Overall Cost Of Care Research Articles

Length of stay and cost of care differences between postoperative patients who board in PACU and those that proceed directly to inpatient bed

BackgroundBottlenecks in PACU throughput are frequently encountered challenges that OR managers must face. This study seeks to examine the impact of extended PACU stay (e.g. boarding) on both total hospital length of stay and overall cost of care. MethodsA total of 4,740 patients were studied having same-day admit surgeries for seven procedure types including: arthroplasty total knee, arthroplasty total hip, fusion spine transforaminal interbody lumbar, revision arthroplasty total knee, revision arthroplasty total hip, posterior cervical fusion, and anterior cervical fusion. 4,471 were identified as non-PACU boarders and 269 as PACU boarders (>6 h in PACU). Included in the analysis were demographics, date of admission, surgical procedure, PACU and hospital length of stay (HLOS), hospital direct costs, case mix index (CMI), and ASA status. ResultsThe median (IQR) PACU times in minutes were 57.00 (80) and 488.00 (453.50) minutes for PACU non-boarders and boarders (p < 0.001). HLOS was significantly (p < 0.001) more elevated in PACU Boarders compared to PACU Non-boarders: median (IQR) 2.00 (2.00) and 2.00 (3.00), (mean HLOS 3.16±2.83 vs 2.60±2.71 days). Median direct costs were ≈14.36% higher (p = 0.008) for the PACU boarders compared to Non-boarders. Direct costs were also not significantly different when using a 4-hour criteria for PACU boarders (14.39% higher median direct costs, p = 0.004). ConclusionsPACU boarding (>4 h) is associated with a statistically significant increased length of stay as well as direct costs compared with non-boarders across a variety of elective orthopedic and spine procedures. Thus, when frequent PACU boarding occurs, OR managers should consider the potential impact to patient care and hospital margins.

Physical Therapists in Primary Care in the United States: An Overview of Current Practice Models and Implementation Strategies.

Given physician shortages and increasing burden in primary care in the United States, inclusion of a physical therapist in a primary care team can improve patient access to care, optimize care navigation, and reduce the overall cost of care for patients with physical and functional needs.

Epidemiology of maxillofacial trauma in elderly patients receiving oral anticoagulant or antithrombotic medication; a Swiss retrospective study

BackgroundThe percentage of elderly trauma patients under anticoagulation and antiplatelet agents has been rising lately. As newer agents are introduced, each comes with its own advantages and precautions. Our study covered elderly patients admitted to the ED with maxillofacial trauma while on anticoagulation (AC) or antiplatelet therapy (APT). We aimed to investigate the demographic characteristics, causes, and types of maxillofacial trauma, along with concomitant injuries, duration of hospitalisation, haemorrhagic complications, and the overall costs of care in the emergency department (ED).MethodsData were gathered from the ED of Bern University Hospital. In this retrospective analysis, patients over 65 of age were included, who presented at our ED with maxillofacial trauma between 2013 and 2019 while undergoing treatment with therapeutic AC/APT.ResultsThe study involved 188 patients with a median age of 81 years (IQR: 81 [74; 87]), of whom 55.3% (n=104) were male. More than half (54.8%, n=103) were aged 80 years or older. Cardiovascular diseases were present in 69.7% (n=131) of the patients, with the most common indications for AC/APT use being previous thromboembolic events (41.5%, n=78) and atrial fibrillation (25.5%, n=48). The predominant cause of facial injury was falls, accounting for 83.5% (n=157) of cases, followed by bicycle accidents (6.9%, n=13) and road-traffic accidents (5.3%, n=10). The most common primary injuries were fractures of the orbital floor and/or medial/lateral wall (60.1%, n=113), zygomatic bone (30.3%, n=57), followed by isolated orbital floor fractures (23.4%, n=44) and nasal bone fractures (19.1%, n=36). Fractures of the mandible occurred in 14.9% (n=28). Facial hematomas occurred in 68.6% of patients (129 cases), primarily in the midface area. Relevant facial bleeding complications were intracerebral haemorrhage being the most frequent (28.2%, n=53), followed by epistaxis (12.2%, n=23) and retrobulbar/intraorbital hematoma (9%, n=17). Sixteen patients (8.5%) experienced heavy bleeding that required emergency treatment. The in-hospital mortality rate was 2.1% (4 cases).ConclusionsThis study indicates that falls are the leading cause of maxillofacial trauma in the elderly, with the most common diagnoses being orbital, zygomatic, and nasal fractures. Haemorrhagic complications primarily involve facial hematomas, especially in the middle third of the face, with intracerebral haemorrhage being the second most frequent. Surgical intervention for bleeding was required in 8.5% of cases. Given the aging population, it is essential to improve prevention strategies and update safety protocols, particularly for patients on anticoagulant/antiplatelet therapy (AC/APT). This can ensure rapid diagnostic imaging and prompt treatment in emergencies.

