Median Total Hospital Charges Research Articles

Trends and Outcomes in Sepsis Hospitalizations With and Without Acute kidney injury: A Nationwide Inpatient Analysis.

Despite rapid advances in treatment, sepsis currently remains a major public health challenge worldwide. Over the past several years, there has been an increase in the clinical incidence of sepsis, as well as an increase in hospitalization rates, which bear the majority of the economic burden associated with sepsis. Sepsis is a public health burden due to the high fatality rates and accompanying morbidity. However, the sepsis-related mortality rates have fallen steadily over the years. One of the most common organs to fail in patients with sepsis is the kidney, and acute kidney injury(AKI) is associated with high mortality rates. This study's primary goal was to assess the impact of AKI on the evolution and outcome of hospitalization of patients with sepsis. Adults (≥18 years) hospitalized for sepsis in the United States between 2010 and 2019 were retrospectively analysed using the nationally representative NIS database.Sepsis and acute kidney injury were defined using the codes of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). Of the 4,258,360 outcomes, 3,946,048 met the inclusion criteria. The prevalence of AKI among sepsis inpatients increased from 39.10% in 2010 to 41% in 2019, but the impact of AKI on mortality declined over time, with in-hospital mortality from AKI among sepsis inpatients decreasing from 26.30% in 2010 to 16.30% in 2019. Hospitalizations linked to AKI were substantially more likely to involve infection sites such as the urinary tract, gastrointestinal tract, and endocarditis. Numerous pathogenic floras, including Escherichia coli [E. coli], Staphylococcus aureus, Streptococcal, Enterococcus, and Pseudomonas, had greater rates among sepsis-related contacts with AKI. Furthermore, compared to hospitalization without comorbid AKI, the median total hospital charges and length of stay days for sepsis hospitalization with comorbid AKI were greater. With time, patients with sepsis have a higher frequency of AKI and a corresponding decline in mortality.

Outcomes Among Hospitalized Patients with Relapsing Multiple Myeloma Utilizing Palliative Care: A United States Population-Based Cohort Study

Background Multiple myeloma has a limiting effect on quality of life, with pain being a commonly reported symptom secondary to lytic lesions. Palliative care plays an important role in both pain management as well as addressing individualized goals of care. Newer treatment options are often implemented in patients with relapsing multiple myeloma, and have the potential to cause further treatment related adverse effects. The role of palliative care in this subgroup needs further exploration. Methods We utilized the 2018-2020 National Inpatient Sample (NIS) Database in conducting a retrospective cohort study. We identified hospitalized patients who have relapsing multiple myeloma and subsequently had a palliative care encounter using appropriate ICD-10 CM codes. We stratified patients based on whether they had a palliative care encounter during the hospitalization or not. A survey multivariable logistic and linear regression analysis was used to calculate adjusted odds ratios (ORs) for the primary and secondary outcomes. A p value of <0.05 was considered statistically significant. The aim of this study is to investigate the outcomes among hospitalized patients with relapsing multiple myeloma with an in-patient palliative care encounter looking primarily at the in-hospital mortality, hospital LOS as well as total hospital charges. Results We identified a total of 16,726 hospitalized patients with relapsing multiple myeloma, of which 11.30% (1890/16,726) had an in-patient palliative care encounter. The overall in-hospital mortality among those with multiple myeloma was 9.86% (1040/16,726). Among those who had a palliative care encounter, the overall in-hospital mortality rate was significantly higher at 29.97% (566/1890) (p=<0.001). Utilizing a stepwise survey multivariable logistic regression model that adjusted for patient and hospital level confounders, the inpatient palliative care encounter among hospitalized multiple myeloma patients significantly increased the risk for in-hospital mortality (adjusted OR 11.99, 95% confidence interval [CI], 8.03-17.92; p=<0.001), longer hospital LOS (median LOS 7 days versus 5 days, p=<0.001) and higher total hospital charges (median total hospital charge 76131 vs 48855, p=0.002) Conclusion Our analysis revealed a statistically significant increased risk of in-hospital mortality, hospital LOS, and total hospital charges in hospitalized patients with relapsing multiple myeloma who had a palliative care encounter. Caution should be exercised in interpreting these results as they may reflect uncontrolled and more advanced disease in patients utilizing palliative care. Further prospective studies are needed to better understand short and long-term outcomes in this patient population.

