Total 90-day Costs Research Articles

Short-Term Out-of-Pocket and Total Costs of Care After Ablation, Resection, or Transplant for Early-Stage Hepatocellular Carcinoma: A National SEER-Medicare Cost Comparison.

Background: Differences in survival and morbidity among treatment options (ablation, surgical resection, and transplant) for early-stage hepatocellular carcinoma (HCC) have been well-studied. Additional understanding of the costs of such care would help to identify drivers of high costs and potential barriers to care delivery. Objective: To quantify total and patient out-of-pocket costs for ablation, surgical resection, and transplant in the management of early-stage HCC and to identify factors predictive of these costs. Methods: This retrospective U.S. population-based study used the SEER-Medicare linked dataset to identify a sample of 1067 Medicare beneficiaries (mean age, 73 years; 674 men, 393 women) diagnosed with early-stage HCC (size ≤5 cm) treated with ablation (N=623), resection (N=201), or transplant (N=243) between January 2009 and December 2016. Total costs and patient out-of-pocket costs for the index procedure as well as for any care within 30 days and 90 days post-procedure were identified and stratified by treatment modality. Additional comparisons were performed among propensity-score matched subgroups of patients treated by ablation or resection (each N=172). Multivariable linear regression models were used to identify factors predictive of total costs and out-of-pocket costs for index procedures as well as for 30-day and 90-day post-procedure periods. Results: For ablation, resection, and transplant, median index-procedure total cost was $6689, $25,614, and $66,034; index-procedure out-of-pocket cost was $1235, $1650, and $1317; 30-day total cost was $9456, $29,754, and $69,856; 30-day out-of-pocket cost was $1646, $2208, and $3198; 90-day total cost was $14,572, $34,984, and $88,103; and 90-day out-of-pocket cost was $2138, $2462, and $3876, respectively (all p<.001). In propensity-matched subgroups, ablation and resection had median index-procedure, 30-day, and 90-day total costs of $6690 and $25,716, $9995 and $30,365, and $15,851 and $34,455, respectively. In multivariable analysis adjusting for socioeconomic factors, comorbidities, and liver-disease prognostic indicators, surgical treatment (resection or transplant) was predictive of significantly greater costs compared with ablation at all time points. Conclusion: Total and out-of-pocket costs for index procedures as well as for 30-day and 90-day post-procedure periods were lowest for ablation, followed by resection and then transplant. Clinical Impact: This comprehensive cost analysis could help inform future cost-effectiveness analyses.

Provider-to-provider telehealth for sepsis patients in a cohort of rural emergency departments.

Telehealth has been proposed as one strategy to improve the quality of time-sensitive sepsis care in rural emergency departments (EDs). The purpose of this study was to measure the association between telehealth-supplemented ED (tele-ED) care, health care costs, and clinical outcomes among patients with sepsis in rural EDs. Cohort study using Medicare fee-for-service claims data for beneficiaries treated for sepsis in rural EDs between February 1, 2017, and September 30, 2019. Our primary hospital-level analysis used multivariable generalized estimating equations to measure the association between treatment in a tele-ED-capable hospital and 30-day total costs of care. In our supporting secondary analysis, we conducted a propensity-matched analysis of patients who used tele-ED with matched controls from non-tele-ED-capable hospitals. Our primary outcome was total health care payments among index hospitalized patients between the index ED visit and 30 days after hospital discharge, and our secondary outcomes included hospital mortality, hospital length of stay, 90-day mortality, 28-day hospital-free days, and 30-day inpatient readmissions. In our primary analysis, sepsis patients in tele-ED-capable hospitals had 6.7% higher (95% confidence interval [CI] 2.1%-11.5%) total health care costs compared to those in non-tele-ED-capable hospitals. In our propensity-matched patient-level analysis, total health care costs were 23% higher (95% CI 16.5%-30.4%) in tele-ED cases than matched non-tele-ED controls. Clinical outcomes were similar. Tele-ED capability in a mature rural tele-ED network was not associated with decreased health care costs or improved clinical outcomes. Future work is needed to reduce rural-urban sepsis care disparities and formalize systems of regionalized care.

