Total Episodes Of Care Research Articles

Patient-specific Risk Factors Increase Episode of Care Costs After Lumbar Decompression.

Retrospective cohort analysis. To determine, which patient-specific risk factors increase total episode of care (EOC) costs in a population of Centers for Medicare and Medicaid Services beneficiaries undergoing lumbar decompression. Lumbar decompression is an effective option for the treatment of central canal stenosis or radiculopathy in patients unresponsive to nonoperative management. Given that elderly Americans are more likely to have one or more chronic medical conditions, there is a need to determine, which, if any, patient-specific risk factors increase health care costs after lumbar decompression. Care episodes limited to lumbar decompression surgeries were retrospectively reviewed on a Centers for Medicare and Medicaid Service reimbursement database at our academic institution between 2014 and 2019. The 90-day total EOC reimbursement payments were collected. Patient electronic medical records were then matched to the selected care episodes for the collection of patient demographics, medical comorbidities, surgical characteristics, and clinical outcomes. A stepwise multivariate linear regression model was developed to predict patient-specific risk factors that increased total EOC costs after lumbar decompression. Significance was set at P <0.05. A total of 226 patients were included for analysis. Risk factors associated with increased total EOC cost included increased age (per year) (β = $324.70, P < 0.001), comorbid depression (β = $4368.30, P = 0.037), revision procedures (β = $6538.43, P =0.012), increased hospital length of stay (per day) (β = $2995.43, P < 0.001), discharge to an inpatient rehabilitation facility (β = $14,417.42, P = 0.001), incidence of a complication (β = $8178.07, P < 0.001), and readmission (β = $18,734.24, P < 0.001) within 90 days. Increased age, comorbid depression, revision decompression procedures, increased hospital length of stay, discharge to an inpatient rehabilitation facility, and incidence of a complication and readmission within 90 days were all associated with increased total episodes of care costs.

Diagnosis-Related Group–Based Payments for Adult Spine Deformity Surgery Significantly Vary across Centers: Results from a Multicenter Prospective Cohort Study

To investigate the variation in total episode-of-care (EOC) payment and quality-adjusted life-year (QALY) gain for complex adult spine deformity surgeries in the United States, adjusting for case type and surgeon preferences. Patients aged >18 years with adult spine deformity with Medicare Severity-Diagnosis-Related Groups (DRGs) 453-460 and a minimum of 2 years of follow-up from index surgery were included. Index and total payments were calculated using Medicare's Inpatient Prospective Payment System. All costs were adjusted for inflation to 2020 U.S. dollar values. QALYs gained were calculated using baseline, 1-year, and 2-year Short-Form 6D scores. Mixed-effect models were used to estimate the proportion of variation in total EOC payment and QALY gain. A total of 330/543 patients from 6 sites were included. Mean age was 62.4 ± 11.9 years, 79% were women, and 92% were white. The mean index and total EOC payment were $77,302 and $93,182, respectively. Patients gained on average 0.15 QALY (P < 0.0001) 2 years after surgery. In unadjusted analysis, 39% of the variation in total EOC payment across the 6 centers was attributable to relative weight of DRG and base rate. Adjusting for patient and procedural factors increased the proportion of variation in total EOC payments across the centers to 56%. Less than 2% of the variation in QALY gain was observed across the 6 centers. Medicare-based payments for complex spine deformity fusions are primarily driven by relative weight of the DRG and the hospital's base rate. Patient and procedural factors are unaccounted for in the DRG-based payments made to the providers.

Robotic-assisted total hip arthroplasty: an economic analysis.

Aim: To evaluate 90-day episode-of-care (EOC) resource consumption in robotic-assisted total hip arthroplasty (RATHA) versus manual total hip arthroplasty (mTHA). Methods: THA procedures were identified in Medicare 100% data. After propensity score matching 1:5, 938 RATHA and 4,670mTHA caseswere included. 90-day EOC cost, index costs, length of stayand post-index rehabilitation utilization were assessed. Results: RATHA patients were significantly less likely to have post-index inpatient rehabilitation or skilled nursing facilityadmissions and used fewer home health agencyvisits, compared with mTHA patients. Total 90-day EOC costs for RATHA patients were found to be US$785 less than thoseof mTHA patients (p=0.0095). Conclusion: RATHA was associated with an overall lower 90-day EOC cost when compared with mTHA. The savings associated withRATHA were driven by reduced utilization and cost of post-index rehabilitation services.