WALANT office based endoscopic cubital tunnel release

Background: Cubital tunnel syndrome is a common condition caused by compression of the ulnar nerve around the medial elbow. Surgical treatment usually involves open in situ ulnar nerve decompression unless ulnar nerve instability is noted. Endoscopic techniques for cubital tunnel release have been developed and implemented with excellent patient and surgeon satisfaction. Endoscopic cubital tunnel release can be performed in an office based procedure room under wide awake local anesthesia no tourniquet principles. We present our setup and technique for performing an endoscopic cubital tunnel release procedure in an office based setting under local anesthesia. Methods: Local anesthesia is injected along the course of the ulnar nerve on the medial arm and forearm extending 10 cm proximal and distal to the medial epicondyle. After allowing approximately 30 min for appropriate vasoconstriction, the patient is placed in a supine position with the arm abducted and externally rotated position. The endoscopic cubital tunnel release is then performed. Discussion: Our described technique eliminates the need for placement of a prophylactic tourniquet and thereby the need for the procedure to be performed within an OR setting. It also utilizes a single-stage anesthetic administration, which facilitates ease of completion and performance in an office based setting. There is a significant cost savings when endoscopic cubital tunnel release is performed in an office-based procedure room compared to in the operating room. Conclusions: Office-based endoscopic cubital tunnel release can be safely performed utilizing WALANT techniques, leading to high patient satisfaction and decreased overall cost of care. Level of Evidence: Therapeutic IV

Impact of Institutional Practices and Surgical Complexity on Sarcoma Surgery Costs: Driving Efficiency in Value-Based Healthcare.

Sarcomas present a unique challenge within healthcare systems due to their rarity and complex treatment requirements. This study explores the economic impact of sarcoma surgeries across three Swiss tertiary healthcare institutions, utilizing a consistent surgical approach by a single surgeon to eliminate variability in surgical expertise as a confounding factor. By analyzing data from 356 surgeries recorded in a real-world-time data warehouse, this study assesses surgical and hospital costs relative to institutional characteristics and surgical complexity. Our findings reveal significant cost variations driven more by institutional resource management and pricing strategies than by surgical techniques. Surgical and total hospitalization costs were analyzed in relation to tumor dignity and complexity scores, showing that higher complexity and malignancy significantly increase costs. Interestingly, it was found that surgical costs accounted for only one-third of the total hospitalization costs, highlighting the substantial impact of non-surgical factors on the overall cost of care. The study underscores the need for standardized cost assessment practices and highlights the potential of predictive models in enhancing resource allocation and surgical planning. By advocating for value-based healthcare models and standardized treatment guidelines, this research contributes to more equitable and sustainable healthcare delivery for sarcoma patients. These insights affirm the necessity of including a full spectrum of care costs in value-based models to truly optimize healthcare delivery. These insights prompt a reevaluation of current policies and encourage further research across diverse geographical settings to refine cost management strategies in sarcoma treatment.