Abstract 16015: The Effect of the 2019 Reduction in Price of PCSK9 Inhibitors on Total Cost, Out-of-Pocket Cost, and Access Among Medicare Part D Beneficiaries

Introduction: Uptake of Proprotein Convertase Subtilisin/Kexin type 9 inhibitors (PCSK9i) among Medicare beneficiaries was initially slow because of coverage restrictions and high out-of-pocket costs. In November 2018, manufacturers announced an unprecedented 60% reduction in the price of PCSK9is. The effect of this price reduction on access and cost has not been previously studied. Hypothesis: Did the large reductions in PCSK9i prices improve coverage and lower out-of-pocket (OOP) costs for Medicare Part D beneficiaries? Methods: Medicare Part D Prescription Drug Plan Formulary, Pharmacy Network, and Pricing Information files (2018-2022) were used to evaluate coverage, 30-day OOP and total costs, and formulary restrictions before (2018Q1-2019Q1) and after (2019Q2-2023Q1) the PCSK9i price reduction. Costs were calculated in the coverage phase, not the deductible or coverage gaps. Paired t-tests were used to determine statistical significance with a two-sided alpha of 0.05. Results: We examined Part D plans in the first quarter of each year from 2018 to 2023 (3,127 to 4,543 plans per year, 79% Medicare Advantage plans). Nearly all plans covered at least 1 PCSK9i before and after the price reduction (97% vs 100% of plans). The price reduction was associated with significant reductions in 30-day total costs (from $1,075 to $585; difference = $489; 95% CI $484 - $494; p &lt;0.001) and 30-day out-of-pocket costs ($306 to $75; difference = $231; 95% CI $228 - $233; p&lt;0.001) (Figure 1). The proportion of plans requiring coinsurance as a proportion as opposed to a fixed copayment amount declined from 97% to 15% (p&lt;0.001). Conclusions: The reduction in prices of PCSK9i was associated with significant declines in total Medicare costs and projected OOP costs for Medicare Part D beneficiaries. Nearly all Part D plans cover at least 1 PCSK9i. Future studies should examine the impact of this price reduction on adherence and cost-effectiveness of these therapies.

Key drivers of 90-day costs in primary total elbow arthroplasty

BackgroundA comprehensive understanding of both surgical care costs and the factors influencing these costs is critical to make progress toward value-based care in orthopedics. Therefore, the purpose of this study was to assess 90-day health system costs in primary total elbow arthroplasty (TEA), the proportion of contribution from each cost group to total hospital cost, and to determine key drivers of 90-day costs in primary TEA. MethodsConsecutive patients who underwent primary TEA between 2014 and 2021 at a tertiary care academic medical center were included. An institutional accounting database was queried to determine direct costs to the health system attributed to TEA. All costs within 90 days of the surgical encounter were included for analysis to reflect the global postoperative period. Descriptive statistics were used to summarize patient and surgical characteristics, as well as cost data. Subcategories were determined to assess the key cost groups that contribute to total hospital fees for the entire cohort, and subanalysis was performed to evaluate only readmitted patients. Furthermore, a linear regression analysis was used to determine key drivers of 90-day costs in the setting of primary TEA. ResultsThirty-five patients who underwent primary TEA were identified from 2014 to 2021; 28 patients with 90-day cost data were included in this study. The mean surgical encounter cost was $18,075 (+/− $9772) and mean 90-day cost was $19,875 (+/− $9885). The largest proportion of health system costs in primary TEA was surgical implants (48%), followed by operating room fees (18%), surgical supplies (9%), and anesthesia (7%). Among readmitted patients, the most significant share of health system costs was attributed to surgical implants (30%) followed by operating room fees (22%). However, hospital fees (19%) experienced a substantial increase. In assessing the key drivers of 90-day health system costs, length of stay (B = 1304.30, 95% confidence interval [CI] 674.54 to 1934.05; P < .001), readmission (B = 16,148.55, 95% CI 7055.01 to 25,240.08; P = .001∗), and Charlson comorbidity index (B = 2247.43, 95% CI 68.64 to 4426.22; P = .044) were statistically significant predictors of increased 90-day costs. ConclusionImplant costs comprise nearly half of total 90-day costs in primary TEA, with operating room costs making the second largest contribution. Additionally, length of stay, readmission, and patient comorbidity burden were significantly associated with increased 90-day costs.

IV Diuresis in Alternative Treatment Settings for the Management of Heart Failure: Implications for Mortality, Hospitalizations and Cost