206. Comparison of patient factors (frailty) vs surgical factors (invasiveness) for optimization of 2-year cost utility: We should focus on the patient factors

206. Comparison of patient factors (frailty) vs surgical factors (invasiveness) for optimization of 2-year cost utility: We should focus on the patient factors

P86. Impact of reoperations on cost of care in adult spinal deformity surgery

<h3>BACKGROUND CONTEXT</h3> Reoperations following adult spinal deformity (ASD) surgery place a significant burden on patient quality of life and overall health care costs. Despite the common knowledge of frequently occurring complications following ASD surgery that require reoperation, little is known on the cost and timing of these complications. Attempts to optimize the cost effectiveness of ASD surgery requires careful examination of the overall impact, frequency and timing of complications requiring reoperation on total cost of care. <h3>PURPOSE</h3> The primary aim of our study was to ascertain the percentage of total cost of care attributed to reoperations, identify the costliest complications requiring reoperation following index surgery and to determine the timing of these complications. <h3>STUDY DESIGN/SETTING</h3> Retrospective analysis of a prospective, multicenter study. <h3>PATIENT SAMPLE</h3> ASD patients with >4 level fusion and eligible for minimum 2-year follow-up were included. <h3>OUTCOME MEASURES</h3> Reoperation rates, Total cost of care. <h3>METHODS</h3> ASD patients with >4 level fusion with 2-year follow-up were included. Index and total episode of care (EOC) costs were calculated using Medicare's inpatient prospective payment system (IPPS) for MS-DRGs 453-460 and adjusted for inflation to 2020 real dollars. QALYs gained were calculated using baseline, 1-year, and 2-year SF-6D scores. Complication categories included: PJK (proximal junctional kyphosis), adjacent segment disease, pseudarthrosis, neurologic complications, malignment, implant malposition, and infections. <h3>RESULTS</h3> DRG data for index and revision surgery was available for 505/889 patients. Mean age was 62.5+12.4 years, 76% women. Eighty-nine patients (18%) required a total of 114 reoperations (range 1-5 per patient). The mean index EOC for the whole cohort was $72,718, compared to a mean cost of $59,130 for each reoperation. Accounting for all reoperations, the tEOC in the revision group was 2.1-times higher than the non-revision group ($151,913 vs $71,978, p<0.0001). The 2-year QALY gain in the revision group was significantly higher than the non-revision group (0.08 vs 0.03, p<0.01). The two most common complications requiring reoperations were PJK (41.2%) and pseudarthrosis (36.8%). Reoperations for PJK and pseudoarthrosis collectively accounted for 77% of reoperation costs, but the majority (53%) occurred after 2 years of index surgery. Infections, implant malposition, or neurologic complications (33% each) were most common requiring reoperations within 30 days of index surgery. <h3>CONCLUSIONS</h3> PJK and pseudarthrosis were the two most common complications requiring reoperation and most occurred most frequently over 2 years after index surgery. Collectively, they contributed to 77% of the total reoperation costs. Efforts to optimize the cost effectiveness of ASD surgery should focus on effective methods to mitigate risk of PJK and pseudarthrosis. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Cost savings for pVAD compared to ECMO in the management of acute myocardial infarction complicated by cardiogenic shock: An episode-of-care analysis.