625 The Impact of the Mexico-San Diego Border Wall Extension on Spinal Injuries

INTRODUCTION: San Diego, California has one of the busiest international land borders in the world, and its unauthorized crossing is a contentious issue. The recent border height extension along the San Diego-Mexico border has led to a new set of physical risks to unauthorized individuals traversing the wall. METHODS: In this retrospective cohort study, patients who presented to the UC San Diego Trauma Center between 2016 and 2021 were considered. Two different cohorts were compared: pre-height extension (Jan 2016-May 2018), and post-height extension (January 2020-December 2021). Demographics, clinical data (fracture morphology, operative intervention, concurrent injuries, length of stay), and hospital costs were collected. Spinal injuries were normalized using Customs and Border Protection (CBP) apprehensions to adjust for changing migration rates. Statistical analysis was completed with Stata MP Version 14.1 (Stata Corp LP). RESULTS: A total of 114 patients met inclusion criteria: 12 in the pre-height extension period, and 102 in the post-height extension period. The increase in spine injuries per month (0.8 to 4.25) and operative spine injuries per month (0.3 to 1.7) were statistically significant (P < 0.001). Concurrent extremity injuries were also significantly increased (8.3 vs. 43.1%, p = 0.02). The severity of injuries and economic costs were reflected in median length of stay (6 vs. 9 days; p = 0.006) and median total hospital charges ($150,914 to $293,798; p < 0.001). CONCLUSIONS: The data support that the San Diego-Mexico border wall extension is correlated with more frequent, severe, and costly spinal injuries. These findings advocate for reevaluating our current border wall infrastructure as this represents a humanitarian and public health crisis.

Reasons for Hospitalization and All-Cause Mortality for Adults with Sarcoidosis

PurposeSarcoidosis is a multisystem immune disease with a high rate of hospitalization. There is a paucity of large population-based studies on sarcoid inpatients. We aimed to examine the reasons for hospitalizations and mortality of adult sarcoid patients utilizing the National Inpatient Sample (NIS) database. MethodsAdult hospitalizations in 2016-2019 NIS database with sarcoidosis (ICD-10 code D86) were analyzed. The “reason for hospitalization” and “reason for in-hospital death” were divided into 19 organ system/disease categories based on their principal ICD-10 hospital billing diagnosis. ResultsAmong the 330,470 sarcoid hospitalizations, cardiovascular (20.4%) and respiratory (16.9%) diagnoses were the most common reasons for hospitalization. The most common individual diagnoses were sepsis and pneumonia. In-hospital death occurred in 2.4% of sarcoid hospitalizations. The most common reasons for death were infectious (30%), cardiovascular (20.7%), and respiratory (20.3%) diagnoses. The most common individual diagnoses in the deceased group were sepsis and respiratory failure. Finally, the sarcoid group had a higher frequency of complications including arrhythmias/heart blocks, heart failure, cranial neuropathies, hypercalcemia, iridocyclitis, myocarditis, and myositis. Sarcoid inpatients had longer length of stay (4 vs 3 days; p < .001) and higher median total hospital charges ($36,865 vs $31,742; p < .001). ConclusionsThe most common reasons for sarcoid hospitalizations were cardiovascular and respiratory. Nearly 1 in 40 hospitalizations resulted in death, with most common complications being conduction abnormalities and heart failure. The most common causes of in-hospital death were sepsis and respiratory failure. Sarcoid hospitalizations had 16% higher total hospital charges compared to nonsarcoid inpatients.

Rates of operative intervention for infection after synthetic or autologous cranioplasty: a National Readmissions Database analysis.