Enhanced Recovery after Cranial Surgery in Elderly: A Review

Enhanced recovery after surgery (ERAS) is a multidisciplinary approach aimed at reducing the length of hospital stay, improving patient outcomes, and reducing the overall cost of care. Although ERAS protocols have been widely adopted in various surgical fields, their application in cranial surgery remains relatively limited. Considering that the aging of the population presents significant challenges to healthcare systems, and there is currently no ERAS protocol available for geriatric patients over the age of 65 requiring cranial surgery, this article proposes a new ERAS protocol for this population by analyzing successful ERAS protocols and optimal perioperative care for geriatric patients described in the literature. Our aim is to develop a feasible, safe, and effective protocol for geriatric patients undergoing elective craniotomy, which includes preoperative, intraoperative, and postoperative assessments and management, as well as outcome measures. This multidisciplinary and evidence-based ERAS protocol has the potential to reduce perioperative morbidity, improve functional recovery, and enhance postoperative outcomes after cranial surgery in elderly. Further research will be necessary to establish strict guidelines.

Helicobacter pylori Infection and Complications of Cirrhosis.

Helicobacter pylori is a significant contributor to conditions such as peptic ulcer disease, gastric cancer, gastric mucosa-associated lymphoid tissue lymphoma, and colorectal cancer. Recent studies have suggested a potential link between H. pylori and cirrhosis. However, the impact of H. pylori on cirrhosis-related mortality, inpatient outcomes, and decompensating events remains unclear. Considering the widespread availability of H. pylori testing and effective treatment options, there is a potential rationale for eradicating H. pylori in cirrhotic patients to mitigate the morbidity and mortality associated with cirrhosis. This study aims to investigate the association between H. pylori and inpatient outcomes and complications related to cirrhosis. The National Inpatient Sample (NIS) database, a part of the Healthcare Cost & Utilization Project, was utilized for this study. Inpatient data from the years 2016 through 2019 were extracted for patients with a primary discharge diagnosis of cirrhosis and a concurrent diagnosis of H. pylori infection. The primary outcomes included inpatient mortality, length of stay, and cost of care. Secondary outcomes involved cirrhosis-related complications during hospitalization, such as gastrointestinal bleeding, hepatic encephalopathy, and hepatorenal syndrome. Over the years 2016 to 2019, 416,410 patients received a primary discharge diagnosis of cirrhosis. Among them, 990 patients (0.2%) had a secondary diagnosis of H. pylori infection. Those with both cirrhosis and H. pylori tended to be younger on average (mean age 54.25 vs. 57.18 years, p=0.01) and more frequently fell within the age range of 18-49 (33.84% vs. 24.71%, P=0.01). H. pylori-infected patients were also more likely to be male (70.71% vs. 63.11%, P<0.028), of Hispanic race (36.4% vs. 18.6%, p< 0.1), and of Black race (20.2% vs. 8.1%, p< 0.1). While H. pylori-exposed patients had lower in-hospital mortality (0.51% vs. 4.44%, p=0.007), their mean length of stay was higher (6.97 days vs. 5.75, p=0.002). The overall cost of care was comparable between the H. pylori-exposed and non-exposed groups (mean USD18,106.18 vs. $16,543.49, P=0.160). H. pylori-exposed patients had a higher overall rate of cirrhosis-related complications (84.85% vs. 67.59%, p< 0.001), gastrointestinal bleeding (48.48% vs. 27.34%, p< 0.001), and hepatorenal syndrome (70.71% vs. 46.99%, p< 0.001), and these differences persisted in multivariable analysis. Initially, rates of hepatic encephalopathy were higher in H. pylori non-exposed patients (21.57% vs. 15.66%, p=0.04), but this discrepancy was corrected after adjusting for potential confounders. While patients in this study were diagnosed with both H. pylori and cirrhosis by discharge, it cannot be definitively concluded that H. pylori was the direct cause of cirrhosis complications. Recognizing this uncertainty, further studies are needed better to understand the associations between cirrhosis and H. pylori complications. Distinguishing the causes of cirrhosis and its relationship with H. pylori may offer deeper insights into whether H. pylori is a causative factor or merely correlated in its effects on patients with cirrhosis.