Acute myocardial infarction complicated by cardiogenic shock (AMICS) occurs in up to 10% of acute myocardial infarction admissions and is associated with high mortality, frequent adverse outcomes, prolonged hospitalizations, extensive medical resource utilization, and major cost. Using hospital cost data for Medicare Fee-for-Service (FFS) patients with AMICS, we sought to evaluate in hospital and 45-day outcomes and cost, comparing patients treated with percutaneous ventricular assist device (pVAD) versus extracorporeal membrane oxygenation (ECMO). The goal of this study was to better understand clinical and economic outcomes of AMICS to help clinicians and hospitals optimize outcomes most economically for AMICS patients. A retrospective claims analysis identified patients from the full census Medicare Standard Analytic Files compiled by the Center for Medicare and Medicaid (CMS) including: Inpatient, Outpatient, Skilled Nursing Facility and Home Health files for Medicare FFS beneficiaries. Study costs were defined as the total costs incurred by providers for treating a population with AMICS. Medicare FFS beneficiaries who experienced an inpatient admission during the index period (January 1, 2015 to March 31, 2017) with a diagnosis of AMICS were eligible for study inclusion and were identified by the presence of appropriate International Classification of Diseases, Ninth and Tenth Versions (ICD-9 and ICD-10) diagnosis and procedure codes. To create a matched sample and control for any baseline differences, a 1:1 Propensity Score Matching (PSM) was performed based on criteria such as age, gender, race, geographic distribution, and 11 high-cost comorbidities (e.g., congestive HF, coronary artery disease, diabetes, etc.). Index length of stay (LOS), index costs, discharge disposition (including mortality), post-index utilization, and episode-of-care (EOC) costs were reviewed. EOC was defined as index admission for all patients plus a 45-day post index period for patients who survived the index admission. Each cohort included 338 patients. Index in-hospital mortality rates were 53% for pVAD versus 64% for ECMO (178 vs. 217; p=.0023), and total EOC in-hospital mortality rates were 66% for pVAD versus 74% for ECMO (222 vs. 250; p=.0160). Index LOS for pVAD was 27% lower versus ECMO (12.12 vs. 16.59; p=.0006). The index LOS for patients discharged alive was 25% lower for pVAD versus ECMO (17.73 vs. 23.62; p=.0016). For patients that experienced in-hospital mortality during their index stay, pVAD had a 44% lower LOS compared to ECMO (7.08 vs. 12.66; p < .0001). Following index hospitalization, the average cost savings with additional inpatient care was 31% lower for pVAD patients ($62,188 vs. $90,087; p=NS). During the EOC, pVAD patients incurred 32% lower costs compared to ECMO patients ($117,849 vs. $172,420; <.0001). This study of Medicare FFS patients demonstrates that hospitals utilizing pVAD for appropriately selected AMICS patients have reduced mortality rates and reduced index LOS with lower index facility costs and lower post index 45-day costs. The study results offer hospitals and clinicians an opportunity to improve clinical outcomes and reduce total EOC costs in treating patients with AMI complicated by CS.

PMD21 ROBOTIC-ASSISTED TOTAL HIP REPLACEMENT: A 90-DAY EPISODE OF CARE ANALYSIS

Robotic-assisted Total Hip Arthroplasty (RATHA), studies have shown increased accuracy in placing implants and improvements in; patient outcomes, satisfaction scores and post-op complications compared to manual THA (mTHA). The purpose of this study was to compare robotic-assisted vs. manual total hip arthroplasty index and post-discharge utilization and costs in a 90-day episode-of-care (EOC). THA procedures were identified using the Medicare 100% Standard Analytic Files. Members included patients with RATHA or mTHA between 10/1/2015-10/1/2018. Propensity score matching (PSM) was performed in a 1-to-5 ratio, robotic to manual. After PSM, 938 rTHA and 4,670 mTHA were identified and included for analysis. Ninety-day episode-of-care cost, index cost, LOS, post-index rehab utilization and costs were assessed. RATHA patients were less likely to have post-index IPR or SNF admissions (0.64% vs. 2.68%; p<0.0001 and 20.79% vs. 24.99%; p=0.0041, respectively). RATHA patients used fewer days in post-index inpatient and SNF care (7.15 vs. 7.91; p=0.8029 and 17.98 vs. 19.64; p=0.5080, respectively) and used fewer HHA visits, (14.06 vs. 15.00; p=0.0006) compared to mTHA. RATHA had lower costs for; IPR ($11,490 vs. $14,674; p=0.0470), SNF ($9,184 vs. $10,408, p=0.0598) and HHA ($3,352 vs. $3,496; p=0.0133) compared to mTHA. Overall, RATHA patients had 12% ($948) lower average post-index costs compared to mTHA patients (p=0.0004). Total 90-day EOC costs for RATHA patients were found to be $785, less than that of mTHA patients ($19,734 vs. $20,519, p=0.0095). Robotic-assisted THA resulted in an overall lower 90-day episode-of-care cost when compared to manual THA. The 90-day EOC cost savings of RATHA were driven by reduced utilization and cost of post-index rehabilitation services including, IPR, SNF and HHA.

