Overall Cost Of Care Research Articles

OHP-075 The Cost of Managing Intracranial Aneurysms by Embolization in Morocco

BackgroundThe overall prevalence of intracranial aneurysm is thought to be between 0.5 to 6% of population, based on angiographic study and autopsies. The frequency of detection and treatment of these...

Biomarkers for sepsis: an unfinished journey

Biomarkers for sepsis: an unfinished journey

Breaking Down Clinical Silos in Healthcare

EACH OF THE feature articles in this issue of Frontiers of Health Services Management begins by addressing the many factors that have developed and are spurring significant changes to healthcare delivery in the United States. To those of us involved in the healthcare industry, these factors are not new. In some cases they were also at play in the early 1990s, when they contributed to both the advent of and the backlash to managed care. What makes this time dif- ferent is that, although unsustainable healthcare costs, decreasing reimburse- ments, and new payment structures mandated by the Affordable Care Act are realities, the changes to the healthcare delivery system are coming from within healthcare itself instead of from the health insurance industry.Both articles emphasize that integration of resources and coordination of care play crucial roles in reaching goals for enhancing community health and reducing the overall cost of care. Both articles also encourage healthcare providers to avail themselves of newer reimbursement models stemming from the Medicare Shared Savings Program, bundled payments, and, ultimately, global capitation. Although both articles discuss transformation, their perspec- tives differ: Leaver focuses on the structural realignment of a large multistate healthcare system, while Molden, Brown, and Griffith focus on a service line realignment within a healthcare system. Whether through disruptive innova- tion, as discussed by Molden, Brown, and Griffith, or through coordinated care, as described by Leaver, each system achieved a new type of service delivery that brought physicians and hospital resources together in a more coordinated way. Each article describes an approach to confronting the clinical silos of care, and each system appears to have made good strides in breaking down the clinical silos in its geographic area.WHY IS BREAKING DOWN SILOS SO DIFFICULT?As the articles illustrate, restructuring, whether of an entire healthcare system or of a service line, is not easy and requires commitment to a shared vision. That vision first needs to be created and then needs to be reinforced over and over until it becomes accepted and sustainable. Many times the initial conversations begin from a need for self-preservation and, as both feature articles note, subsequent progress requires hard discussions and real dedication to work- ing from common ground. Healthcare is composed of a host of special interest groups whose members have their own special- ized, academic preparation, social system, and approach to the work they do. The many differences can lead to widespread mistrust, which can be dispelled only by the passage of time and working together to build relationships. Eventually, broader understanding will help the groups to put new approaches into perspective and check their biases at the door when meetings are held. And ultimately, they will recognize that the issues at stake are more important than their differences and that collaboration will make their goals more attainable.I believe these articles reflect the laser- beam perspective that today's healthcare leaders and boards of directors have about how to organize, integrate, and align their organizations to be successful with fewer resources and how to genuinely improve healthcare quality and patient satisfaction. The changes described in these articles have massive structural and cultural ramifications, and their architects should be applauded for their foresight and their dedicated, consistent leadership in achieving their goals. Another area of focus, however, is equally important to the discussion of breaking down the silos we have in healthcare today, and it is far more granular and pervasive in our healthcare delivery system.WHERE IS PATIENT SAFETY IN THIS CONVERSATION?As both articles show, the organization of healthcare delivery is both specialized and complex. As new structures are formed, the delivery system expands to include them, whether as owned or as contracted resources. …

Arthroscopic Ankle Fusion: A Change of the “Gold Standard”

The twentieth-century economist John Maynard Keynes once described the “gold standard” as “a barbarous relic” and noted that “the difficulty lies not so much in developing new ideas as in escaping from old ones.”1 Often our clinical judgment is borne from the principles that we learned from our mentors during our training, and the practicing orthopaedist may struggle with the “gold standard” dictum when exposed to new techniques. In the past few years, access to cutting-edge procedures has become readily available through web-based media and web symposia, permitting instant dissemination of new treatments that may not have been adequately or objectively peer-reviewed. The late 1990s marked the advent of minimally invasive hip and knee replacement, image guidance, percutaneous fracture plating, and reliable arthroscopic shoulder techniques. In the past decade, our profession has made great strides in performing musculoskeletal procedures that focus on the preservation of surrounding soft tissues and the reduction of postoperative pain. Between 1997 and 2004, the number of Medicare-approved ambulatory surgery centers nearly doubled, and a drastic change in the ratio of inpatient to outpatient procedures occurred from the early 1980s to the 2000s2. These advances have allowed for shorter hospital stays and a shift toward more outpatient procedures, which can lower the rate of complications and decrease the overall cost of care. While the aforementioned trends are exciting for patients and surgeons alike, our profession must be …