A Cautionary Tale: Malaligned Incentives in Total Hip and Knee Arthroplasty Payment Model Reforms Threaten Promising Innovation and Access to Care

Over the past several years, there have been notable changes and controversies involving Medicare reimbursement for total hip (THA) and total knee arthroplasty (TKA). We have seen the development and implementation of experimental bundled payment model pilot programs goals of improving quality and decreasing overall costs of care during the last decade. Many orthopaedic surgeons have embraced these programs and have demonstrated the ability to succeed in these new models by implementing strategies, such as preservice optimization, to shift care away from inpatient or postdischarge settings and reduce postoperative complications. However, these achievements have been met with continual reductions in surgeon reimbursement rates, lower bundle payment target pricings, modest increases in hospital reimbursement rates, and inappropriate valuations of THA and TKA Common Procedural Terminology (CPT) codes. These challenges have led to an organized advocacy movement and spurred research involving the methods by which improvements have been made throughout the entire episode of arthroplasty care. Collectively, these efforts have recently led to a novel application of CPT codes recognized by payers to potentially capture presurgical optimization work. In this paper, we present an overview of contemporary payment models, summarize notable events involved in the review of THA and TKA CPT codes, review recent changes to THA and TKA reimbursement, and discuss future challenges faced by arthroplasty surgeons that threaten access to high-quality THA and TKA care.

“Just as curry is needed to eat rice, antibiotics are needed to cure fever”—a qualitative study of individual, community and health system-level influences on community antibiotic practices in rural West Bengal, India

ObjectivesTo understand community antibiotic practices and their drivers, comprehensively and in contextually sensitive ways, we explored the individual, community and health system-level factors influencing community antibiotic practices in rural West...

INSURANCE DENIALS AND DELAYS IN CARE FOR PEDIATRIC PATIENTS WITH INFLAMMATORY BOWEL DISEASE

Abstract INTRODUCTION Biologics are effective medications used for induction and maintenance of remission in pediatric patients with inflammatory bowel disease (IBD). Insurance companies often require clinicians to obtain prior authorization (PA) prior to administration of biologics. Recent data determined that PA was associated with delays in care in pediatric IBD patients and an increased risk of subsequent healthcare utilization. Our study aim was to assess the effect of the PA process and its impact on care delivery for pediatric patients with IBD. METHODS A retrospective chart review of pediatric patients with IBD was conducted, including those with the diagnosis of ulcerative colitis or Crohn’s disease prescribed a biologic medication. Data obtained from medical records included demographics, IBD characteristics, insurance PAs, and clinical outcomes from 2015 to 2023. Outcome measures included time from initial PA submission to completion of the PA process, time from initial PA submission to first outpatient dose, frequency of insurance mandated medication changes, and number of hospitalizations for an inpatient dose. Analyses examined differences between those with PAs that were approved versus those who were initially denied. RESULTS We analyzed 134 patients who received a new biologic during our study period, of which 100 were newly diagnosed patients. Of the total sample, mean age was 12.5 years, 53.7% were male, with 96.2% non-Hispanic, 77.6% white, and 69.4% patients had Crohn’s disease. The most common medication prescribed was infliximab (81.3%). Of the patients in the approved group, 72.9% of patients had commercial insurance compared to 52.1% in the denied group (p=0.0152). Median time from initial PA submission to completion of PA process was 13 days for those denied vs. 3 days for those approved (p&amp;lt;0.0001). Of the patients denied, median time from initial PA submission to denial was 4 days (0-27) and median time from denial to subsequent approval was 7 days (0-75). Median time from initial PA submission to first outpatient dose was 30 days in the denied group vs. 13 days for the approved group (p&amp;lt;0.0001). 51% of patients in the denied group required hospitalization for their first biologic dose after PA initiation compared to 20% in the approved group (p=0.0002). CONCLUSION We found a significant delay in care for patients who received a prior authorization denial from insurance. Time from initial authorization submission to first dose was significantly different between the approved and denied groups. Prior authorization denials were also associated with significantly higher rate of hospitalizations for an infusion, potentially driving up overall cost of care.