The aim of this study was to characterize the clinical utilization and associated charges of autologous bone flap (ABF) versus synthetic flap (SF) cranioplasty and to characterize the postoperative infection risk of SF versus ABF using the National Readmissions Database (NRD). The authors used the publicly available NRD to identify index hospitalizations from October 2015 to December 2018 involving elective ABF or SF cranioplasty after traumatic brain injury (TBI) or stroke. Subsequent readmissions were further characterized if patients underwent neurosurgical intervention for treatment of infection or suspected infection. Survey Cox proportional hazards models were used to assess risk of readmission. An estimated 2295 SF and 2072 ABF cranioplasties were performed from October 2015 to December 2018 in the United States. While the total number of cranioplasty operations decreased during the study period, the proportion of cranioplasties utilizing SF increased (p < 0.001), particularly in male patients (p = 0.011) and those with TBI (vs stroke, p = 0.012). The median total hospital charge for SF cranioplasty was $31,200 more costly than ABF cranioplasty (p < 0.001). Of all first-time readmissions, 20% involved surgical treatment for infectious reasons. Overall, 122 SF patients (5.3%) underwent surgical treatment of infection compared with 70 ABF patients (3.4%) on readmission. After accounting for confounders using a multivariable Cox model, female patients (vs male, p = 0.003), those discharged nonroutinely (vs discharge to home or self-care, p < 0.001), and patients who underwent SF cranioplasty (vs ABF, p = 0.011) were more likely to be readmitted for reoperation. Patients undergoing cranioplasty during more recent years (e.g., 2018 vs 2015) were less likely to be readmitted for reoperation because of infection (p = 0.024). SFs are increasingly replacing ABFs as the material of choice for cranioplasty, despite their association with increased hospital charges. Female sex, nonroutine discharge, and SF cranioplasty are associated with increased risk for reoperation after cranioplasty.

Epidemiology and Predictors of 30-Day Readmission in CAR-T Cell Therapy Recipients

The novel cellular immunotherapy using chimeric antigen receptor (CAR) T cells has transformed the management of several previously incurable hematologic malignancies. Since the first CAR-T cell product was approved by the Food and Drug Administration in 2017, five additional products have been approved for various hematologic malignancies. Although there is now more experience with outpatient administration, CAR-T therapy was initially delivered in an inpatient setting. The unique complications of cytokine release syndrome (CRS) and neurologic side effects (commonly known as immune effector cell-associated neurotoxicity syndrome [ICANS]), along with a higher risk for infection, increase the risk for hospital readmission. Given the recent approval of CAR-T therapy, large-scale epidemiologic data are lacking. The present study aimed to characterize the epidemiology of hospitalizations, readmissions, and factors associated with all-cause 30-day readmission post CAR-T therapy. This retrospective cohort study used the Nationwide Readmissions Database from 2017 to 2019 to identify hospitalizations for CAR-T therapy administration. A descriptive analysis was performed after categorizing these hospitalizations as non-Hodgkin lymphoma, multiple myeloma, or leukemia. The readmission rate was calculated, and etiologies of readmission were identified. A Cox proportional hazards model was used to elucidate factors associated with 30-day readmission. We also estimated the healthcare utilization related to readmissions, including total hospital charges and length of stay. The 2,964 CAR-T therapy-related admissions included 2,176 with a diagnosis of non-Hodgkin lymphoma, 344 with multiple myeloma, and 445 with leukemia. The median length of stay was 15 days. Most CAR-T therapy recipients were male (63.4%), admitted to a teaching hospital (99.2%); 49.3% had private insurance, and 33.2% belonged to the highest-income communities. CAR-T therapy was administered mostly in privately owned (89.5%) large-sized hospitals (74.4%) in large metropolitan regions (91.4%). Median total hospital charges were highest for non-Hodgkin lymphoma, followed by leukemia and multiple myeloma ($945,645 versus $265,034 versus $184,194; P < .001). All-cause mortality during index hospitalization was highest for leukemia at 8.6%, followed by 3.6% for non-Hodgkin lymphoma and 1.4% for multiple myeloma (P < .001). The 30-day all-cause readmission rate was 23.6%, and the median time to readmission was 7 days. The readmission rate was highest for leukemia, followed by non-Hodgkin lymphoma and multiple myeloma (34.2% versus 22.8% versus 15.7%; P < .001). Readmission incurred an additional median total hospital charge of $64,561. During readmission, median length of stay was 5 days, and in-hospital mortality was 4.9%. Top etiologies for readmission were cancer or treatment-related (22%), sepsis or infection (18%), neurologic events (15%), neutropenia or pancytopenia (11%), and fever, hypotension, or hypoxia (8%). On multivariable analysis, non-Hodgkin lymphoma and leukemia (compared with multiple myeloma), transfer to a facility at discharge, chronic renal disease, cerebrovascular disease, and noninvasive ventilation were associated with higher odds of readmission. In contrast, admission to a teaching hospital predicted lower odds of readmission. Almost a quarter of CAR-T therapy recipients are readmitted within the first 30 days resulting in additional economic burden and substantial healthcare utilization.

The impact of the Mexico-San Diego border wall extension on spine injuries: a retrospective cohort review.