Two-Team Simultaneous Open Surgical Treatment in Bilateral Shoulder Fracture Dislocation

Different surgical options have been described for the treatment of bilateral shoulder fracture dislocations. We report 2 cases of bilateral shoulder fracture dislocation treated simultaneously by 2 surgical teams. One case had bilateral hemiarthroplasty performed, and the second case had 1 hemiarthroplasty and McLaughlin procedure on the other shoulder. A device to allow holding the patient in a bend chair position, with both shoulders hanging outside the operative table, allowing their free movement, was designed. At 1-year follow-up, neither of the patients had complications and both are pleased with their early result. Simultaneous treatment of both the shoulders by 2 different surgical teams in bilateral shoulder fracture dislocations that need surgical treatment has the advantages of reduced overall hospitalization time, reduced anesthetic risk, faster return to work, and reduced overall cost of care. The decision for simultaneous bilateral shoulder surgery must be made in concert with the patient, medical consultant, and anesthesiologist. Level IV-case series.

Improving Value in Healthcare

Improving Value in Healthcare

Regional Versus General Anesthesia for Carotid Endarterectomy: The American College of Surgeons National Surgical Quality Improvement Program Perspective

Background The ideal anesthetic technique for carotid endarterectomy remains a matter of debate. This study used the American College of Surgeons National Surgical Quality Improvement Program to evaluate the influence of anesthesia modality on outcomes after carotid endarterectomy. Methods Postoperative outcomes were compared for American College of Surgeons National Surgical Quality Improvement Program patients undergoing carotid endarterectomy between 2005 and 2009 with either general or regional anesthesia. A separate analysis was performed on a subset of patients matched on propensity for undergoing carotid endarterectomy with regional anesthesia. Results For the entire sample of 24,716 National Surgical Quality Improvement Program patients undergoing carotid endarterectomy and the propensity-matched cohort of 8,050 patients, there was no difference in the 30-day postoperative composite stroke/myocardial infarction/death rate based on anesthetic type. Within the matched cohort, the rate of other complications did not differ (2.8% regional vs 3.6% general anesthesia; P = .07), but patients receiving regional anesthesia had shorter operative (99 ± 36 minutes vs 119 ± 53 minutes; P P P Conclusion Anesthesia technique does not impact patient outcomes after carotid endarterectomy, but may influence overall cost of care.

