Professional Fees Research Articles

Low Yield and High Cost of Gastric and Duodenal Biopsies for Investigation of Symptoms of Abdominal Pain During Routine Esophagogastroduodenoscopy

Esophagogastroduodenoscopy (EGD) referrals for symptoms of abdominal pain are common. Current guidelines for dyspepsia recommend biopsies of gastric mucosa for Helicobacter pylori in all patients referred for EGD. Our study aimed to determine the clinical yield and cost-effectiveness of gastric and duodenal biopsy in EGDs performed for abdominal pain. Three hundred and ninety-one outpatient EGDs performed at a single academic tertiary care center were studied. For each procedure, endoscopic as well as pathologic findings from the stomach and duodenum were then recorded. Charge of biopsy was calculated using the increased charges for professional fees, forceps, and pathology fees when a biopsy was performed. Gastric biopsies were obtained on 304 EGDs performed with 13 (4.2%) patients diagnosed with H. pylori. In patients with abnormal gastric mucosa on EGD, 11 of 167 (6.5%) were positive for H. pylori compared to 2 of 137 (1.4%) with normal appearing mucosa (p=0.02). Charge per diagnosis of H. pylori for normal mucosa was calculated to be $43,073. Duodenal biopsies were performed in 263 cases. Celiac disease was diagnosed in 4 of 263 cases (1.5%). Of patients with abnormal duodenal mucosa on EGD, 1 of 36 (2.7%) were positive for celiac disease compared to 3 of 227 (1.3%) with normal mucosa (p=0.57). Charge per diagnosis of celiac disease for normal mucosa was calculated to be $47,580. Routine biopsy during EGD for symptoms of abdominal pain has low yield with high costs. Practice of routine biopsies of normal appearing tissue and the present guidelines should be reconsidered in the investigation of abdominal pain with EGD.

Using Chargemaster Data to Understand Childhood Leukemia Costs

Introduction: Recent changes in health care financing have increased the out-of-pocket costs borne by families. The potential "financial toxicity" can pose challenges for families beyond those encountered in the treatment of cancer. Several families of children diagnosed with leukemia at our center have recently requested information on the expected costs of the planned treatment. There is little published information on the patient's cost (that is, the health system patient charges) for childhood cancer treatment, and costs can be expected to vary between patients and institutions. To better understand the cost of leukemia treatment at our center, the charges accumulated over the course of therapy for a cohort of children with acute lymphoblastic leukemia (ALL) and acute myeloid leukemia (AML) were analyzed.Methods: A sample of children who successfully completed treatment at our institution in 2014 using the current Children's Oncology Group (COG) treatment protocols for standard risk ALL (AALL0932) and AML (AAML0531) was chosen. All inpatient and outpatient charges for the entire course of therapy for each child were used to determine total charges for treatment and types of charges (room and board, medications, laboratory, radiology, professional fees). Using our health system's chargemaster data, the expected charges for ALL therapy based upon protocol requirements was estimated and compared to actual charges. We analyzed high frequency and high cost items to identify potential drivers of charges to suggest areas for potential cost reduction.Results: Charges for 11 patients with ALL and 7 with AML were assessed. The average charges for ALL therapy were $311,000 (range $182,000-634,000) and for AML were $1.05 million (range $733,000-$1,346,000). For ALL, room and board, medications, and laboratory accounted for 37%, 16%, and 19% of charges respectively. For AML, room and board medications and laboratory accounted 66%, 14%, and 14% of charges respectively. (Figure 1) Low risk ALL treatment had higher overall charges driven by increased inpatient chemotherapy. Expected charges for low risk ALL treatment were $245,000 compared to $165,000 for average risk standard therapy. Actual charges however did not differ greatly between low risk and average risk ALL subtypes. (Figure 2) The highest charges for items in ALL therapy were for intravenous immune globulin (IVIG), asparaginase, and inpatient stays (intensive care and oncology ward). For AML, the most expensive items were inpatient stays (intensive care and oncology ward), blood products, and complete blood counts (CBC).Conclusion: AML therapy is more expensive than ALL therapy, driven primarily by the prolonged hospitalizations awaiting count recovery after each cycle. ALL treatment charges were highly variable depending upon experienced toxicities and arm of therapy. Low risk therapy for ALL has the potential to be the most expensive ALL therapy due to six inpatient courses of intermediate dose methotrexate. Estimates for ALL therapy charges did not capture medical toxicity expense or other supportive care related charges. Many drivers of cost cannot be altered without affecting quality of care, but increasing outpatient therapy has the potential to provide the largest reduction in charges. The use of IVIG in some ALL patients and the frequency of CBCs in AML patients highlighted areas where clinical interventions could be implemented without obvious decrements to care quality and with potential cost savings. Understanding data on patient charges can provide an expected range of charges for families and may inform areas to target for cost savings. [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