Recent advances in heart failure (HF) care have sought to shift management from inpatient to outpatient and observation settings. We evaluated the association among HF treatment in the (1) inpatient; (2) observation; (3) emergency department (ED); and (4) outpatient settings with 30-day mortality, hospitalizations and cost. Using 100% Medicare inpatient, outpatient and Part B files from 2011-2018, 1,534,708 unique patient encounters in which intravenous (IV) diuretics were received for a primary diagnosis of HF were identified. Encounters were sorted into mutually exclusive settings: (1) inpatient; (2) observation; (3) ED; or (4) outpatient IV diuretic clinic. The primary outcome was 30-day all-cause mortality. Secondary outcomes included 30-day hospitalization and total 30-day costs. Multivariable logistic and linear regression were used to examine the association between treatment location and the primary and secondary outcomes. Patients treated in observation and outpatient settings had lower 30-day mortality rates (observation OR 0.67, 95% CI 0.66-0.69; P < 0.001; outpatient OR 0.53, 95% CI 0.51-0.55; P < 0.001) compared to those treated in inpatient settings. Observation and outpatient treatment were also associated with decreased 30-day total cost compared to inpatient treatment. Observation relative cost -$5528.77, 95% CI -$5613.63 to -$5443.92; outpatient relative cost -$7005.95; 95% CI -$7103.94 to -$6907.96). Patients treated in the emergency department and discharged had increased mortality rates (OR 1.15, 95% CI 1.13-1.17; P < 0.001) and increased rates of hospitalization (OR 1.72, 95% CI 1.70-1.73; P < 0.001) compared to patients treated as inpatients. Medicare beneficiaries who received IV diuresis for acute HF in the outpatient and observation settings had lower mortality rates and decreased costs of care compared to patients treated as inpatients. Outpatient and observation management of acute decompensated HF, when available, is a safe and cost-effective strategy in certain populations of patients with HF.

The effect of myelopathic symptoms on hospital costs, length of stay, and discharge location in anterior cervical discectomy and fusion.

Cervical spondylotic myelopathy (CSM) is a common clinical degenerative disease treated with anterior cervical discectomy and fusion (ACDF), which seriously impacts quality of life and causes severe disability. The objective of the study was to determine the effect of different characteristics of the neurological deficit found in myelopathic patients undergoing ACDFs on hospital cost, length of stay (LOS), and discharge location. This is a retrospective review of ACDF cases performed at a single institution by multiple surgeons from 2011 to 2017. Patient symptomatology, complications, comorbidities, demographics, surgical time, LOS, and discharge location were collected. Patients with readmissions or reoperations were excluded. Symptoms evaluated were based on clinical diagnosis, Japanese Orthopaedic Association classification, Ranawat grade, and Cooper scales. Symptoms were further grouped using principal component analysis. Cost was defined as surgical episode hospital stay costs plus outpatient clinic costs plus discharge disposition cost. Multivariate linear regression models were created to evaluate correlations with outcomes. The primary outcome was total 90-day hospital costs. Secondary outcomes were discharge location and LOS. A total of 250 patients were included in the analyses. Discharge location, neuromonitoring use, number of surgical vertebral levels, cage use, LOS, surgical time, having a complication, and sex were all found to be predictive of total 90-day costs. Myelopathic symptomatology was not found to be associated with increased 90-day costs (p ≥ 0.131) when correcting for these other factors. Lower-extremity functionality was found to be associated with increased LOS (p < 0.0001). Upper-extremity myelopathy was found to be associated with increased discharge location needs (p < 0.0001). Cervical myelopathy was not found to be predictive of total 90-day costs using symptomatology based on multiple myelopathy grading systems. Lower-extremity functionality was, however, found to predict LOS, while upper-extremity myelopathy was found to predict increased discharge location needs. This implies that preoperative deficits from myelopathy should not be considered in a bundled payment system; however, certain myelopathic symptoms should be considered when determining the cost of care.

Impact of a dedicated center for atrial fibrillation on resource utilization and costs.

Atrial fibrillation (AF) affects millions of Americans each year and can lead to high levels of resource utilization through emergency department (ED) visits and inpatient stays. We hypothesized that referral of patients to a dedicated Center for AF from the ED would reduce costs of care. The University of Pittsburgh Center for AF serves as a rapid referral center for patients with AF to avoid unnecessary inpatient admissions and provide specialized care. Patients that presented to the ED with AF and met prespecified criteria were directed to rapid outpatient follow-up instead of inpatient admission. The primary outcome of interest was 30-day total costs. Secondary outcomes included outpatient costs, inpatient costs, 90-day costs, and inpatient stay characteristics. We identified 96 patients (median age 65, 38% women) referred to the center for AF for a new diagnosis of AFbetween October 2017 and December 2019 and matched 96 control patients. After 30 days of follow-up, patients referred to the center for AF had a lower average cost ($619 vs. $1252, p < 0.001) compared to controls, driven by lower costs of ED care tempered by slightly higher outpatient costs. Thirty-day admissions and lengths of stay were also lower. These differences were persistent at 90 days. Directing patients with AF that present to the ED to follow-up at a dedicated Center for AF significantly reduced overall costs, while reducing subsequent inpatient admissions and total lengths of stay in the hospital.

Treatment Patterns and Health Care Resource Utilization of Iatrogenic Spinal Cerebrospinal Fluid Leaks in the United States.