A cost-consequences and budget impact analysis of blue light-guided cystoscopy with Hexvix in patients diagnosed with non-muscle-invasive bladder cancer in France

AimsFrench guidelines for the management of non-muscle-invasive bladder cancer recommend that blue-light cystoscopy should be used in patients where the risk of missing residual tumor is highest. Despite evidence for its cost-effectiveness, budgetary concerns have limited uptake in France. The aim of this analysis was to model the cost-consequences of adopting the recommendations in a French urology unit.Materials and methodsA budget impact model was developed in Excel, using a decision tree approach derived from guidelines issued by L’Academie franҫaise d’urologie. Risk profiles were derived from an analysis of studies using white-light cystoscopy; estimates for the impact of blue-light cystoscopy were derived from a published Cochrane Review. Costs were based on published tariff prices from L’Agence Technique de L’Information sur L’Hospitalisation. The model allowed results to be tailored to activity levels and projected blue-light usage in the chosen urology unit.ResultsTwo scenarios were evaluated, based on a 3-year time horizon. Full implementation of all recommendations within a large public hospital was estimated to yield incremental costs of €269 per procedure (∼10% increase overall); a more targeted approach within a smaller private hospital yielded incremental costs of €133 per procedure (5% increase overall).LimitationsThe basis of the model is a change in the time to first recurrence. There are no data available for subsequent recurrences or progression, both of which could have an influence on expenditure. Secondly, recurrence rates for blue-light cystoscopy were not specifically available for each patient group identified in the guidelines: extrapolation of data may have resulted in bias. Finally, the data were derived from clinical trials, which may not be generalisable to real-world clinical practice.ConclusionsThe model has shown that the additional expenditure required to implement blue-light cystoscopy is modest and not disproportionate to the overall cost of care.

The burden of hospital admissions for skeletal dysplasias in Sri Lanka: a population-based study

BackgroundSkeletal dysplasias are a diverse group of rare disorders in the chondro-osseous tissue that can have a significant impact on patient’s functionality. The worldwide prevalence of skeletal dysplasias at birth is approximately 1:5000 births. To date, disease burden and trends of skeletal dysplasias in the Sri Lankan population have not been described in any epidemiological study. Our aim was to evaluate the burden and the current trends in hospital admissions for skeletal dysplasias in the Sri Lankan population. A retrospective evaluation of hospital admissions for skeletal dysplasia during 2017–2020 was performed using population-based data from the eIMMR database which covers government hospitals in the entire country. The trends in hospital admissions for skeletal dysplasias by calendar year, age, and types of skeletal dysplasia were described using appropriate summary statistics.ResultsRespective crude admission rates of skeletal dysplasias in the years 2017, 2018, 2019 and 2020 were 5.2, 8.1, 8.0, and 6.5 per million population. A female predominance (1.4:1) was noted during the studied period. Of all reported cases the majority (n = 268; 44.2%) were children less than 4 years. Each year, 0–4 years age group represented 40–47% of the total hospital admissions. More than half of the cases were reported from Colombo (28.1%) and Kandy (25.4%) districts combined. 60% of cases were diagnosed as osteogenesis imperfecta (OI). Rising trends were observed in the hospital admissions for osteogenesis imperfecta, achondroplasia and osteopetrosis, while other skeletal dysplasia types collectively showed a relatively stable trend.ConclusionThis preliminary study revealed a female predominance of skeletal dysplasias and a relatively high admission rate of osteogenesis imperfecta in the Sri Lankan population. A distinct trend was not visible in the studied years probably due to the impact on hospital services due to COVID- Pandemic. Future research on the healthcare burden on families affected by skeletal dysplasia is required to better understand the overall cost of care and identify therapies that reduce admission rates. This study highlights the value of analysing population-based data on rare diseases to improve healthcare in low-resource countries.