Prioritizing Partners Across the Continuum

With the advent of accountable care organizations, bundled payments, value-based purchasing, and penalties for preventable hospital readmission, tight connections and collaboration across the care continuum will become critical to achieve successful patient outcomes and to reduce the cost of care delivery. Lehigh Valley Health Network (LVHN), the largest provider of health services in eastern Pennsylvania, set out on a journey to build collaborative relationships with skilled nursing facilities (SNFs) in their eastern Pennsylvania community. LVHN desired SNF partners with mutual interests in improving quality of care and lowering costs of delivery where possible. Recognizing that not all SNFs are alike, LVHN developed a Collaborative Partner Prioritization Tool to assess and prioritize skilled nursing facilities in an effort to determine those that would make the best collaborators. SNFs were reviewed based on their volume of mutual patients, quality of care delivery, and their perceived willingness to align with LVHN. Six variables were used to assess these facilities, including (1) patient discharge destination volume by SNF; (2) 30-day all-cause readmission rate to an LVHN hospital; (3) Medicare's Nursing Home Compare 5-Star Overall Rating; (4) the health network affiliation of the SNF's medical director; (5) the level of LVHN-employed or -affiliated physician presence at the SNF; and (6) the SNF's current participation in LVHN-sponsored programs and meetings. Through use of the Collaborative Partner Prioritization Tool, it was discovered that roughly 70% of LVHN patients who required skilled nursing care following their inpatient stay received care at 1 of 20 SNFs. Of these, 5 facilities performed well on the 6-variable assessment, deeming them the "Tier 1 Facilities" to initially focus collaborative efforts. LVHN has strategically deployed physician resources and has increased physician presence at these "Tier 1 SNFs." These facilities have also gained remote read-only access to LVHN's inpatient electronic medical record and have had opportunity to participate in LVHN-sponsored programs. Special projects have been co-developed with several SNFs, including a telemedicine-based Parkinson's disease program to increase patient access to a neurologist specially trained in movement disorders. The Collaborative Partner Prioritization Tool has become a powerful tool when used for prioritization of relationships and allocation of LVHN physicians and resources. Collaboration with strong SNF partners has offered a shared opportunity to improve quality of care, reduce costs, and prepare for the many policies affecting the health care industry. Future outcomes of this work will include quality metrics, such as readmissions, patient satisfaction with care, time for decision to admit, and overall costs of care. The data and metrics used to define the prioritization tool will continue to be adapted as the post-acute market and hospital-SNF relationships continue to evolve.

Coronary CT Angiography versus Standard Evaluation in Acute Chest Pain

BackgroundIt is unclear whether an evaluation incorporating coronary computed tomographic angiography (CCTA) is more effective than standard evaluation in the emergency department in patients with symptoms suggestive of acute coronary syndromes.MethodsIn this multicenter trial, we randomly assigned patients 40 to 74 years of age with symptoms suggestive of acute coronary syndromes but without ischemic electrocardiographic changes or an initial positive troponin test to early CCTA or to standard evaluation in the emergency department on weekdays during daylight hours between April 2010 and January 2012. The primary end point was length of stay in the hospital. Secondary end points included rates of discharge from the emergency department, major adverse cardiovascular events at 28 days, and cumulative costs. Safety end points were undetected acute coronary syndromes.ResultsThe rate of acute coronary syndromes among 1000 patients with a mean (±SD) age of 54±8 years (47% women) was 8%. After early CCTA, as compared with standard evaluation, the mean length of stay in the hospital was reduced by 7.6 hours (P<0.001) and more patients were discharged directly from the emergency department (47% vs. 12%, P<0.001). There were no undetected acute coronary syndromes and no significant differences in major adverse cardiovascular events at 28 days. After CCTA, there was more downstream testing and higher radiation exposure. The cumulative mean cost of care was similar in the CCTA group and the standard-evaluation group ($4,289 and $4,060, respectively; P=0.65).ConclusionsIn patients in the emergency department with symptoms suggestive of acute coronary syndromes, incorporating CCTA into a triage strategy improved the efficiency of clinical decision making, as compared with a standard evaluation in the emergency department, but it resulted in an increase in downstream testing and radiation exposure with no decrease in the overall costs of care. (Funded by the National Heart, Lung, and Blood Institute; ROMICAT-II ClinicalTrials.gov number, NCT01084239.)

Causes, prevention and management of surgical site infection

Superficial surgical site infection (SSI) usually resolves quickly causing only short-term discomfort. However, SSI involving deeper tissues is a leading cause of morbidity and mortality and increases the overall cost of care. Although SSI commonly originates in the operating theatre, signs and symptoms of infection often do not appear until patients have been discharged from hospital. Nurses in a range of clinical settings are involved in the care of patients who either develop or are at risk of developing SSI and therefore need to know how to advise and manage these patients.