The recent San Diego-Mexico border wall height extension has resulted in an increased injury risk for unauthorized immigrants falling from greater heights. However, the effects of the border wall extension on frequency and morbidity of spinal injuries and related economic costs have yet to be highlighted. We retrospectively compared two cohorts who presented to the UC San Diego Health Trauma Center for border wall falls: pre-height extension (12 patients; January 2016-May 2018), and post-height extension (102 patients; January 2020-December 2021). Patients presented during border wall construction (June 2018-December 2019) were excluded. Demographics, clinical data and hospital costs were collected. Spinal injuries were normalized using Customs and Border Protection apprehensions. Costs were adjusted for inflation using the 2021 medical care price index. The increase in spine injuries per month (0.8-4.25) and operative spine injuries per month (0.3- 1.7) was statistically significant (P < 0.001). Increase in median length of stay from 6 [interquartile range (IQR) 2-7] to 9days (IQR 6-13) was statistically significant (P = 0.006). Median total hospital charges increased from $174 660 to $294 421 and was also significant (P < 0.001). The data support that the recent San Diego-Mexico border wall extension is correlated with more frequent, severe and costly spinal injuries. This current infrastructure should be re-evaluated as border-related injuries represent a humanitarian and public health crisis.

Methods of Bloodless Care, Clinical Outcomes, and Costs for Adult Patients Who Decline Allogeneic Transfusions.

Providing bloodless medical care for patients who wish to avoid allogeneic transfusion can be challenging; however, previous studies have demonstrated favorable outcomes when appropriate methods are used. Here, we report one of the largest series of patients receiving bloodless care, along with the methods used to provide such care, and the resulting outcomes. In a retrospective cohort study, 1111 adult inpatients (age ≥18 years) at a single institution who declined allogeneic transfusion for religious or personal reasons between June 2012 and June 2016 were included, and the patient blood management methods are described. Patient characteristics, laboratory data, and transfusion rates, as well as clinical outcomes (morbidity, mortality, and length of stay) were compared to all other patients in the hospital who received standard care, including transfusions if needed (n = 137,009). Medical and surgical patients were analyzed as subgroups. The primary outcome was composite morbidity (any morbid event: infectious, thrombotic, ischemic, renal, or respiratory). Secondary outcomes included individual morbid events, in-hospital mortality, length of stay, total hospital charges, and costs. The bloodless cohort had more females and a lower case mix index, but more preadmission comorbidities. Mean nadir hemoglobin during hospitalization was lower in the bloodless (9.7 ± 2.6 g/dL) compared to the standard care (10.1 ± 2.4 g/dL) group (P < .0001). Composite morbidity occurred in 14.4% vs 16.0% (P = .16) of the bloodless and standard care patients, respectively. Length of stay and in-hospital mortality were similar between the bloodless and standard care patients. After Bonferroni adjustment for multiple comparisons, hospital-acquired infection occurred less frequently in the bloodless compared to the standard care cohort (4.3% vs 8.3%) (P < .0001) in the medical patient subgroup, but not in the surgical subgroup. After propensity score adjustment in a multivariable model and adjustment for multiple comparisons, bloodless care was associated with less risk of hospital-acquired infection (OR, 0.56; 95% CI, 0.35-0.83; P = .0074) in the medical subgroup, but not in the surgical subgroup. Median total hospital charges (by 8.5%; P = .0017) and costs (by 8.7%; P = .0001) were lower in the bloodless compared to the standard care cohort, when all patients were included. Overall, adult patients receiving bloodless care had similar clinical outcomes compared to patients receiving standard care. Medical (but not surgical) bloodless patients may be at less risk for hospital-acquired infection compared to those receiving standard care. Bloodless care is cost-effective and should be considered as high-value practice.

Costs Associated With Surgical Infections at a Tertiary Referral Hospital in Rwanda