PENGARUH KEPEMILIKAN PERUSAHAAN, CORPORATE GOVERNANCE, DAN EARNINGS MANAGEMENT TERHADAP TIPE AUDITOR DAN AUDIT FEES (Studi Empiris Pada Perusahaan yang Terdaftar di BEI dan IICG Tahun 2011-2013)

Audit Fee is a dilemmatic problem for an auditor because auditor get a fee from the audited client. On the other side, auditor must be independent in giving their opinion while they also get a fee for services rendered. The purpose of this study is to provide information to companies, auditors, and other information users about the factors that influence the company in selecting the type of auditors and audit fees. The independent variables in this study ar Firm Ownership, Corporate Governance, and Earnings Management with the dependent variablesare the type of auitor and audit fees. Firm ownership in this study was divided into two, the state-owned companies (BUMN)and private companies. Earnings management was measured by discreationary acccruals (DACC) Jones model. Corporate governance in this study was measured by looking at Corporate Governance Perception Index (CGPI). Type of auditors in this study were divided into two, KAP the big four and non-the big four. Audit fees in this studywas measured by natural logarithm of the professional fees. The population of this study is companies listed in the Indonesian Stock Exchange (IDX) and also listed in the Indonesian Institute of Corporate Governance (IICG) in 2011- 2013 with the total sample is 51 company datas for 3 years. The hypotheses in this study were tested using logistic regression and multiple regression. The results of this study indicate that firm ownership does not influence the selection of the type of auditors and audit fees, while corporate governance and earnings management influence the selection of the type of auditors and audit fees.

Cost analysis of iliac stenting performed in the operating room and the catheterization lab: A case-control study

BackgroundIliac arterial stenting is performed both in the operating room (OR) and the catheterization lab (CL). To date, no analysis has compared resource utilization between these locations. MethodsConsecutive patients (n = 105) treated at a single center were retrospectively analyzed. Patients included adults with chronic, symptomatic iliac artery stenosis with a minimum Rutherford classification (RC) of 3, treated with stents. Exclusion criteria were prior stenting, acute ischemia, or major concomitant procedures. Immediate and two-year outcomes were observed. Patient demographics, perioperative details, physician billings, and hospital costs were recorded. Multivariable regression was used to adjust costs by patient and perioperative cost drivers. ResultsFifty-one procedures (49%) were performed in the OR and 54 (51%) in the CL. Mean age was 57, and 44% were female. Severe cases were more often performed in the OR (RC ≥ 4; 42% vs. 11%, P < 0.001) and were associated with increased total costs (P < 0.01). OR procedures more often utilized additional stents (stents ≥ 2; 61% vs. 46%, P = 0.214), thrombolysis (12% vs. 0%, P = 0.011), cut-down approach (8% vs. 0%, P = 0.052), and general anesthesia (80% vs. 0%, P < 0.001): these were all associated with increased costs (P < 0.05). After multivariable regression, location was not a predictor of procedure room or total costs but was associated with increased professional fees. Same-stay (5%) and post-discharge reintervention (33%) did not vary by location. ConclusionsThe OR was associated with increased length of stay, more ICU admissions, and increased total costs. However, OR patients had more severe disease and therefore often required more aggressive intervention. After controlling for these differences, procedure venue per se was not associated with increased costs, but OR cases incurred increased professional fees due to dual-provider charges. Given the similar clinical results between venues, it seems reasonable to perform most stenting in the CL or utilize conscious sedation in the OR.

Assessing Telemedicine Utilization by Using Medicaid Claims Data.