Retrospective cohort study. We aimed to characterize the treatment patterns and the associated costs in patients with cerebrospinal fluid (CSF) leak after spine procedures in the United States. CSF leak is a common complication after spinal procedures. However, there is a little data regarding the national patterns of treatment choice and the associated health care resource utilization. We utilized the IBM MarketScan Research databases to retrospectively analyze adult US patients diagnosed with CSF leak within 30 days of spine procedures between 2001 and 2018. Treatment prevalence, treatment failure, and health care resource utilization data within 30 days of the CSF leak were collected. A subanalysis was performed on patients who received epidural blood patches (EBP) to better understand health care utilization attributable to this treatment modality. Twenty one thousand four hundred fourteen patients were identified. The most common causes of CSF leak were diagnostic spinal tap (59.2%) and laminectomy/discectomy (18.7%). With regard to treatment prevalence, 40.4% of the patients (n=8651) had conservative medical management, 46.6% (n=9987) received epidural blood patch repair, 9.6% required surgical repair (n=2066), and 3.3% (n=710) had lumbar drain/puncture. Nine hundred sixty-seven (9.7%), 150 (21.1%), and 280 (13.5%) patients failed initial EBP, lumbar drain, and surgery, respectively, and the overall failure rate was 10.9% (n=1397). The median 30-day total cost across all groups was $5,101. Patients who received lumbar drain ($22,341) and surgical repair ($30,199) had higher 30-day median total costs than EBP ($8,140) or conservative management ($17,012). The median 30-day total cost for patients whose EBP failed ($8,179) was substantially greater than those with a successful EBP repair ($3,439). National treatment patterns and costs for CSF leaks were described. When used in the correct patient cohort, EBP has the lower failure rates and costs than comparable alternatives. EBP may be considered more often in situations where conservative management or lumbar drains are currently being used.

Outpatient versus inpatient total shoulder arthroplasty: A cost and outcome comparison in a comorbidity matched analysis

BackgroundPrevious studies comparing total and reverse shoulder arthroplasty (TSA/RSA) are subject to surgeon selection bias. This study objective is to compare the outcomes and cost of outpatient TSA/RSA to inpatient TSA/RSA. Methods108,889 elective inpatient and outpatient TSA/RSA from Medicare claims data (2016–2018). 90-day readmission and total 90-day costs were compared following propensity score matching. ResultsYounger and healthier patients are receiving outpatient TSA/RSA. Outpatient TSA/RSA was associated with fewer 90-day readmissions (OR 0.48 CI 0.38–0.59, p < 0.001) and lower 90-day costs (−20.1% CI -19.1%; −21.1%, p < 0.001). ConclusionsOutpatient TSA/RSA surgery offers lower complication rates and total costs. Level of evidenceIII.

P55. What is the value of undergoing surgery for spinal metastases at dedicated cancer centers?

BACKGROUND CONTEXT The Alliance of Dedicated Cancer Centers is an organization of 11 leading cancer institutions/affiliated hospitals that are exempt from the Medicare prospective system (PPS) hospital reimbursement policies. Because of their focus on cancer care, as well as participation in innovative cancer treatment methods/protocols, these hospitals are largely reimbursed based on their actual billings. Due to the lack of incentive to meet a pre-determined target price and/or reduce costs, recent critics have often questioned the value of cancer care at these institutions. PURPOSE The current study aims to evaluate differences in 90-day outcomes for patients undergoing surgical treatment (decompression or fusion) for spinal metastases at dedicated cancer centers (DCC) versus other non-DCC hospitals. STUDY DESIGN/SETTING Retrospective review of the 100% Medicare Standard Analytical Files (SAF100). PATIENT SAMPLE The 2005-2014 100% Medicare Standard Analytical Files (SAF100) was queried using International Classification of Diseases 9th Edition (ICD-9) procedure and diagnosis codes to identify patients undergoing decompression or fusion for spinal metastases. Medicare hospital provider IDs/CCNs were used to identify the 11 DCC hospitals. OUTCOME MEASURES Ninety-day complications, readmissions, mortality and costs. METHODS Multi-variate logistic regression analyses were used to compare rates of 90-day complications and 90-day mortality between DCC and Non-DCC hospitals, while controlling for baseline clinical characteristics, procedural factors and hospital-level factors. Generalized linear regression modeling was used to evaluate differences in total 90-day costs between DCC and Non-DCCs. RESULTS A total of 17,776 patients were included – out of which 1,138 (6.4%) underwent management at one of the 11 DCC hospitals. DCCs were more likely to treat patients with spinal metastases due to renal cancers, slightly higher comorbidity burden and those with a median household income below the national quintile. DCCs were also more likely to treat patients with either fusion or decompression and fusion, as compared to decompression alone. DCCs also were more likely to do longer fusions, and treat patients with postoperative radiation and chemotherapy. After adjusting for differences in baseline clinical characteristics, procedural factors and hospital-level factors, patients undergoing surgery at DCC (vs a non-DCC) had a significantly lower risk of experiencing sepsis (6.5% vs 9.9%; OR 0.55, p CONCLUSIONS Based on our findings, it appears that DCCs offer high-value care, as evidenced by lower complication rates and reduced costs, following surgery for spinal metastases. Further study is required to better understand the processes of care adopted at these institutions, so that additional cancer centers may also be able to deliver high-value care. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Ninety-day hospital costs associated with prolonged air leak following lung resection.