Regional versus general anesthesia for carotid endarterectomy: The American College of Surgeons National Surgical Quality Improvement Program perspective

The ideal anesthetic technique for carotid endarterectomy remains a matter of debate. This study used the American College of Surgeons National Surgical Quality Improvement Program to evaluate the influence of anesthesia modality on outcomes after carotid endarterectomy. Postoperative outcomes were compared for American College of Surgeons National Surgical Quality Improvement Program patients undergoing carotid endarterectomy between 2005 and 2009 with either general or regional anesthesia. A separate analysis was performed on a subset of patients matched on propensity for undergoing carotid endarterectomy with regional anesthesia. For the entire sample of 24,716 National Surgical Quality Improvement Program patients undergoing carotid endarterectomy and the propensity-matched cohort of 8,050 patients, there was no difference in the 30-day postoperative composite stroke/myocardial infarction/death rate based on anesthetic type. Within the matched cohort, the rate of other complications did not differ (2.8% regional vs. 3.6% general anesthesia; P = .07), but patients receiving regional anesthesia had shorter operative (99 ± 36 minutes vs 119 ± 53 minutes; P < .0001) and anesthesia times (52 ± 29 minutes vs. 64 ± 37 minutes; P < .0001) and were more likely to be discharged the next day (77.0% vs 64.4%; P < .0001). Anesthesia technique does not impact patient outcomes after carotid endarterectomy, but may influence overall cost of care.

Is There a Starling Curve for Intensive Care?

Large differences exist in the provision of ICU beds worldwide, with a complicated mix of risks and benefits to the population of having either too few or too many beds. Having too few beds can result in delayed admission of patients to the ICU or no admission at all, with either scenario potentially increasing mortality. Potential societal benefits of having few beds include lower costs for health care and less futile intensive care at the end of life. With added ICU beds for a population, mortality benefit should accrue, but there is still the question of whether the addition of beds always means that more lives will be saved or whether there is a point at which no additional mortality benefit is gained. With an abundance of ICU beds may come the possibility of increasing harm in the forms of unnecessary costs, poor quality of deaths (ie, excessively intensive), and iatrogenic complications. The possibility of harm may be likened to the concept of falling off a Starling curve, which is traditionally used to describe worsening heart function when overfilling occurs. This commentary examines the possible implications of having too few or too many ICU beds and proposes the concept of a family of Starling curves as a way to conceptualize the balance of societal benefits and harms associated with different availability of ICU beds for a population.

Editorial: Imaged-Enhanced Technologies for Colorectal Polyp Detection and Classification

An early diagnosis of colorectal polyp can be achieved through screening and surveillance programs. In the past few years, advances in endoscopic imaging of the colorectal mucosa have been extensively developed, leading to an increased detection of pre-malignant lesions as well as low-grade and nonneoplastic polyps. In order to reduce the overall cost of care with minimal impact on the quality of care in colorectal cancer prevention, the "diagnosis and discard" strategy has been considered. High-definition, narrow band imaging and confocal endomicroscopy are image enhancement technologies that have been widely studied lately. The studies from Pasha et al. and Kuiper et al. demonstrate the limitations of these new advanced imaging technologies and that further studies should continue to be developed.

Complications nearly double the cost of care after pancreaticoduodenectomy

BackgroundDespite considerable data focused on the morbidity of pancreaticoduodenectomy (PD), the financial impact of complications has been infrequently analyzed. This study evaluates the impact of the most common complications associated with PD on the cost of care. Additionally, we identified cost centers that were significantly affected by complications. MethodsA retrospective analysis of a prospective database in a network of community-based teaching hospitals was performed. All patients (n = 145) who underwent PD were included for years 2005 to 2009. Of these, 144 had complete in-hospital cost data. Complications were assessed and classified into major and minor categories according to Dindo et al. Forty-nine cost centers were analyzed for their association with the cost of complications. Univariate and multivariate linear regression analyses were performed. Significance was reported for P < .05. ResultsThe median cost for PD was $30,937. Patients with major complications had significantly higher median cost compared with those without ($56,224 vs $29,038; P < .001). Independent predictors of increased cost included reoperation; sepsis; pancreatic fistula; bile leak; delayed gastric emptying; and pulmonary, renal, and thromboembolic complications. Cost center analysis showed significant added charges for patients with major complications for blood bank ($1,018), clinical laboratory ($3,731), a computed tomography scan ($4,742), diagnostic imaging ($697), intensive care unit ($4,986), pharmacy ($33,850) and respiratory therapy ($1,090) (P < .05, all). ConclusionsThis study identified the major complications of PD, which are significantly associated with a higher cost. Substantial cost center increases were associated with major complications, particularly in pharmacy ($33,850). Measures aimed at limiting complications through centralization of care or care pathways may reduce the overall cost of care for patients after pancreatic resection.