To Bundle or Not to Bundle? The Financial Impact of Pathologic Hip Disease on Hip Arthroplasty Episodes of Care

BackgroundThe Comprehensive Care for Joint Replacement model aims to support more efficient care for patients. We examined the impact of patient and surgical characteristics, post-acute care, and clinical outcomes on episode of care (EOC) costs in patients undergoing hip arthroplasty for all diagnoses. MethodsWe retrospectively collected data from a large database of patients undergoing hip arthroplasty for oncologic and nononcologic diagnoses between 2014 and 2017. We compared EOC costs and outcomes between the 2 groups using Student’s t-tests. We estimated the association between an oncologic-associated procedure and EOC costs from a multiple regression analysis. ResultsThere were 2122 total patients included: 1993 in the nononcologic group and 129 in the oncologic group. The length of stay was significantly greater in the oncologic group (7.2 vs 4.2 days, P = .00). In the post-acute period, a greater proportion of oncologic patients was readmitted (29% vs 14%, P = .05) and discharged to skilled nursing (93% vs 51%, P = .00). Index hospitalization costs (mean difference [MD] $1561, P = .05), skilled nursing costs (MD $5932, P = .001), and total EOC costs (MD $20,012, P = .00) were all greater in the oncologic group. Along with increasing age and fracture diagnosis, an oncologic diagnosis is independently associated with greater EOC costs from a multivariate analysis (β = 16,163 ± 2258, P = .00, r2 = 29%). ConclusionComprehensive Care for Joint Replacement should incorporate risk adjustment for oncologic disease because hip arthroplasty for an oncologic diagnosis is associated with worse outcomes and greater costs than in the general population.

Cost Analysis of Medicare Patients with Varying Complexities Who Underwent Total Knee Arthroplasty

The effort to reduce overall healthcare costs may affect more complex patients, as their pre- and postoperative care can be substantially involved. Therefore, the purpose of this study was to use a large nationwide insurance database to compare (1) costs, (2) reimbursements, and (3) net losses of 90-day episodes of care (EOC) for total knee arthroplasty (TKA) patients according to Elixhauser's Comorbidity Index (ECI) scores. All TKAs performed between 2005 and 2014 in the Medicare Standard Analytic Files were extracted from the database and stratified based on ECI scores, ranging from 1 to 5. ECI 1 patients served as the control cohort, while ECI 2, 3, 4, and 5 patients were considered study cohorts. Each study cohort and control cohort were matched based on age and sex, resulting in a total of 715,398 patients included for analysis. Total EOC costs, reimbursements, and total net losses (defined as total EOC costs minus total EOC reimbursements) were compared between the cohorts. Overall, total EOC costs increased with ECI. For example, compared with the matched ECI 1 cohorts, the total EOC costs for ECI 5 patients ($56,589.19 vs. $51,747.54) were significantly greater (p < 0.01). Although reimbursements increased with increasing ECI, so did net losses. The net losses for ECI 5 patients were greater than that for ECI 1 patients ($42,309.39 vs. $40,007.82). The bundled payments for care improvement (BPCI) and comprehensive care for joint replacement (CJR) are alternative payment models that might de-incentivize treatment of more complex patients. Our study found that despite increasing reimbursements, overall costs, and therefore net losses, were greater for more complex patients with higher ECI scores.