Our goal was to assess the postoperative 90-day hospital costs of patients with prolonged air leak (PAL) including costs incurred after discharge from the initial index hospitalization. We performed a retrospective analysis of 982 patients undergoing lobectomy (898) or segmentectomy (78) (April 2014-August 2018). A total of 167 operations were open, 780 were video-assisted thoracoscopic surgery and 28 were robotic. A PAL was defined as an air leak >5 days. The 90-day postoperative costs included all fixed and variable costs incurred during the 90 days following surgery. The postoperative costs of patients with and without PAL were compared. The independent association of PAL with postoperative 90-day costs was tested after adjustment for patient-related factors and other complications by a multivariable regression analysis. PAL occurred in 261 patients (27%). Their postoperative stay was 4 days longer than that of those without PAL (9.6 vs 5.7; P < 0.0001). Compared to patients without PAL, those with PAL had 27% higher index postoperative costs [7354€, standard deviation (SD) 7646 vs 5759€, SD 7183, P < 0.0001] and 40% higher 90-day postoperative costs (18 340€, SD 23 312 vs 13 102€, SD 10 264; P < 0.0001). The relative postoperative costs (the difference between 90-day and index postoperative costs) were 50% higher in PAL patients compared to non-PAL patients (P < 0.0001) and accounted for 60% of the total 90-day costs. Multivariable regression analysis showed that PAL remained an independent factor associated with 90-day costs (P < 0.0001) along with the occurrence of other cardiopulmonary complications (P < 0.0001), male gender (P = 0.018), low carbon monoxide lung diffusion capacity (P = 0.043) and thoracotomy approach (P = 0.022). PAL is associated not only with increased index hospitalization costs but also with increased costs after discharge. Evaluation of the cost-effectiveness of measures to prevent air leaks should also include post-discharge costs.

Same Day versus Staged Total Knee Arthroplasty: Do Cost Savings Justify the Risk?

Same-day bilateral total knee arthroplasties (BTKAs) are associated with increased complications compared with staged procedures; however, as complication rates and lengths of stay (LOS) for same-day procedures decrease, they may become attractive alternatives to staged procedures. The void of recent nationwide studies comparing the 30-day total cost and risks of these procedures inspired this propensity matched review. Therefore, we compared 30-day outcomes in staged and same-day BTKAs occurring in 2016 and 2017 using the National Readmission Database (NRD), a nationwide database. The NRD was queried for all same-day and staged BTKA patients from January 1 to November 30 for both 2016 and 2017. Since the NRD links readmissions within one calendar year, TKAs occurring in this month were excluded to allow 30-day follow-up. Propensity matching was performed based on demographics, producing 19,334 patients in both cohorts. Thirty-day readmission, revision, and mortality rates, hospital costs, LOS, discharge dispositions, and complications were analyzed. Chi-square and Student's t-tests assessed categorical and continuous variables, respectively. A p-value of <0.05 was set as the threshold for statistical significance. The analysis demonstrated that less same-day patients were readmitted, with statistical but not clinical difference in revisions, and mortality (all p < 0.050). Higher 30-day cost ($33,522 vs. $29,053, p < 0.001), decreased total LOS (4.52 vs. 4.94 days, p < 0.001), and lower rates of PEs (0.3 vs. 1.1%, p < 0.001) and transfusions (2.1 vs. 8.5%, p < 0.001) but similar total complications (p >0.050) were associated staged compared with same-day BTKAs. The results suggest inpatient cost savings associated with same-day surgeries should be weighed against the slight increase in LOS and PEs. Ultimately, as LOS and PE rates continue to decrease from innovations and quality improvements, same-day BTKA may become an attractive alternative to staged BTKAs, especially if payer's incentive surgeons by increasing physician reimbursements.