IntroductionIn low-income and middle-income countries, there is a high demand for surgical care, although many individuals lack access due to its affordability, availability, and accessibility. Costs are an important metric in healthcare and can influence healthcare access and outcomes. The aim of this study was to determine the financial impact of infections in acute care surgery patients and factors associated with inability to pay the hospital bill at a Rwandan referral hospital. Materials and methodsThis was a prospective observational study of acute care surgery patients at a tertiary referral hospital in Rwanda with infections. Data were collected on demographics, clinical features, hospital charges, and expenses. Factors associated with inability to pay the hospital bill were analyzed using Chi-squared and Wilcoxon rank sum tests. ResultsOver 14 mo, 191 acute care surgery patients with infections were enrolled. Most (n = 174, 91%) patients had health insurance. Median total hospital charges were 414.24 United States Dollars (interquartile range [IQR]: 268.20, 797.48) and median patient charges were 41.53 USD (IQR: 17.15, 103.09). At discharge, 53 (28%) patients were unable to pay their hospital bill. On a univariate analysis actors associated with inability to pay the bill included transportation via ambulance, occupation as a farmer, diagnosis, complications, surgical site infection, and length of hospital stay. On a multivariable analysis, intestinal obstruction (adjusted odds ratio 4.56, 95% confidence interval 1.16, 17.95, P value 0.030) and length of hospital stay more than 7 d (adjusted odds ratio 2.95, 95% confidence interval 1.04, 8.34, P value 0.042) were associated with inability to pay the final hospital bill. ConclusionsAlthough there is broad availability of health insurance in Rwanda, hospital charges and other expenses remain a financial burden for many patients seeking surgical care. Further innovative efforts are needed to mitigate expenses and minimize financial risk.

Practice patterns of vasal reconstruction in a large United States cohort.

We aimed to characterise diverse practice patterns for vasal reconstruction and to determine whether surgeon volume is associated with vasoepididymostomy performance at the time of reconstruction. We identified adult men who underwent vasal reconstruction from 2000 to 2020 in Premier Healthcare Database and determined patient, surgeon, cost and hospital characteristics for each procedure. We identified 3,494 men who underwent either vasovasostomy-alone (N=2,595, 74.3%) or any-vasoepididymostomy (N=899, 25.7%). The majority of providers (N=487, 88.1%) performed only-vasovasostomy, 10 (1.8%) providers performed only-vasoepididymostomy and 56 (10.1%) providers performed both. Median total hospital charge of vasoepididymostomy was significantly higher than vasovasostomy ($39,163, interquartile range [IQR]$11,854-53,614 and $17,201, IQR$10,904-29,986, respectively). On multivariable regression, men who underwent procedures at nonacademic centres (OR 2.71, 95% CI 2.12-3.49) with higher volume surgeons (OR 11.60, 95% CI 8.65-16.00) were more likely to undergo vasoepididymostomy. Furthermore, men who underwent vasoepididymostomy were more likely to self-pay (OR 2.35, 95% CI 1.83-3.04, p<.001) and more likely had procedures in the Midwest or West region (OR 2.22, 95% CI 1.66-2.96 and OR 2.11, 95% CI 1.61-2.76, respectively; p<.001). High-volume providers have increased odds of performing vasoepididymostomy at the time of reconstruction but at a significantly higher cost. These data suggest possibly centralising reconstructive procedures among high-volume providers.

Prophylactic colectomy for children with familial adenomatous polyposis: resource utilization and outcomes for open and laparoscopic surgery.

Laparoscopic approach for the surgical management of familial adenomatous polyposis (FAP) has become increasingly common for pediatric patients. The purpose of this study was to compare short-term outcomes and resource utilization between open and laparoscopic surgery for prophylactic colectomy in children with FAP. The Kids' Inpatient Database (2009 and 2012) was analyzed for children (age ≤20 years) with FAP that underwent prophylactic total colectomy or proctocolectomy. Patient demographics, treating hospital characteristics, hospital charges, and short-term outcomes were compared according to the surgical technique utilized (open versus laparoscopic). Overall, we identified 216 patients with FAP that underwent elective total colectomy, of which 95 cases were performed by open surgery and 121 were done laparoscopically. The majority of patients were treated at large, not-for-profit, urban teaching hospitals, and the median age was equal (16 years) in both groups. Complications that were more common for open procedures included accidental perforation or hemorrhage (4% vs. 0%, P=0.023), reopening of surgical site (3% vs. 0%, P=0.049), and pneumonia (3% vs. 0%, P=0.049). Simultaneous proctectomy was performed more commonly in the open cohort (91% vs. 71%, P<0.001) as well as ileostomy creation (74% vs. 49%, P<0.001). The median length of stay was similar in the open and laparoscopic groups (7 vs. 6 days, P=0.712). Median total hospital charges were also similar ($67,334 vs. $68,717, P=0.080). A laparoscopic approach for prophylactic colectomy can be safely performed in children with FAP, and total hospital charges are equivalent compared to open surgery. However, simultaneous proctectomy was performed less often with laparoscopic surgery.