Abstract 242: Incidence, Predictors, Causes, and Costs for 30-day Readmission After In-Hospital Cardiopulmonary Resuscitation Discharge in United States

Background: Readmissions after in-hospital cardiopulmonary resuscitation (ICPR) are common and contribute to increased health care utilization and costs. This is the first study to estimate the burden and patterns of 30-day readmission after ICPR from Nationwide Readmission Database (NRD). Methods and Results: Patients undergoing ICPR (International Classification of Diseases-Ninth Revision-Clinical Modification codes 99.60 and 99.63) between January and November 2014 from NRD were included. Incidence, predictors, causes, and costs of 30-day readmission were analyzed using discharge weights to obtain national estimates. Among estimated 27278 index admissions survived to hospital discharges after ICPR, 5439 (20.0%) were readmitted within 30 days. Length of stay (LOS) ≧15 days during index hospitalization (hazard ratio [HR], 1.29; 95% confidence interval [CI], 1.16-1.42), Medicare or Medicaid insurance (HR, 1.34; 95% CI, 1.19-1.51), heart failure (HR, 1.2; 95% CI, 1.1-1.32), and discharge of metropolitan teaching hospital (HR, 1.19; 95% CI, 1.07-1.33) were independent predictors of 30-day readmission. Among 5439 readmissions, Sepsis (13.7%), heart failure (10.8%), respiratory failure (6.4%), and cardiac dysrhythmias (5.2%) were the most common causes. Estimated total costs of readmission were $102 million and mean of $19122 ±30201, which is accounted for 25.7% of total episode of care (index+readmission). The mean LOS was 8.0 ±10.5 days. The patients with readmission revealed high mortality rate of 10.1%. Conclusions: Thirty-day readmissions after ICPR are frequent and are related to baseline comorbidities and hospital characteristics. Awareness of these predictors can help identify and target high-risk patients for interventions, to reduce readmissions and costs.

Skilled Nursing Facilities After Total Knee Arthroplasty: The Time for Selective Partnerships Is Now!

BackgroundBundled payment initiatives for total knee arthroplasty (TKA) patients are dramatically impacted by discharges to skilled nursing facilities (SNFs), making target prices set by the Center for Medicare and Medicaid Services difficult to achieve. However, we hypothesized that a granular examination of SNF discharges would reveal that some may disproportionately increase costs compared to others. MethodsThe institutional database was retrospectively queried for primary TKA patients under bundled payment initiatives. The 4 most common SNFs utilized by our patient population (A, B, C, and D) were investigated for length of stay, cost of care, and whether the overall target price for the episode of care (EOC) was reached. ResultsIn total, 1223 TKA patients were analyzed, with 378 (30.9%) discharged to an SNF and 246 patients selecting one of the 4 most common SNFs (A: 198, B: 21, C: 15, D: 12). Each SNF represented a significant fiscal portion of the total EOC; however, SNF D had significantly longer length of stay (21 vs 13 days, P < .001) and cost of care ($11,805 vs $6015, P < .001) relative to the others, resulting in no EOC under the target price. SNF costs >24.6% of the total EOC were predictive of exceeding the target price. ConclusionBundled payment models are significantly impacted by SNF disposition; however, select facilities disproportionately impact this system. In order to maintain free patient selection for disposition, post-acute care facilities must be held accountable for controlling cost, or a separate bundled payment provided.

Center variation in episode-of-care costs for adult spinal deformity surgery: results from a prospective, multicenter database

