RM36,917.86 ± 23,697.34 or $9052.26 ± $5810.59 for severe head injury. Severe head injury (p = 0.001), sustaining 2 or more intracranial pathologies (p = 0.01), having a poor Glasgow Outcome Scale (GOS) score (GOS score 1-3) (p = 0.02), requiring a tracheostomy (p < 0.001), and contracting pneumonia (p < 0.001) were significantly associated with higher cost. Logistic regression analysis revealed that cost of care increased by RM591.60 or $145.06 per year increment of age (β = RM591.60, p = 0.05). CONCLUSIONS The mean cost of treatment for traumatic head injury is high compared to the per capita income of RM37,900 in 2016. The cost values generated in this study provide baseline cost estimates that the authors hope will be used as a guide to determine where adequate funding should be allocated to provide timely and appropriate delivery of care.