This study characterized telemedicine utilization among Medicaid enrollees by patients' demographic characteristics, geographic location, enrollment type, eligibility category, and clinical conditions. This study used 2008-2009 Medicaid claims data from 28 states and the District of Columbia to characterize telemedicine claims (indicated by GT for professional fee claims or Q3014 for facility fees) on the basis of patients' demographic characteristics, geographic location, enrollment type, eligibility category, and clinical condition as indicated by ICD-9 codes. States lacking Medicaid telemedicine reimbursement policies were excluded. Chi-square tests were used to compare telemedicine utilization rates and one-way analysis of variance was used to estimate mean differences in number of telemedicine encounters among subgroups. A total of 45,233,602 Medicaid enrollees from the 22 states with telemedicine reimbursement policies were included in the study, and .1% were telemedicine users. Individuals ages 45 to 64 (16.4%), whites (11.3%), males (8.5%), rural residents (26.0%), those with managed care plans (7.9%), and those categorized as aged, blind, and disabled (28.1%) were more likely to receive telemedicine (p<.001). Nearly 95% of telemedicine claims were associated with a behavioral health diagnosis, of which over 50% were for bipolar disorder and attention-deficit disorder or attention-deficit hyperactivity disorder (29.3% and 23.4%, respectively). State-level variation was high, ranging from .0 to 59.91 claims per 10,000 enrollees (Arkansas and Arizona, respectively). Despite the touted potential for telemedicine to improve health care access, actual utilization of telemedicine in Medicaid programs was low. It was predominantly used to treat behavioral health diagnoses. Reimbursement alone is insufficient to support broad utilization for Medicaid enrollees.

Charges associated with imaging techniques in evaluation of pediatric hearing loss

ObjectiveThe best imaging study for evaluation of pediatric hearing loss is debated and it is well known magnetic resonance imaging is more costly than computed tomography. The objective of this study is to evaluate charges of computed tomography temporal bone (CTTB) versus magnetic resonance imaging brain, internal auditory canal/cerebellopontine angle (MRI IAC/CPA), with and without sedation in the pediatric population in order to assess to what extent the charges for the procedure are increased. In addition, differences in need for sedation and duration of sedation will be evaluated. MethodsAll patients, 0–18 years that underwent CTTB or MRI IAC/CPA, between January 2013 through December 2014 within department of otolaryngology. Results120 CTTBs (118 non-sedated and 2 sedated) and 51 MRI IAC/CPAs (32 non-sedated and 19 sedated) were performed. Average charge for non-sedated CTTB was $1856. CTTB scan under sedation incurred total additional charges of $2385. Average charges for non-sedated MRI IAC/CPA was $3770. Technical charges for sedated MRI IAC/CPA was $151 lower ($2858) but had additional sedation charges of $2256, a recovery room charge of $250, and additional professional fees of $1496 for total charges of $7621. 37% of MRI IAC/CPAs needed sedation to be completed in comparison to 1.6% of CTTB. ConclusionMRI IAC/CPAs are, on average, twice as costly as CTTBs. Almost 40% of patients need sedation to complete MRI IAC/CPA. These considerations may factor into decision making when choosing imaging modality in evaluation of pediatric hearing loss.

Estimación de costos económicos en la atención de la neumonía nosocomial en un hospital regional peruano, 2009 al 2011

To estimate and compare the economic costs for the care of patients with and without nosocomial pneumonia at Hospital II Huánuco EsSalud during 2009-2011, in Peru.This was a partial economic evaluation of paired cases and controls. A collection sheet was used.nosocomial pneumonia.direct health costs, direct non-health costs, indirect costs, occupation, age, comorbidities, sex, origin, and education level. A bivariate analysis was performed.Forty pairs of cases and controls were identified. These patients were hospitalized for >2 weeks and prescribed more than two antibiotics. The associated direct health costs included those for hospitalization, antibiotics, auxiliary examinations, specialized assessments, and other medications. The direct non-health costs and associated indirect costs included those for transportation, food, housing, foregone payroll revenue, foregone professional fee revenue, extra-institutional expenses, and payment to caregivers during hospitalization and by telephone.The direct health costs for nosocomial pneumonia patients were more than three times and the indirect costs were more than two times higher than those for the controls. Variables with the greatest impact on costs were identified.