Implementing robotic surgery for uterine cancer in the United States: Better outcomes without increased costs

ObjectiveTo examine the effect of robotic-assisted surgery implementation for treatment of endometrial cancer in the United States on 30-day clinical outcomes and costs. MethodsWe retrospectively reviewed data of adult patients who underwent total hysterectomy for endometrial cancer in the US hospitals in Premier Healthcare Database between January 1, 2008 and September 30, 2015. We conducted trend analyses comparing the proportions of surgical approaches with the associated clinical outcomes and costs over the study period using Mann-Kendall tests. Clinical outcomes and costs of robotic-assisted surgery, laparoscopic and open surgery have been compared after propensity score 1:1 matching in the most recent 3 years (January 1, 2013–September 30, 2015). ResultsOf a total of 35,224 patients, use of robotic-assisted surgery increased from 9.48% to 56.82% while open surgery decreased from 70.4% to 28.1% over the study period. A 2.5% decrease in major complications (P < .001), a 2.9% decrease in minor complications (P = .001), and a 2.0% decrease 30-day readmissions (P = .001) was observed across all surgical approaches. Perioperative 30-day total cost slightly decreased from US $11,048 to US $10,322 (P = .08). Among propensity-score matched patients, robotic-assisted surgery was associated with shorter hospitalization than open surgery (median [interquartile range], 2.0 [2.0–3.0] vs 4.0 [3.0–6.0] days) and laparoscopic surgery (2.0 [2.0–3.0] vs 3.0 [2.0–4.0] days), fewer 30-day complications (20.1% vs 33.7%) (all P < .001), and comparable perioperative 30-day total costs (median [interquartile range], US $12,200 [US $9,509-US $16,341] vs US $12,018 [US $8,996-US $17,162]; P = .34) with open surgery. ConclusionRobotic-assisted surgery facilitated the widespread diffusion of a minimally invasive approach nationally for endometrial cancer, with reduction of perioperative morbidity and no increase in overall treatment-related 30-day costs at national level.

63. Orthopedic vs neurosurgery: understanding 90-day complications and costs in patients undergoing elective 1- to 2-level posterior lumbar fusions by different specialties

BACKGROUND CONTEXT Spine surgery is routinely performed by either orthopedic or neurological spine surgeons. Controversy still exists as to whether a provider's specialty (orthopedic vs neurosurgery) influences outcomes. PURPOSE With present evidence limited to inpatient-only and 30-day outcomes, the current study aims to understand differences in 90-day complication rates and health care resource utilization/costs between orthopedic and neurosurgical spine surgeons performing elective 1- to 2-level posterior lumbar fusions. STUDY DESIGN/SETTING Retrospective review of insurance claims from the Humana Commercial Database. PATIENT SAMPLE The 2007-2015Q2 Humana Commercial Database was queried using Current Procedural Terminology codes (22612, 22614, 22630, 22632, 22633 and 22634) to identify patients undergoing 1-to-2 level posterior lumbar fusions with active enrollment up to 90-days post-procedure. Patients undergoing fusion due to trauma, deformity and/or malignancy were excluded to capture a relevant study population of patients with degenerative lumbar pathology. OUTCOME MEASURES The 90-day complications included wound, pulmonary, cardiac, thromboembolic, sepsis, pneumonia, urinary tract infections, renal, dural tears and mechanical complications. Additional outcomes included emergency department (ED) visits, revision surgeries and readmissions within 90 days. The surgical and 90-day resource utilization costs for the two groups were compared, by studying average reimbursements for acute-care (index hospitalization, surgeon and anesthesia) and postacute care categories (office visits, nursing care, home health services, physical therapy, emergency department visits and readmissions). METHODS All 90-day complications and costs were compared using multivariable logistic and linear regression techniques while controlling for baseline differences in age, gender, race, region, Elixhauser Co-morbidity Index (ECI) and type of plan/benefit. RESULTS A total of 10,509 patients (5,523 = orthopedic, 4,986 = neurosurgery) underwent an elective 1- to 2- level posterior lumbar fusion during the time period. With the exception of a significantly lower odds of wound complications (OR 0.81) and a higher odds of dural tears (OR 1.29) in elective posterior lumbar fusions performed by orthopedic surgeons, no statistically strong differences were seen in 90-day complication rates between the two groups. Total 90-day costs were also similar between orthopedic and neurosurgeons, with the only exception being that surgeon reimbursement was lower for orthopedic surgery vs neurosurgery ($1,202 vs $1,372; p CONCLUSIONS A provider's specialty does not largely influence 90-day surgical safety outcomes and costs. The results of the study promote the formation and acceptance of dual training pathways for entry into the realm of spine surgery. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Orthopedic versus Neurosurgery–Understanding 90-Day Complications and Costs in Patients Undergoing Elective 1-Level to 2-Level Posterior Lumbar Fusions by Different Specialties