Abstract 091: Efficacy Of A Patient-engagement Platform In Reducing Uncontrolled Hypertension In Community Health Clinics

Introduction: Hypertension affects 47% of US adults and can lead to serious sequelae such as myocardial infarction and stroke when uncontrolled. Over 37 million US adults have blood pressure (BP) higher than 140/90 mmHg. Medication to treat hypertension is effective, yet, approximately 50% of patients do not take medication as prescribed and non-adherence to cardioprotective medications increases a patient’s risk of death from 50% to 80%. Objective: To use a novel patient engagement platform to assist federally qualified health centers (FQHCs) in improving BP control. Methods: We enrolled patients treated at FQHCs in a digital hypertension management program. Patients were prompted to submit their BP and responses to questions about medication adherence and potential side effects of medication either daily or weekly in English or Spanish. The responses were prioritized by level of concern. The clinic reviewed these data, in real-time and provided coaching or treatment changes. We analyzed first and last systolic and diastolic BPs of patients who participated for ≥90 days (range 90-721 days) and considered BP &lt;140/90 mmHg to be controlled. Results: The cohort included 2500 patients, 38.6% male, with a mean age of 53.9 years (range 14-100 years) from 43 FQHCs across the US. Of these patients, 30.7% (768 of 2500) had an initial controlled BP and 61.2% (1529 of 2500) demonstrated a final controlled BP measurement. In patients with an initial uncontrolled BP, 55.4% (959 of 1732) had a controlled final BP. The Spanish language version was used by 551 patients, and in this subgroup, 35.2% (194 of 551) and 70.4% (388 of 551) had controlled BPs on initial and final measurements, respectively, with 66.0% (235 of 356) of initially uncontrolled patients having a controlled final BP. Conclusion: This novel hypertension control program, which used technology to gather and prioritize data, facilitating the clinic’s efficient response, improved BP control rates by over 30% in a real-world, underserved population. BP control was higher in the Spanish-speaking population. Remote digital monitoring with intervention improves clinical outcomes without increasing the overall cost of care, thereby promoting value-based care strategies for chronic diseases such as hypertension.

Integrative Medicine: An Opportunity for Improving Quality of Care in the Inpatient Setting.

As medicine shifts to a value-based focus, health care providers in inpatient settings are actively seeking approaches to providing high-quality patient care without exacerbating prevailing cost burden. Complementary and integrative medicine may offer one potential solution for this challenge. Although the benefits of utilizing integrative practices in the inpatient setting have not been explored extensively thus far, early evidence demonstrates great promise of using integrative modalities to improve symptom burden in the inpatient setting while increasing patient pain satisfaction and reducing overall costs of care. Currently, social, educational, and financial barriers exist, limiting the widespread incorporation of complementary and integrative medicine into the inpatient setting. Nonetheless, a more robust body of literature demonstrating the effectiveness of complementary and integrative medicine in reducing costs of care and improving patient outcomes may help address these limitations and lead to the acceptance of integrative practices as the standard of high-value inpatient care.

The Cost We Bear: Financial Implications for Hip Fracture Care Amidst the COVID-19 Pandemic.