Effect of a Documentation Improvement Program for an Academic Otolaryngology Practice.

Physicians recognize the value of accurate documentation to facilitate patient care, communication, and the distribution of professional fees. However, the association between inpatient documentation, hospital billing, and quality metrics is less clear. To identify areas of deficiency in inpatient documentation and to instruct health care professionals on how to improve the quality and accuracy of clinical records. A single-arm pre-post study was conducted from January 1, 2013, to December 31, 2014, among 17 attending and 12 resident physicians treating 1188 patients at an academic medical center. Data from 1 year prior to the intervention were compared with data for 10 months following the intervention. All increases were analyzed as a percentage increase after the intervention relative to before the intervention. Areas for improvement were identified, and all physicians in the department received education on inpatient coding and documentation. The capture rate for complications or comorbidities and major complications or comorbidities, the case mix index (the average diagnosis related group relative weight for a hospital or department), and severity of illness and risk of mortality scores. A total of 1188 inpatients were included in the analysis: 743 in the preintervention period and 445 in the postintervention period. Review of our documentation identified major areas of comorbidity that were frequently underreported. Inadequate nutrition diagnoses (moderate malnutrition, severe protein-calorie malnutrition) were most often underreported. In addition, we found inadequate documentation supporting the presence of neck metastases. Among 1188 patients, the case mix index increased 5.3% (from 2.81 to 2.96) after the intervention, but this was not a statistically significant difference (P = .21). The normalized case mix index increased 21.7% (from 37.3 to 45.4; P < .01). The percentage of patients with a documented complication or comorbidity or major complication or comorbidity increased 27.1% (from 50.2% to 63.8%; P < .01). The percentage of patients assigned a severity of illness score of 3 or 4 increased 24.3% (from 34.7% to 43.0%; P < .01). The percentage of patients assigned a risk of mortality score of 3 or 4 increased 32.1% (from 18.7% to 24.7%; P = .01). After educational sessions, multiple measures of patient acuity increased significantly owing to improved documentation of common comorbid conditions. Although physicians intuitively appreciate the importance of good documentation, education on the technical aspects of coding can significantly improve the quality and accuracy of clinical records.

Bankruptcy Tourism in the European Union: Myth or Reality?

Does bankruptcy tourism exist in personal insolvency? If so, is bankruptcy tourism a problematic issue for the English and Welsh courts? This article sets out to examine these questions through an examination of case law developments in the field of personal insolvency in England and Wales and in a number of other European Union (EU) Member States. It is argued that the English and Welsh court’s reputation as a ‘Bankruptcy Brothel’ is one that should be embraced. Viewing the attractiveness of our bankruptcy system as a positive attribute helps focus attention on the increased professional fees and business that increased use of our system brings (“insolvency madame thesis”). Furthermore, it is argued that what we are seeing is not a bankruptcy tourism phenomenon but rather a small and sophisticated group of debtors taking advantage of ANY opportunity to protect assets from creditors. In focusing on the technical acquisition of Centre of Main Interest (COMI) and avoiding a thorough examination of debtor motive (“debtor motives thesis”) the English and Welsh courts are helping to support what is termed the insolvency madame thesis in this article. This English approach is different to the French courts who are examining debtor motives more closely. In so doing the French courts are giving effect to the intentions of the European legislature but failing to adhere to the free movement of persons philosophy that underpins the EU.

Off-therapy procedures are not beneficial in pediatric B-cell acute lymphoblastic leukemia

ABSTRACTAcute lymphoblastic leukemia (ALL) is the most common childhood cancer. Although curable, approximately 20% of patients relapse. In an effort to detect relapse earlier, our institution performed surveillance bone marrow (BM) and cerebrospinal fluid (CSF) evaluations every 3 months from the end of therapy to 1 year off. This study retrospectively reviewed all patients with B-cell ALL (B-ALL) from September 2005 to September 2010 to determine the benefit and cost of these procedures. Forty-one patients completed therapy and had 190 BMs and 190 lumbar punctures (LPs) performed. Four of 41 patients (9.8%) experienced a relapse. Relapse was detected in only 1 patient by routine BM evaluation (0.5%). Zero LPs were positive. The professional fees for the procedures were $8,738/patient. Therefore, off-therapy BM and CSF evaluations are not effective at detecting relapse and are expensive. Our institution has abandoned off-therapy surveillance for ALL.