Lumbar fusions are routinely performed by either orthopedic or neurologic spine surgeons. Controversy still exists as to whether a provider's specialty (orthopedic vs. neurosurgery) influences outcomes. The 2007-2015Q2 Humana Commercial Database was queried using Current Procedural Terminology codes (22612, 22614, 22630, 22632, 22633 and 22634) to identify patients undergoing elective 1-to-2 level posterior lumbar fusions (PLFs) with active enrollment up to 90 days after procedure. Ninety-day complication rates were calculated for the 2 specialties. The surgical and 90-day resource utilization costs for the 2 groups were compared, by studying average reimbursements for acute-care and post-acute-care categories. Ninety-day complications and costs were compared using multivariable logistic and linear regression analyses. A total of 10,509 patients (5523 orthopedic and 4986 neurosurgery) underwent an elective 1-to-2 level PLF during the period. With the exception of a significantly lower odds of wound complications (odds ratio, 0.81) and a higher odds of dural tears (odds ratio, 1.29) in elective PLFs performed by orthopedic surgeons, no statistically strong differences were seen in 90-day complication rates between the 2 groups. Total 90-day costs were also similar between orthopedic surgeons and neurosurgeons, with the only exception being that surgeon reimbursement was lower for orthopedic surgery versus neurosurgery ($1202 vs. $1372; P< 0.001). It seems that a provider's specialty does not largely influence 90-day surgical outcomes and costs after elective PLFs. The results of the study promote the formation and acceptance of dual training pathways for entry into spine surgery.

PMD33 - BUDGET IMPACT ANALYSIS OF A DUAL-LAYER STENT RETRIEVER (DLSR) FOR THE TREATMENT OF PATIENTS WITH ACUTE ISCHEMIC STROKE (AIS) IN ENGLAND

The National Institute for Health and Care Excellence (NICE) recommends mechanical clot retrieval (MCR) for the treatment of acute ischemic stroke (AIS). Recently, a large clinical trial in AIS patients treated with a dual-layer stent retriever (DLSR) reported excellent functional independence outcomes, an important goal of stroke therapy that impacts patient quality of life. While the clinical benefits of MCR have been demonstrated, studies assessing the economic implications of technology selection are limited. Thus, this study estimated the budget impact of adopting a DLSR for patients with AIS from a 12-month National Health Service (NHS) perspective. The analysis compared a cost scenario considering a DLSR to a scenario with single-layer stent retrievers only, assuming a 25% adoption rate of DSLR. Acute (90-day) healthcare costs based on patient functional independence measured using the modified Rankin Scale (mRS) were included. Index procedure costs were limited to the acquisition cost of MCR technology, as evidence indicates other procedural resources to be similar between MCR devices. Functional outcomes, acute costs per mRS, and MCR technology acquisition costs were obtained from peer-reviewed literature. Case volume, treatment mix, and cost of the DLSR were obtained from market research data. Costs were reported as 2018 GBP. Among 655 patients treated with MCR over 12 months, 246 patients achieved good functional outcomes (mRS 0-2) in the scenario without the DLSR, compared with 294 patients in the scenario with the DLSR. Total 90-day costs in the scenario with the DLSR were £401,738 lower than the scenario with the DLSR (£10,127,235 vs. £10,528,973). In this analysis, adoption of a DLSR for AIS was associated with improvements in patient functional status. Functional independence may be achieved in 20% more patients in a scenario with the DLSR , which may translate to cost-savings for the NHS.

Intersurgeon Cost Variability in Anterior Cervical Discectomy and Fusion

Retrospective review of prospective patient outcomes and cost data. To analyze the contribution of surgeon-specific variability in cost and patient-reported outcomes (PROs) to overall variability in anterior cervical discectomy and fusion (ACDF), whereas adjusting for patient comorbidities. Cost reduction in surgical care has received increased attention. Patient factors contributing to cost variability in ACDF have been described; however, intersurgeon cost and outcome variability has received less attention in the literature. Adult patients undergoing elective primary ACDF by five different surgeons were analyzed from a prospective registry database. Direct and indirect 90-day costs were compared across each surgeon, along with PROs. Predicted costs were calculated based on patient co-morbidities, and an "observed versus expected" cost differential was measured for each surgeon; this O/E cost ratio was then compared with PROs. A total of 431 patients were included in the analysis. There were no differences in comorbidities, age, smoking status, or narcotic use. There was significant variation between surgeons in total 90-day costs, as well as variation between each surgeon's observed versus expected cost ratio. Despite these surgeon-specific cost variations, there were no differences in PROs across the participating surgeons. Intersurgeon cost variation in elective ACDF persists even after adjusting for patient comorbidities. There was no apparent correlation between increased surgeon-specific costs and 90-day PROs. These findings show there is opportunity for improvement in inter-surgeon cost variation without compromise in PROs. 3.