Targeted Antimicrobial Prophylaxis Using Rectal Swab Cultures in Men Undergoing Transrectal Ultrasound Guided Prostate Biopsy is Associated With Reduced Incidence of Postoperative Infectious Complications and Cost of Care

We evaluated targeted antimicrobial prophylaxis in men undergoing transrectal ultrasound guided prostate biopsy based on rectal swab culture results. From July 2010 to March 2011 we studied differences in infectious complications in men who received targeted vs standard empirical ciprofloxacin prophylaxis before transrectal ultrasound guided prostate biopsy. Targeted prophylaxis used rectal swab cultures plated on selective media containing ciprofloxacin to identify fluoroquinolone resistant bacteria. Patients with fluoroquinolone susceptible organisms received ciprofloxacin while those with fluoroquinolone resistant organisms received directed antimicrobial prophylaxis. We identified men with infectious complications within 30 days after transrectal ultrasound guided prostate biopsy using the electronic medical record. A total of 457 men underwent transrectal ultrasound guided prostate biopsy, and of these men 112 (24.5%) had rectal swab obtained while 345 (75.5%) did not. Among those who received targeted prophylaxis 22 (19.6%) men had fluoroquinolone resistant organisms. There were no infectious complications in the 112 men who received targeted antimicrobial prophylaxis, while there were 9 cases (including 1 of sepsis) among the 345 on empirical therapy (p=0.12). Fluoroquinolone resistant organisms caused 7 of these infections. The total cost of managing infectious complications in patients in the empirical group was $13,219. The calculated cost of targeted vs empirical prophylaxis per 100 men undergoing transrectal ultrasound guided prostate biopsy was $1,346 vs $5,598, respectively. Cost-effectiveness analysis revealed that targeted prophylaxis yielded a cost savings of $4,499 per post-transrectal ultrasound guided prostate biopsy infectious complication averted. Per estimation, 38 men would need to undergo rectal swab before transrectal ultrasound guided prostate biopsy to prevent 1 infectious complication. Targeted antimicrobial prophylaxis was associated with a notable decrease in the incidence of infectious complications after transrectal ultrasound guided prostate biopsy caused by fluoroquinolone resistant organisms as well as a decrease in the overall cost of care.

Early Results From Adoption Of Bundled Payment For Diabetes Care In The Netherlands Show Improvement In Care Coordination

In 2010 a bundled payment system for diabetes care, chronic obstructive pulmonary disease care, and vascular risk management was introduced in the Netherlands. Health insurers now pay a single fee to a contracting entity, the care group, to cover all of the primary care needed by patients with these chronic conditions. The initial evaluation of the program indicated that it improved the organization and coordination of care and led to better collaboration among health care providers and better adherence to care protocols. Negative consequences included dominance of the care group by general practitioners, large price variations among care groups that were only partially explained by differences in the amount of care provided, and an administrative burden caused by outdated information and communication technology systems. It is too early to draw conclusions about the effects of the new payment system on the quality or the overall costs of care. However, the introduction of bundled payments might turn out to be a useful step in the direction of risk-adjusted integrated capitation payments for multidisciplinary provider groups offering primary and specialty care to a defined group of patients.

Making “Health in All Policies” a Reality Requires You!

Making “Health in All Policies” a Reality Requires You!

Economic Analysis of Alvimopan for Prevention and Management of Postoperative Ileus