Cost and radiation exposure in the workup of febrile pediatric urinary tract infections

BackgroundTechnetium-99m dimercaptosuccinic acid (DMSA) scans are often used in the evaluation of pediatric patients with febrile urinary tract infections (UTIs). Given the prevalence of febrile UTIs, we sought to quantify the cost, radiation exposure, and clinical utility of DMSA scans when compared with dedicated pediatric renal ultrasounds (RUSs). Materials and methodsAn institutional review board approved retrospective study of children under the age of 18 years evaluated at our institution for febrile UTIs between the years 2004-2013 was conducted. The patients had to meet all of the following inclusion criteria: a diagnosis of vesicoureteral reflux, a fever >38°C, a positive urine culture, and evaluation with a DMSA scan and RUS. A chart review was used to construct a cost analysis of technical and professional fees, radiographic results, and radiation dose equivalents. ResultsOverall, 104 children met the inclusion criteria. A total of 122 RUS and 135 DMSA scans were performed. The technical costs of a DMSA scan incurred a 35% cost premium as compared to an RUS. The average effective radiation dose of a single DMSA scan was 2.84 mSv. New radiographic findings were only identified on 7% of those patients who underwent greater than 1 DMSA scan. ConclusionsThe utility of the unique information acquired from a DMSA scan as compared to a RUS in the evaluation of febrile UTI must be evaluated on an individual case-by-case basis given the increased direct costs and radiation exposure to the patient.

Distribution and predictors of emergency department charges: the case of a tertiary hospital in Lebanon.

BackgroundAs health care costs continue to increase worldwide, health care systems, and more specifically hospitals are facing continuous pressure to operate more efficiently. One service within the hospital sector whose cost structure has been modestly investigated is the Emergency Department (ED). The study aims to report on the distribution of ED resource use, as expressed in charges, and to determine predictors of/contributors to total ED charges at a major tertiary hospital in Lebanon.MethodsThe study used data extracted from the ED discharge database for visits between July 31, 2012 and July 31, 2014. Patient visit bills were reported under six major categories: solutions, pharmacy, laboratory, physicians, facility, and radiology. Characteristics of ED visits were summarized according to patient gender, age, acuity score, and disposition. Univariate and multivariate analyses were conducted with total charges as the dependent variable.ResultsFindings revealed that the professional fee (40.9 %) followed by facility fee (26.1 %) accounted for the majority of the ED charges. While greater than 80 % of visit charges went to physician and facility fee for low acuity cases, these contributed to only 52 and 54 % of the high acuity presentations where ancillary services and solutions’ contribution to the total charges increased. The total charges for males were $14 higher than females; age was a predictor of higher charges with total charges of patients greater than 60 years of age being around $113 higher than ages 0–18 after controlling for all other variables.ConclusionUnderstanding the components and determinants of ED charges is essential to developing cost-containment interventions. Institutional modeling of charging patterns can be used to offer price estimates to ED patients who request this information and ultimately help create market competition to drive down costs.

Estimating the cost-savings of a comprehensive hospital-based palliative care program.

2 Background: In FY 2012, Johns Hopkins Medicine (JHM) established a palliative care inpatient unit (PCU). The PCU received patients as transfers and direct admissions. PCUs can improve care (Roza K, et al. JPM 2015) and lower per diem costs compared to usual care (Smith TJ, et al. JPM 2003; Goldstein J, et al. JPSM 2015). This project studied the financial impact of the PCU and PC program on JHM. Methods: Using one fiscal year of admissions, the team calculated the per day variable cost of pre-transfer in to palliative care (from ED) and palliative care transfer. These fees were multiplied by the number of patients transferred to the PCU (153) and by the average length of stay in the PCU (5.11 days). These variable costs were added together to reach the combined savings. Consultation savings were estimated using established methods (Morrison RS, et al. Arch Int Med 2008; adjusted to 2014 dollars). Results: The PCU operated at 54% occupancy in the first year. The daily loss pre-transfer of $1,672 was reduced 59% to $785 post-transer. Over 60% of transfers came from the ICU, freeing beds. The PCU saved JHM $367,751 in direct costs; additional cost savings for PC consultation were estimated at $4.3M (1,335 live discharges × $2,374, 165 decedent discharges × $6,872) and $370,000 was collected in professional fees, for a total contribution of approximately $5M. Conclusions: The PCU and PC program had a favorable impact on the health system. As JH moves to an acountable care organization model being both provider and insurer, such improved quality, cost savings, and increased ICU availability are desirable.