The purpose of this study was to assess the impact of COVID-19 on the cost of hip fracture care in the geriatric/middle-aged cohort, hypothesizing the cost of care increased during the pandemic, especially in COVID+ patients. Between October 2014 and January 2022, 2,526 hip fracture patients older than 55 years were analyzed for demographics, injury details, COVID status on admission, hospital quality measures, and inpatient healthcare costs from the inpatient admission. Comparative analyses were conducted between: (1) All comers and high-risk patients in the prepandemic (October 2014 to January 2020) and pandemic (February 2020 to January 2022) cohorts and (2) COVID+ and COVID- patients during the pandemic. Subanalysis assessed the difference in cost breakdown for patients in the overall cohorts, the high-risk quartiles, and between the prevaccine and postvaccine pandemic cohorts. Although the total costs of admission for all patients, and specifically high-risk patients, were not notably higher during the pandemic, further breakdown showed higher costs for the emergency department, laboratory/pathology, radiology, and allied health services during the pandemic, which was offset by lower procedural costs. High-risk COVID+ patients had higher total costs than high-risk COVID- patients ( P < 0.001), most notably in room-and-board ( P = 0.032) and allied health ( P = 0.023) costs. Once the pandemic started, subgroup analysis demonstrated no change in the total cost in the prevaccine and postvaccine cohort. The overall inpatient cost of hip fracture care did not increase during the pandemic. Although individual subdivisions of cost signified increased resource utilization during the pandemic, this was offset by lower procedural costs. COVID+ patients, however, had notably higher total costs compared with COVID- patients driven primarily by increased room-and-board costs. The overall cost of care for high-risk patients did not decrease after the widespread administration of the COVID-19 vaccine. III.

RWD121 Developing a Risk Prediction Model for the Early Identification of Alzheimer’s Disease (AD) in Elderly Patients

This study helps in predicting the incidence of AD based on multiple variables that were identified during the prodromal phase. Identification and timely intervention delays disease progression and improves the quality of life that leads to reduction in overall cost of care.

Comparison of Value per Operative Time between Primary and Revision Surgery for Adult Spinal Deformity: A Propensity Score-Matched Analysis.

Retrospective cohort study. To compare the relative value units (RVUs) per minute of operative time between primary and revision surgery for adult spinal deformity (ASD). Surgery for ASD is technically demanding and has high risks of complications and revision rates. This common need for additional surgery can increase the overall cost of care for ASD. RVU is used to calculate reimbursement from Medicare and to determine physician payments nationally. In calculating RVUs, the physician's work, the expenses of the physician's practice, and professional liability insurance. Cost effectiveness of surgeries for ASD have been evaluated, except for RVUs per minute compared between primary and revision surgery. Data were obtained from the American College of Surgeons National Surgical Quality Improvement Program database. Patients aged ≥18 years who underwent surgery for spinal deformity between 2011 and 2019 were identified and included. To ensure a homogenous patient cohort, those who underwent anterior-only and concurrent anterior-posterior fusions were excluded. Propensity score matching analysis was performed, and Mann-Whitney U test, Pearson chi-square test, or Fisher's exact test were used to compare matched cohorts as appropriate. A total of 326 patients who underwent revision surgery were matched with 206 primary surgery patients via propensity score matching. Demographic characteristics, comorbidities, preoperative laboratory values, and readmission and reoperation rates were not significantly different between groups. The revision surgery group had significantly higher mean RVUs per minute than that of the primary surgery group (0.331 vs. 0.249, p <0.001), as well as rates of morbidity and blood transfusion. Compared to primary surgery, revision surgery for ASD is associated with significantly higher RVUs per minute and total RVUs and higher rates of 30-day morbidity and blood transfusions. Readmission and reoperation rates are similar between surgeries.

Treatment of GERD Irrespective of Symptoms and Severity in COPD: To be or not to be!

COPD and GERD more commonly diagnosed and frequently reported health issues due to overlapping pathophysiological mechanisms and now considered as ‘two sides of same coin’. COPD related anatomical changes and medications will alter the course of existing GERD and increase the risk of new onset GERD. Proximal and distal anatomical locations of GERD have variable presentations such as worsening of COPD, acute non-infective exacerbations, recurrent cough, and respiratory failure. Proximal pathways involve direct lung injury by means of microaspiration of gastric contents and microbiological colonization. Distal pathway involves indirect mechanisms by sharing common anatomical and embryological developments with involvement of vagus nerve mediated noradrenergic cholinergic mediator’s related effects on bronchi and bronchioles. Both proximal and distal pathways have effects on lung functions. GERD has negative impact on natural course of COPD and exists in asymptomatic and symptomatic types. Prevalence of GERD should be actively sought in all COPD cases to prevent exacerbations, decrease lung functions decline, lower the risk of clinical and physiological worsening, and overall cost of care because of these high index issues. PPI therapy has significant effects on patients with COPD in reducing the number of acute attacks, adverse reactions, and mortality. Recurrent exacerbations need GERD to be ruled out in all cases of COPD to have successful treatment outcome. Only symptomatic cases treatment has shown positive outcome in GERD with COPD. Hence, ‘to be or not to be is the real question’ and no treatment is recommended for asymptomatic GERD cases with COPD irrespective of disease severity.