Patient selection for pediatric gastrostomy tubes: Are we placing tubes that are not being used?

IntroductionIdentifying pediatric patients who may benefit from gastrostomy tube (GT) placement can be challenging. We hypothesized that many GTs would no longer be in use after 6 months. MethodsInpatient GT placements in patients < 18 years old at a tertiary children's hospital from 9/2014 to 2/2020 were included. The primary outcome was GT use <6 months (short-term). Secondary outcomes included age at placement, indication for GT, and operations for GT-related issues. ResultsFifteen percent (22/142) of GTs were used for <6 months post-operatively. The median duration of short-term GT use was 1.6 months (IQR 0.9–3.4 months). Short-term GTs were more likely to be placed in patients with traumatic brain injury (TBI) (18.2% vs. 4.2%, p = 0.03) and adolescents (≥12 years old, 22.7% vs. 4.0%, p = 0.005). Gastrocutaneous fistula closure was required in 33.3% of short-term patients who had their GTs removed (n = 6/18), with median total hospital charges of $29,989 per patient. ConclusionFifteen percent of pediatric GTs placed as inpatients were used for <6 months, more commonly among adolescents and in TBI patients. One-third of patients with short-term GTs required gastrocutaneous fistula closure. Adolescents and TBI patients may benefit from consideration of short-term nasogastric tube (NGT) feeds rather than surgical GT placement. Level of EvidenceIII

Evaluating the Effects of Enhanced Recovery Pathways in Craniosynostosis: National Trends in Hospitalization Charges and Length of Stay in Craniosynostosis Surgery.

Enhanced Recovery After Surgery (ERAS) pathways are multimodal approaches aimed at minimizing postoperative surgical stress, reducing hospitalization time, and lowering hospitalization charges. Enhanced Recovery After Surgery is broadly and increasingly implemented in hospitals across the country. Early reports have shown ERAS to reduce length of stay (LOS) after commonly performed pediatric surgeries. However, LOS and hospital charges after craniosynostosis have not been studied. We hypothesized that extended hospital LOS is correlated with increased hospitalization charges associated with open cranial vault surgery (CVS) and that over a multiyear timeframe, LOS and cost would decrease because of the increased adoption of ERAS in pediatric surgery. The Healthcare Cost and Utilization Project's National Inpatient Sample database was analyzed from January 2007 to December 2014. All patients who were diagnosed with craniosynostosis who underwent CVS were included. Variables of interest included demographic data, hospital characteristics, hospitalization data, and total hospital charges. Univariate and generalized linear regression models were used to examine associations between selected variables and the hospitalization charges. There were 54,583 patients diagnosed with craniosynostosis between 2007 and 2014. Of these patients, 22,916 (41.9%) received CVS. The median total hospital charge was $66,605.77 (interquartile range, $44,095.60-$101,071.17). The median LOS was 3 days (interquartile range, 2-4 days), and there was no significant change in LOS by year (P = 0.979). However, despite a stable LOS, mean hospitalization charge increased significantly by year (P < 0.01). Regression analysis demonstrated the proportion of eligible patients who underwent CVS substantially increased over the selected timeframe (P < 0.01). Most procedures were performed in urban teaching hospitals and high-volume hospitals. There was no significant association between hospital volume and hospitalization charge (P = 0.331). Increasing hospital charges despite constant LOS for craniosynostosis CVS procedures was observed between 2007 and 2014. Although ERAS has reduced LOS for common pediatric surgical procedures, no decrease in LOS for CVS has been observed. The charges significantly increased over the same period including high-volume centers. Further study to safely lower LOS and hospitalization charges for this procedure may reduce the overall health care burden.

Surgical treatment of breast cancer in liver transplant recipients: a cross-sectional analysis