Darkness on the edge of town? Or is the calculation of consequential losses in dilapidations claims harder than it looks? (Part 2)

This paper addresses one aspect of the quantification of damages for breach of the tenant's covenants to yield up the demised premises in repair at the end of the term: consequential losses. Part one of the paper summarises the different ways of quantifying such damages, shortly restating the contrasting rules in Joyner v. Weeks [1891] 2 QB 31 (CA) and in Ruxley Electronics &amp; Construction v. Forsyth [1996] AC 344 (HL). It also summarises the general law on causation, remoteness of damage, and recovering the reasonable costs of mitigation. Part two of the paper then applies these principles to the specific issues arising in dilapidations cases: loss of rent, the inability to recover service charges, insurance and rates, liability for professional fees and preliminaries, the incidence of VAT, recovering the cost of preparing schedules, recovering the costs of re-certification and liability to pay interest. This paper was first presented at RICS Dilapidations Conference in 2015.

Professional Fee Ratios for US Hospital Discharge Data

Professional Fee Ratios for US Hospital Discharge Data

Darkness on the edge of town? Or is the calculation of consequential losses in dilapidations claims harder than it looks? (Part 1)

This paper addresses one aspect of the quantification of damages for breach of the tenant's covenants to yield up the demised premises in repair at the end of the term: consequential losses. Part one of the paper summarises the different ways of quantifying such damages, shortly restating the contrasting rules in Joyner v. Weeks [1891] 2 QB 31 (CA) and in Ruxley Electronics &amp; Construction v. Forsyth [1996] AC 344 (HL). It also summarises the general law on causation, remoteness of damage, and recovering the reasonable costs of mitigation. Part two of the paper then applies these principles to the specific issues arising in dilapidations cases: loss of rent, the inability to recover service charges, insurance and rates, liability for professional fees and preliminaries, the incidence of VAT, recovering the cost of preparing schedules, recovering the costs of re-certification and liability to pay interest.

Economic implications of labor induction.

To assess health service costs associated with labor induction according to different clinical situations in a tertiary-level hospital. In a prospective study, individual patient cost data were assessed for women admitted for induction of labor at a tertiary hospital in Spain between November 1, 2012, and August 31, 2013. The costs of labor induction were estimated according to maternal and neonatal outcomes, method of delivery, cervical condition at admission, and obstetric indication. Direct costs including professional fees, epidural, maternal stay, consumables, and drugs were calculated. Overall, 412 women were included in the final cost analysis. The mean total cost of labor induction was €3589.87 (95% confidence interval [CI] 3475.13-3704.61). Cesarean delivery after labor induction (€4830.45, 95% CI 4623.13-5037.58) was significantly more expensive than spontaneous delivery (€3037.45, 95% CI 2966.91-3179.99) and instrumental vaginal delivery (€3344.31, 95%CI 3151.69-3536.93). The total cost for patients with a very unfavorable cervix (Bishop score <2; €4283.47, 95% CI 4063.06-4503.88) was almost double that for women with a favorable cervix (€2605.09, 95% CI 2327.38-2837.58). Labor induction for hypertensive disorders of pregnancy was the most expensive obstetric indication for induction of labor (€4347.32, 95% CI 3890.45-4804.18). Following the induction of labor, a number of patient- and treatment-related factors influence costs associated with delivery.