The “Bundle Busters”: Incidence and Costs of Postacute Complications Following Total Joint Arthroplasty

BackgroundRecently, a bundled payment model was implemented in the United States to improve quality and reduce costs. While hospitals may be rewarded for lowering costs, they may be financially exposed by high cost complications, the so-called bundle busters. We aimed at determining the incidence, etiology, and costs of postacute complications after total joint arthroplasty (TJA). MethodsA retrospective study was conducted using a prospectively collected database of patients who underwent primary total hip arthroplasty (THA) or total knee arthroplasty (TKA) from January 2015 to April 2016. Nurse navigators performed postoperative surveillance to identify patients with complications and unplanned clinical events in the 90-day postoperative period. This was combined with episode-of-care costs provided by third-party payers to derive the mean and per capita costs of postacute complications and clinical events. ResultsAmong 3018 THA and 5389 TKA patients, 3.35% of THA and 2.62% of TKA patients sought emergency department or urgent care services, 2.62% of THA and 3.69% of TKA patients required hospital readmission, and 3.99% of TKA patients required manipulation. Joint-related complications were more common following THA, whereas medical complications were more frequent after TKA. The most costly complications after THA were periprosthetic fracture, dislocation, and myocardial infarction, compared to deep infection, myocardial infarction, and pulmonary embolism after TKA. ConclusionJoint-related complications were among the most costly events after TJA, and given their higher incidence after THA, had a larger impact on per capita costs. Medical complications were more common after TKA and more costly. Despite these events, postacute complications made up less than 5% of the total 90-day costs of TJA.

Rigid Plate Fixation Versus Wire Cerclage: Patient-Reported and Economic Outcomes From a Randomized Trial

In a multicenter randomized trial, sternal closure after cardiac operations using rigid plate fixation (RPF) compared with wire cerclage (WC) resulted in improved sternal healing, reduced sternal complications, and was cost neutral at 6 months. Additional secondary end points are presented from this trial. Twelve United States centers randomized 236 patients to RPF (n= 116) or WC (n= 120). Patient-reported outcomes measures, including pain, function, and quality of life scores, were assessed through 6 months and correlated to computed tomography-derived sternal healing scores using logistic regression. Cost analysis through 90 days was performed to mimic bundled care models. All patient-reported outcomes measures were numerically better in RPF patients than in WC patients at all assessments. RPF resulted in more patients reporting no sternal pain after coughing at 3 weeks (41.1% vs 19.6%; p= 0.001) and 6 weeks (54.5% vs 35.1%; p= 0.005) and at rest at 6 weeks (74.1% vs 58.8%; p= 0.02) and 3 months (87.6% vs 75.9%; p= 0.03) compared with WC. Better sternal healing scores correlated to having no sternal pain at rest (odds ratio, 1.6; 95% confidence interval, 1.2 to 2.2; p= 0.002) and after coughing (odds ratio, 1.6; 95% confidence interval, 1.2 to 2.2; p= 0.0007). RPF resulted in improvements in the 36-Item Short Form Health Survey quality of life scores at 3 weeks (53.5 ± 8.7 vs 50.5 ± 10.4; p= 0.03), 6 weeks (45.3 ± 8.4 vs 42.7 ± 8.4; p= 0.03), and 6 months (56.4 ± 6.8 vs 53.9 ± 9.0; p= 0.04) compared with WC. Through 90 days, RPF compared with WC was $1,888 less (95% confidence interval, -$8,889 to $4,273; p= 0.52). In patients undergoing sternal closure after median sternotomy, RPF compared with WC resulted in reduced sternal pain, improved upper extremity function, and similar total 90-day costs.

Skilled Nursing Facility Partnerships May Decrease 90-Day Costs in a Total Joint Arthroplasty Episode Under the Bundled Payments for Care Improvement Initiative

BackgroundThe Bundled Payments for Care Improvement initiative was developed to reduce costs associated with total joint arthroplasty through a single payment for all patient care from index admission through a 90-day post-discharge period, including care at skilled nursing facilities (SNFs). The aim of this study is to investigate whether forming partnerships between hospitals and SNFs could lower the post-discharge costs. We hypothesize that institutionally aligned SNFs have lower post-discharge costs than non-aligned SNFs. MethodsA cohort of 615 elective, primary total hip and knee arthroplasty subjects discharged to an SNF under the Bundled Payments for Care Improvement from 2014 to 2016 were included in our analysis. Patients were grouped into one of the 3 categories of SNF alignment: group 1: non-partners; group 2: agreement-based partners; group 3: institution-owned partners. Demographics, comorbidities, length of stay (LOS) at SNF, and associated costs during the 90-day post-operative period were compared between the 3 groups. ResultsMean index hospital LOS was statistically shortest in group 3 (mean 2.7 days vs 3.5 for groups 1 and 2, P = .001). SNF LOS was also shortest in group 3 (mean 11 days vs 19 and 21 days in groups 2 and 1 respectively, P < .001). Total SNF costs and total 90-day costs were both significantly lower in group 3 compared with groups 1 and 2 (P < .001 for all), even after controlling for medical comorbidities. ConclusionInstitution-owned partner SNFs demonstrated the shortest patient LOS, and the lowest SNF and total 90-day costs, without increased risk of readmissions, compared with other SNFs.