To determine whether alvimopan for prevention of postoperative ileus in patients undergoing small- or large-bowel resection by laparotomy is associated with lower total costs compared with standard care. Pharmacoeconomic analysis using a formal decision model. Four phase III clinical trials, two pooled analyses, and one meta-analysis. A cohort of patients who underwent bowel resection with primary anastomosis by laparotomy and received either standardized, accelerated postoperative care (usual care) or usual care plus alvimopan. Clinical outcomes, obtained from pooled analyses of published studies, were time to discharge order written, postoperative nasogastric tube insertion, postoperative ileus-related readmission within 7days, and occurrence of nausea and vomiting. Cost inputs included drugs, nursing labor, readmissions, and hospitalizations. Costs were assessed by determining the net cost of alvimopan use and subsequent reduction in length of stay. Sensitivity and scenario analyses were conducted. Costs for alvimopan were $570 based on an average of 9.5 doses. Given the 18.4-hour mean reduction in time to discharge order written, use of alvimopan reduced hospitalization costs by $2021. Mean difference in overall cost of care, as determined by Monte Carlo simulation, was $1168 (95% certainty interval -$437 to $5879), favoring the use of alvimopan. In the sensitivity analysis, association of alvimopan with lower costs was robust to several changes in key parameters including cost and number of doses of alvimopan, time to discharge order written, readmission rates, and hospitalization cost. In the scenario analyses, alvimopan use yielded a net cost of $226 when no difference in time to discharge order written was assumed. In the scenario analysis using data from a study that did not enforce opioid use, alvimopan resulted in a cost saving of $65/patient. Alvimopan was cost saving for prevention of postoperative ileus in patients undergoing bowel resection by laparotomy, although these potential cost savings were highly dependent on a difference in time to discharge order written. This finding is not applicable to the less-invasive laparoscopic surgical approach for which quality data on alvimopan use are lacking. Limitations of this analysis included use of time to discharge order written as a proxy for length of stay and difficulty interpreting study results due to inconsistent reporting and conduct of the clinical trials evaluating alvimopan. More research is needed to determine the cost-effectiveness of alvimopan.

Venous Thromboembolism (VTE) In Hospitalized Patients: What Proportion Is Attributable to Malignancy?

Abstract 5250 Background:VTE is a public health burden in hospitalized patients, affecting the length of hospital stay and overall cost of care. Recent studies suggest increasing incidence of VTE among cancer patients, but contemporary data regarding proportion of VTE attributable to cancer and non-cancer populations are lacking. Methods:Hospital-acquired VTE is a reportable event to New York State and we studied all reported VTE events among patients hospitalized at the University of Rochester Medical Center from January 2003 through April 2009. We utilized electronic medical records to identify additional information including demographics and diagnosis of malignancy. Results:We identified 2031 patients with 2185 documented VTE events during the study period. Of these, 1102 (54.3%) were men and 929 (45.7%) were women. VTE events included deep vein thrombosis (DVT) (N=1428, 65 %), pulmonary embolism (PE) (N=757, 34.6%), and concurrent DVT and PE (N=153, 7 %). Of the 2031 hospitalized patients with VTE, 492 (24.2%) had a concurrent diagnosis of cancer and 1539 (75.8%) did not. Of 492 cancer-related VTE, 167 (34%) were associated with hematologic malignancies, and 324 (66%) with solid tumors. The proportion of cancer-associated VTE varied by year, ranging from 21% to 31%. Conclusions:Approximately one-fourth of all VTE in hospitalized patients occurred in patients with cancer, including a substantial proportion with hematologic malignancy. Public health efforts to reduce hospital-associated VTE should focus on improving compliance with thromboprophylaxis for this population. Disclosures:No relevant conflicts of interest to declare.

The California Challenge: Ensuring Primary Care Access for Medi-Cal Recipients under the Affordable Care Act

THE CALIFORNIA Journal of Politics & Policy Volume 3, Issue 4 The California Challenge: Ensuring Primary Care Access for Medi-Cal Recipients under the Affordable Care Act Donald A. Barr Stanford University Abstract This paper describes options for expanding access to care for California’s Medi- Cal population. Recent federal policy initiatives and an expanding set of research reports have begun to focus considerable attention on developing new models for the organization of primary care services. Initial results suggest that these innova- tive delivery models can both decrease the overall cost of care while improving the quality of care. This conclusion is especially relevant for those who provide care to Medi-Cal recipients with chronic medical conditions—the population that con- tributes by far the most to the cost of Medi-Cal. The exigencies of containing both federal and state health care expenditures for all covered populations make consid- eration of alternative modes of health care delivery an essential part of any analysis of the potential impacts of ACA, both in California and throughout the country. Keywords: medical care, Affordable Care Act, Medi-Cal, Medicaid Copyright © 2011 The Berkeley Electronic Press. All rights reserved. www.bepress.com/cjpp