Background ContextAdult spinal deformity (ASD) surgery is associated with significant resource utilization, costing more than $958 million in charges for Medicare patients and more than $1.7 billion in charges for managed care population in the last decade. Given the recent move toward bundled payment models, it is important to understand the various care components a patient receives over the course of a defined clinical episode, its associated cost, and the proportion of cost for each component toward the bundled payment. PurposeTo examine the degree and determinants of variation in inpatient episode-of-care (EOC) cost, resource utilization, and patient-reported outcomes for patients undergoing ASD surgery across four spine deformity centers in the United States. Study Design/SettingRetrospective analysis of prospective, multicenter database. Patient SampleConsecutive patients enrolled in an ASD database from four spinal deformity centers. Outcome MeasuresTotal in-patient EOC costs and Short Form (SF)-6D. MethodsThe study used a multicenter database of 210 consecutively enrolled operative patients from 2008 to 2013 at four participating centers in the United States. Demographic, surgical, and direct cost data, expressed in 2013 dollars, for the entire inpatient EOC were obtained from administrative databases from the respective hospitals. Mixed models and multivariable linear regression were used to evaluate the impact of center on total costs adjusting for patient characteristics, length of stay (LOS), and surgical factors. ResultsA total of 126 patients with complete baseline and 2-year follow-up data were included. The percentages of patients from each center were 36.5%, 7.1%, 24.6%, and 31.7%. Overall, the mean patient age was 58.4±12.6 years, 86% were women, and 94% were Caucasian. The proportion of total cost variation explained by the center at which the patient was treated was 17%. After adjusting for patient, LOS, and surgical factors the cost variation reduced to 4%. In multivariable analysis, each additional level fused increased total cost variation by $2,500, whereas recombinant human bone morphogenetic protein-2 (BMP) use and posterior-only surgical approach lowered total EOC costs by $10,500 and $9,400, respectively. No significant difference was observed in 2-year quality-adjusted life year across centers. ConclusionsTotal EOC costs for ASD surgery varied significantly by center. Levels fused, BMP use, and surgical approach were the primary drivers of cost variation across centers. Differences in resource utilization had no impact on 2-year quality-adjusted life year improvement across centers.

Economic burden related to chemotherapy-related adverse events in patients with metastatic breast cancer in an integrated health care system.

BackgroundBreast cancer is treated with many different modalities, including chemotherapy that can be given as a single agent or in combination. Patients often experience adverse events from chemotherapy during the cycles of treatment which can lead to economic burden.ObjectiveThe objective of this study was to evaluate costs related to chemotherapy-related adverse events in patients with metastatic breast cancer (mBC) in an integrated health care delivery system.MethodsPatients with mBC newly initiated on chemotherapy were identified and the first infusion was defined as the index date. Patients were ≥18 years old at time of index date, had at least 6 months of health plan membership and drug eligibility prior to their index date. The chemotherapy adverse events were identified after the index date and during first line of chemotherapy. Episodes of care (EOC) were created using healthcare visits. Chart review was conducted to establish whether the adverse events were related to chemotherapy. Costs were calculated for each visit, including medications related to the adverse events, and aggregated to calculate the total EOC cost.ResultsA total of 1,682 patients with mBC were identified after applying study criteria; 54% of these patients had one or more adverse events related to chemotherapy. After applying the EOC method, there were a total of 5,475 episodes (4,185 single episodes [76.4%] and 1,290 multiple episodes [23.6%]) related to chemotherapy-related adverse events. Within single episodes, hematological (1,387 EOC, 33.1%), musculoskeletal/pain related (1,070 EOC, 25.6%), and gastrointestinal (775 EOC, 18.5%) were the most frequent adverse events. Patients with adverse events related to single EOC with anemia and neutropenia had the highest total outpatient costs with 901 EOC ($81,991) and 187 EOC ($17,017); these patients also had highest total inpatient costs with 46 EOC ($542,798) and 16 EOC ($136,768). However, within multiple episodes, hematological (420 EOC, 32.6%), followed by infections/pyrexia (335 EOC, 25.9%) and gastrointestinal (278 EOC, 22.6%) were the most frequent adverse events.ConclusionThe economic burden related to chemotherapy adverse events in patients with mBC is substantial.

Comparative Effectiveness of Dexamethasone versus Prednisone in Children Hospitalized with Asthma

To study the comparative effectiveness of dexamethasone vs prednisone/prednisolone in children hospitalized with asthma exacerbation not requiring intensive care. This multicenter retrospective cohort study, using the Pediatric Health Information System, included children aged 4-17 years who were hospitalized with a principal diagnosis of asthma between January 1, 2007 and December 31, 2012. Children with chronic complex condition and/or initial intensive care unit (ICU) management were excluded. Propensity score matching was used to detect differences in length of stay (LOS), readmissions, ICU transfer, and cost between groups. 40,257 hospitalizations met inclusion criteria; 1166 (2.9%) received only dexamethasone. In the matched cohort (N = 1284 representing 34 hospitals), the LOS was significantly shorter in the dexamethasone group compared with the prednisone/prednisolone group. The proportion of subjects with a LOS of 3 days or more was 6.7% in the dexamethasone group and 12% in the prednisone/prednisolone group (P = .002). Differences in all-cause readmission at 7- and 30 days were not statistically significant. The dexamethasone group had lower costs of index admission ($2621 vs $2838; P < .001) and total episode of care (including readmissions) ($2624 vs $2856; P < .001) compared with the prednisone/prednisolone group. There were no clinical significant differences in ICU transfer or readmissions between groups. Dexamethasone may be considered an alternative to prednisone/prednisolone for children hospitalized with asthma exacerbation not requiring admission to intensive care.