Financial burden associated with discordance to intravenous iron therapies in US patients with iron deficiency anemia.

BACKGROUND: Iron deficiency anemia (IDA) affects approximately 5 million people in the United States and has a significant impact on human health. Intravenous (IV) iron is indicated for treatment of IDA when oral iron is not effective or not tolerated. Several IV iron products are available, including oldergeneration and newer-generation products. Newer agents have certain benefits, including the ability to administer high iron doses in fewer infusions; despite the benefits, some payors require failure on older iron products before use of newer iron products in prior authorization processes. IV iron replacement regimens requiring multiple infusions may lead to patients not receiving recommended IV iron treatment per label; potential costs of this discordance may outweigh the difference in price between the older and newer products. OBJECTIVE: To quantify the burden of discordance to IV iron therapy and associated economic consequences. METHODS: This is a retrospective study using administrative claims data between January 2016 and December 2019 from adult patients who are enrolled in a commercial insurance program with a regional health plan. A course of IV iron therapy is defined as all infusions that occur within 6 weeks of the initial infusion. Discordance to therapy is defined as having received less than 1,000 mg of iron over a course of therapy. RESULTS: There were 24,736 patients included in the study. Baseline demographics were similar between the patients who received older- vs newer-generation products and patients who were concordant vs discordant. Discordance to IV iron therapy overall was 33%. Patients who received newer-generation products were less discordant to therapy (16%) than patients who received older-generation products (55%). In general, patients who received newer-generation products had a lower total cost of care than patients who received older-generation products. CONCLUSIONS: Discordance to the older-generation products was significantly higher than that to the newer-generation products. Patients who were concordant to therapy and on a newer-generation product had the lowest total cost of care, suggesting that overall cost of care is not necessarily proportional to the purchase price of the chosen IV iron replacement therapy. Optimizing concordance to IV iron therapy may lead to lower total cost of care in the IDA population. DISCLOSURES: Magellan Rx Management received funding for this study from Pharmacosmos Therapeutics Inc. AESARA contributed to study design and data analysis. Magellan Rx Management contributed to the study design, data analysis, and interpretation of results. Pharmacosmos Therapeutics Inc. participated in the study design and interpretation of results.

Treatment with oral or inhaled bronchodilator without inhaled corticosteroids in bronchial asthma: A dangerous weapon!

Abstract Bronchial asthma is the most common chronic lung disease in the obstructive airway disease category with the characteristic feature of “reversible” airflow obstruction. Despite an increase in awareness of risk factors, diagnosis, and treatment options available to treat bronchial asthma, more than half of cases received irrational treatment. Inadequate treatment is reasoning more morbidity and mortality of this easily treatable disease. Inhaled short- and long-acting bronchodilators, antimuscarinic agents, and inhaled corticosteroids (ICSs) are the cornerstone of the treatment of asthma and are categorized as “rescue and controller” role in disease management. Bronchodilators without ICSs are not recommended because of more harm than benefit in bronchial asthma. ICSs are the gold standard and the recommended treatment for asthma due to their anti-inflammatory and disease-modifying property labeled as “game changer role.” Bronchodilators with ICSs will have added benefit of symptom control, improvement in quality of life, and decrease in exacerbation. Combo of bronchodilators with ICSs will decrease the overall cost of care in asthma by improving disease control and decrease in emergency room visits and hospitalizations in intensive care units due to exacerbations.