The cost of failure: The economic impact of failed primary closure in classic bladder exstrophy

PurposeFailure of primary closure in classic bladder exstrophy (CBE) is a significant cause of morbidity, and yet its relative economic impact has not been well characterized. The authors aim to determine whether CBE patients who underwent failed primary closure incur greater economic burden in the year following their successful closure than those patients who underwent a successful primary closure. Materials and MethodsAfter institutional review board approval CBE patients who were successfully closed between 1993 and 2013 were identified in an institutional exstrophy–epispadias database. Patients who were never closed at the study institution and those who had no documented successful closure were excluded. Inpatient hospital charges, hospital costs, and professional fees were collected for the year following successful closure. Results162 patients met the inclusion and exclusion criteria and accounted for 312 inpatient admissions in the year following and including their respective successful bladder closures. 62 of the patients failed their primary closure and the remaining 100 succeeded. Adjusting for covariates, patients who underwent successful primary closure experienced a reduction in inpatient hospital charges of $8497, hospital costs of $9046 and professional fees of $11,180 in the year following their successful closure compared to those patients who failed their primary closure. ConclusionApart from the self-evident financial advantages of a successful primary closure, namely the avoidance of reclosure, there appears to be a lasting negative financial impact of failed primary closure even after these patients undergo successful reclosure at the study institution.

Paravertebral regional blocks decrease length of stay following surgery for pectus excavatum in children

PurposeManagement of postoperative pain following repair of pectus excavatum has traditionally included thoracic epidural analgesia, narcotics, and benzodiazepines. We hypothesized that the use of intercostal or paravertebral regional blocks could result in decreased inpatient length of stay (LOS). MethodsWe conducted a retrospective cohort study of 137 patients (118 Nuss and 19 Ravitch — Nuss and Ravitch patients were analyzed separately) who underwent surgical repair of pectus excavatum with pain management via epidural, intercostal, or paravertebral analgesia from January 2009–December 2012. Measured outcomes included LOS, pain scores, benzodiazepine/narcotic requirements, emesis, professional fees, hospital cost, and total cost. ResultsIn the Nuss patients, LOS was significantly reduced in the paravertebral group (p<0.005) and the intercostal group (p<0.005) compared to the epidural group, but was paradoxically countered by a nonsignificant increase in total cost (p=0.09). While benzodiazepine doses/day was not increased in the paravertebral group (p=0.08), an increase was seen in narcotic use (p<0.005). Despite increased narcotic use, no differences were seen in emesis between epidural and paravertebral use. Compared to epidural, pain scores were higher for both intercostal and paravertebral on day one (p<0.005), but equivalent for paravertebral on day three (p=0.62). The Ravitch group was too small for detailed independent statistical analysis but followed the same overall trend seen in the Nuss patients. ConclusionOur use of paravertebral continuous infusion pain catheters for pectus excavatum repair was an effective alternative to epidural analgesia resulting in shorter LOS but not a decrease in overall cost.

Professional Fee Ratios for US Hospital Discharge Data.

US hospital discharge datasets typically report facility charges (ie, room and board), excluding professional fees (ie, attending physicians' charges). We aimed to estimate professional fee ratios (PFR) by year and clinical diagnosis for use in cost analyses based on hospital discharge data. The subjects consisted of a retrospective cohort of Truven Health MarketScan 2004-2012 inpatient admissions (n=23,594,605) and treat-and-release emergency department (ED) visits (n=70,771,576). PFR per visit was assessed as total payments divided by facility-only payments. Using ordinary least squares regression models controlling for selected characteristics (ie, patient age, comorbidities, etc.), we calculated adjusted mean PFR for admissions by health insurance type (commercial or Medicaid) per year overall and by Major Diagnostic Category (MDC), Diagnostic Related Group, Healthcare Cost and Utilization Project Clinical Classification Software, and primary International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) diagnosis, and for ED visits per year overall and by MDC and primary ICD-9-CM diagnosis. Adjusted mean PFR for 2012 admissions, including preceding ED visits, was 1.264 (95% CI, 1.264, 1.265) for commercially insured admissions (n=2,614,326) and 1.177 (1.176, 1.177) for Medicaid admissions (n=816,503), indicating professional payments increased total per-admission payments by an average 26.4% and 17.7%, respectively, above facility-only payments. Adjusted mean PFR for 2012 ED visits was 1.286 (1.286, 1.286) for commercially insured visits (n=8,808,734) and 1.440 (1.439, 1.440) for Medicaid visits (n=2,994,696). Supplemental tables report 2004-2012 annual PFR estimates by clinical classifications. Adjustments for professional fees are recommended when hospital facility-only financial data from US hospital discharge datasets are used to estimate health care costs.