Are we targeting the right metric for heart failure? Comparison of hospital 30-day readmission rates and total episode of care inpatient days

Hospitals are challenged to reduce length of stay (LOS), yet simultaneously reduce readmissions for patients with heart failure (HF). This study investigates whether 30-day rehospitalization or an alternative measure of total inpatient days over an episode of care (EOC) is the best indicator of resource use, HF quality, and outcomes. Using data from the American Heart Association's Get With The Guidelines-Heart Failure Registry linked to Medicare claims, we ranked and compared hospitals by LOS, 30-day readmission rate, and overall EOC metric, defined as all hospital days for an HF admission and any subsequent admissions within 30 days. We divided hospitals into quartiles by 30-day EOC and 30-day readmission rates. We compared performance by EOC and readmission rate quartiles with respect to quality of care indicators and 30-day postdischarge mortality. The population had a mean age of 80 ± 7.95 years, 45% were male, and 82% were white. Hospital-level unadjusted median index LOS and overall EOC were 4.9 (4.2-5.6) and 6.2 (5.3-7.4) days, respectively. Median 30-day readmission rate was 23.2%. Hospital HF readmission rate was not associated with initial hospital LOS, only slightly associated with total EOC rank (r = 0.26, P = .001), and inversely related to HF performance measures. After adjustment, there was no association between 30-day readmission and decreased 30-day mortality. In contrast, better performance on the EOC metric was associated with decreased odds of 30-day mortality. Although hospital 30-day readmission rate was poorly correlated with LOS, quality measures, and 30-day mortality, better performance on the EOC metric was associated with better 30-day survival. Total inpatient days during a 30-day EOC may more accurately reflect overall resource use and better serve as a target for quality improvement efforts.

Self-Referral in Medical Imaging: A Meta-Analysis of the Literature

In the current political and economic climate, there is a desire to reduce health care costs; diagnostic imaging expenditure is one area of particular interest. The authors present a meta-analysis of the relative frequency of imaging utilization in the setting of self-referral compared with that of non-self-referral and a simulation of increased cost to Medicare Part B on the basis of this relative frequency. The MEDLINE database was searched systematically. Specific inclusion criteria for relative frequency calculations were a numerator (number of patients imaged) and denominator (number of total patients seen) in each group (self-referrers and radiologist referrers). The relative risk of self-referral was determined for each group and is defined by the "relative frequency" of imaging utilization for the self-referrers divided by the frequency for the radiologist referrers. Relative frequency represents the increased (if >1) or decreased (if <1) chance of imaging by self-referrers over radiologist referrers. The meta-analysis was used to combine imaging frequencies for each referral condition of the individual studies that met inclusion criteria for an overall estimate of relative frequency, using a random-effects model to account for the variations among the studies. Relative frequency data were then used to perform a cost simulation to Medicare Part B using 2006 data. The initial search yielded 334 articles, 5 of which met the threshold for inclusion. In these 5 studies, 76,905,162 total episodes of care were analyzed. The individual relative frequency of imaging in the setting of self-referral ranged from 1.60 to 4.50. The combined relative frequency was 2.16 (95% confidence interval, 2.15-2.16) using the fixed-effects model and 2.48 (95% confidence interval, 1.90-3.24) using the random-effects model. For 2006 Government Accountability Office (GAO) data, the estimated cost of increased imaging in the setting of self-referral was $3.6 billion, but a range of costs was also provided to account for potential inaccuracies in the GAO data. The existing literature yields a combined relative frequency of imaging of 2.48 (95% confidence interval, 1.90-3.24) for self-referrers compared with non-self-referrers. Precise extrapolation of Medicare Part B costs attributable to self-referral would require changes in reporting requirements for imaging equipment ownership. Cost simulation results total billions of dollars annually and may be irrespective of potential inaccuracies in the GAO data as a result of Current Procedural Terminology(®) coding ambiguity and nontransparent reporting of equipment ownership.