Presenter: David Stillman MD | Albany Medical Center Background: Orthotopic liver transplantation is the gold standard for curative treatment of end-stage liver disease. Since Theodore Starzl performed the first human liver transplant in 1963, outcomes have dramatically improved as understanding of the immune response has grown hand-in-hand with the burgeoning armamentarium of immunosuppressant medications. Increased graft and host survival has drawn the medical community’s attention to the long-term care of this unique patient population, including the relationship between transplantation, immunosuppression, and malignancy. Breast cancer is the most common non-skin cancer in women, and outcomes research investigating the intersection of breast cancer and liver transplant is sparse. Here, we present a cross-sectional study examining outcomes of patients with history of liver transplant who underwent lumpectomy or mastectomy using data queried from the National Inpatient Sample database from 2005 to 2014. Methods: The 99 liver transplant patients who met our criteria were compared to 273,841 breast cancer patients, with both groups having tissue diagnosis of malignancy or carcinoma in situ and having undergone uni- or bilateral mastectomy or lumpectomy, with or without reconstruction. Hospital and patient-level characteristics were compared with student T, Mann-Whitney, and chi squared tests where appropriate, revealing grossly similar populations and facilities. Elixhauser Comorbidity Index scores were calculated to compare degree of comorbidity. Logistic regression models were employed for outcomes investigation. Financial and length of stay data were evaluated with linear regression modeling, adjusted based on Consumer Price Index 2020. Multivariate logistic regressions were used to compare outcomes between hospital settings. Results: Elixhauser Comorbidity Index scores were calculated with a significant difference in scores >10, 20.5% in transplant recipients vs 10.2% in those without (p = 0.001). Logistic regression models showed no statistically significant difference in morbidity between groups with the exception of increased rate of acute renal failure in the transplanted population (9.9% vs 0.6%, p < 0.001). Financial and length of stay data evaluated with linear regression modeling showed significantly higher median total hospital charges in the transplanted cohort ($63,724 vs $43,002; p < 0.001), however multivariate logistic regressions used to compare outcomes between hospital settings showed this difference in cost of care disappeared in transplant and teaching centers. Conclusion: Overall, this study shows that despite the increased complexity of caring for liver transplant recipients with breast cancer, teaching hospitals and transplant centers deliver cost-effective surgical treatment of breast cancer without increased mortality and morbidity compared to the non-transplanted population.

A cost analysis of managing cancer-related pain among hospitalized US cancer patients.

7079 Background: Pain is a common symptom of cancer, affecting patients' function and quality of life. It is also a common cause of hospitalization for cancer patients. The aim of this study was to evaluate the cost of in-hospital pain management among US cancer patients. Methods: A retrospective analysis of data from all US hospitals that contributed to the National Inpatient Sample for 2011-2015 was conducted. All cancer patients admitted for pain management were included in the analysis. Main outcomes were factors significantly associated with hospital length of stay, total charge per hospital stay, and in-hospital mortality. Weighted chi-square test was used for categorical covariates and univariate analysis was performed using a logistic model. Results: 122,776 patient discharges were identified. Mean age was 59.3 years and 52.3% were female. 65.9% stayed in the hospital for longer than 72 hours, with a median total hospital charge of $48,156. Conversely, the median total hospital charge for those spending less than 72 hours on admission was $15,966. Median total charge per hospital stay was similar among insured and uninsured/self-pay patients ($32,879 vs. $32,323; p=0.013), but higher in patients without metastatic disease ($33,315 vs. $29,369; p&lt;0.001). It was also higher in those with the highest income quartile when compared with lowest income patients ($38,223 vs. $30,047; p&lt;0.001). Co-morbid medical illnesses were more prevalent in those with longer hospital stay (15 vs. 12; p&lt;0.001) and the overall in-hospital mortality rate was 8.2%. There was no significant difference in median total hospital charges between those who died in, or those discharged from the hospital ($33,746 vs. $32,795; p&lt;0.001). On multivariate analyses, gender, race, insurance status, diagnosis of metastatic cancer, age, number of co-morbid medical illnesses, year of diagnosis, and median income were significant predictors of length of stay. Race, insurance payor, metastatic cancer, age, and number of co-morbid medical illnesses were significant predictors of total hospital charges, after adjusting for other covariates. Conclusions: In-patient pain management of cancer patients is associated with significant health care costs. Optimization of outpatient pain management strategies could significantly lower the cost of care for cancer.

Implementation of a sentinel lymph node mapping algorithm for endometrial cancer: surgical outcomes and hospital charges

IntroductionThe purpose of this study was to compare operative times, surgical outcomes, resource utilization, and hospital charges before and after the implementation of a sentinel lymph node (SLN) mapping algorithm...

Trends and presentation patterns of acute rheumatic fever hospitalisations in the United States.

Rheumatic fever, an immune sequela of untreated streptococcal infections, is an important contributor to global cardiovascular disease. The goal of this study was to describe trends, characteristics, and cost burden of children discharged from hospitals with a diagnosis of RF from 2000 to 2012 within the United States. Using the Kids' Inpatient Database, we examined characteristics of children discharged from hospitals with the diagnosis of rheumatic fever over time including: overall hospitalisation rates, age, gender, race/ethnicity, regional differences, payer type, length of stay, and charges. The estimated national cumulative incidence of rheumatic fever in the United States between 2000 and 2012 was 0.61 cases per 100,000 children. The median age was 10 years, with hospitalisations significantly more common among children aged 6-11 years. Rheumatic fever hospitalisations among Asian/Pacific Islanders were significantly over-represented. The proportion of rheumatic fever hospitalisations was greater in the Northeast and less in the South, although the highest number of rheumatic fever admissions occurred in the South. Expected payer type was more likely to be private insurance, and the median total hospital charges (adjusted for inflation to 2012 dollars) were $16,000 (interquartile range: $8900-31,200). Median length of stay was 3 days, and the case fatality ratio for RF in the United States was 0.4%. Rheumatic fever persists in the United States with an overall downwards trend between 2003 and 2012. Rheumatic fever admissions varied considerably based on age group, region, and origin.

Safe surgery in the elderly: A review of outcomes following robotic proctectomy from the Nationwide Inpatient Sample in a cross-sectional study.

BackgroundAs our nation's population ages, operating on older and sicker patients occurs more frequently. Robotic operations have been thought to bridge the gap between a laparoscopic and an open approach, especially in more complex cases like proctectomy.MethodsOur objective was to evaluate the use and outcomes of robotic proctectomy compared to open and laparoscopic approaches for rectal cancer in the elderly. A retrospective cross-sectional cohort study utilizing the Nationwide Inpatient Sample (NIS; 2006–2013) was performed. All cases were restricted to age 70 years old or greater.ResultsWe identified 6740 admissions for rectal cancer including: 5879 open, 666 laparoscopic, and 195 robotic procedures. The median age was 77 years old. The incidence of a robotic proctectomy increased by 39%, while the open approach declined by 6% over the time period studied. Median (interquartile range) length of stay was shorter for robotic procedures at 4.3 (3–7) days, compared to laparoscopic 5.8 (4–8) and open at 6.7 (5–10) days (p < 0.01), while median total hospital charges were greater in the robotic group compared to laparoscopic and open cases ($64,743 vs. $55,813 vs. $50,355, respectively, p < 0.01). There was no significant difference in the risk of total complications between the different approaches following multivariate analysis.ConclusionRobotic proctectomy was associated with a shorter LOS, and this may act as a surrogate marker for an overall improvement in adverse events. These results demonstrate that a robotic approach is a safe and feasible option, and should not be discounted solely based on age or comorbidities.

IPEG 2019 The 28th Annual Congress for Endosurgery in Children March 20-22, 2019, Santiago, Chile.

IPEG 2019 The 28th Annual Congress for Endosurgery in Children March 20-22, 2019, Santiago, Chile.

Acute kidney injury is associated with higher mortality and healthcare costs in hospitalized patients with cirrhosis

Introduction and ObjectivesAKI is known to be associated with increased risk of mortality, however limited information is available on how AKI impacts healthcare costs and resource utilization in hospitalized patients with cirrhosis. Previous studies have had variable definitions of AKI, resulting in inconsistent reporting of the true impact of AKI in patients with cirrhosis. MethodsData from the Nationwide Inpatient Sample (NIS) which contains data from 44 states and 4378 hospitals, accounting for over 7 million discharges were analyzed. The inclusion data were all discharges in the 2012 NIS dataset with a discharge diagnosis of cirrhosis. ResultsA total of 32,605 patients were included in the analysis, incidence of AKI was 12.12% in patients with cirrhosis. Crude mortality was much higher for patients with cirrhosis and AKI (14.9% vs. 1.8%, OR 9.42, p<0.001) than for patients without AKI. In addition, mean LOS was longer (8.5 vs. 4.3 days, p<0.001) and median total hospital charges were higher for patients with AKI ($43,939 vs. $22,270, p<0.001). In multivariate logistic regression, controlling for covariates and mortality risk score, sepsis, ascites and SBP were predictors of AKI. ConclusionsAKI is relatively common in hospitalized patients with cirrhosis. Presence of AKI results in significantly higher inpatient mortality as well as LOS and resource utilization. Median hospitalization cost was twice as high in AKI patients. Early identification of patients at high risk for AKI should be implemented to reduce mortality and contain costs. Prognosis could be enhanced by utilizing biomarkers which could rapidly detect AKI.