Use of darbepoetin alfa and epoetin alfa in clinical practice in patients with cancer-related anemia

Background: Patients with cancer may receive erythropoiesis-stimulating agents (ESAs), including darbepoetin alfa (DA) or epoetin alfa (EA), to treat cancer-related anemia (CRA). DA and EA differ, however, with respect to their assumed duration of effect and thus their approved frequency of dosing, complicating direct comparison of their doses and costs. Objective: The objective of this study was to examine, from the perspective of a third-party payer, patterns of use and costs of DA and EA in patients with CRA, using episode-based methodology to account for differences in assumed duration of effect and frequency of dosing with these products. Methods: Using a large US health insurance claims database, we identified all patients with cancer who received ESAs between January 1, 2005, and June 30, 2005 (study period). For each such patient, we identified all unique episodes of care (EOCs) with DA or EA, and then compared mean weekly dose and cost of ESA therapy within these EOCs, which were calculated using the ratio of total dose received and total cost of ESA therapy, respectively, to total EOC duration; only the first EOC for each patient was considered. EOCs were assumed to begin on the date of first ESA admin-istration within the study period, and end on the date of final ESA administration (within the episode) plus an assumed duration of effect based on the ESA received and corresponding dose. We also estimated the ratio of mean weekly dose of EA (in units) to mean weekly dose of DA (in micrograms) (EA/DA weekly dose ratio). Multivariate regression was used to control for differences in baseline characteristics of EA and DA patients. Results: We identified a total of 1226 patients with complete EOCs with ESAs (EA, 381; DA, 845). DA patients were more likely to have had evidence of receipt of chemotherapy (54% vs 47% for EA; P = 0.02); they also had more comorbidities (mean Charlson comorbidity scores, 4.3 and 3.9, respectively; P < 0.01). Estimated mean (95% CI) weekly dose within EOCs was 97 μg (94-99) for DA, and 43,184 U (40,181-46,589) for EA; EA/DA weekly dose ratio was 445:1. Adjustment for differences in patient characteristics yielded a slightly lower ratio (403:1). Results were sen-sitive to the exclusion of EOCs consisting of a single administration of ESA therapy and/or the addition of an assumed duration of effect to the final ESA dose administered. Conclusions: Cost comparisons of DA and EA are sensitive to the assumed duration of effect added to the final dose of ESA therapy, especially for EOCs with relatively few administrations.

Hospital care at home: an evaluation of a scheme for orthopaedic patients.

We report on an evaluation of the practicality and acceptability of the 'Going Home Service', an early discharge intensive patient support scheme for orthopaedic patients in their own homes. Patient outcomes were assessed in terms of health and functional status and the impact on patient's carers was assessed. Eight-seven patients who were successfully discharged from the service were compared with 17 patients readmitted to hospital prior to their discharge from the service, 44 patients suitable for the service who did not take it up and 15 patients discharged from hospital traditionally immediately prior to the service becoming operational. Data were collected via face to face semistructured interviews and note searching. Twenty-six of the patients' informal carers were also interviewed. The majority of patients in all four groups were elderly women, readmitted patients being significantly older than those successfully discharged. The readmitted patients were also more likely to have been admitted originally for traumatic surgery and less likely to have been independently mobile prior to the initial admission. Hospital length of stay was shorter amongst Going Home Service patients than those cared for traditionally, but the total episode of care was greater. Patients and carers were well satisfied with the service. Although there was no evidence that quality of life or functionality were affected by their early discharge, at three months post operation, there was some evidence that Going Home Service patients were experiencing less pain than those discharged traditionally. This early discharge service provided a good quality of health and social care for the majority of patients. However, it did not suit all patients and a minority were re-admitted. The findings reported here add to those obtained in other settings and highlight new aspects for consideration in the planning and delivery of high quality hospital at home schemes.