Payer Type Research Articles

Trauma Activation Fees Vary Widely Across US Trauma Centers.

Trauma activation fees are intended to help trauma centers cover the costs of providing lifesaving care at all times, but they have fallen under greater scrutiny because of a lack of regulation and wide variability in charges. We leveraged the federal Hospital Price Transparency rule to systematically describe trauma activation fees as captured in the Turquoise Health database for all Level I-III trauma centers nationally and across payer types. As of April 18, 2023, a total of 38percent of US trauma centers published trauma activation fees. These fees varied widely by payer type. The minimum fee charged was $40 (for a Medicaid contract); the maximum fees charged were $28,356 (self-pay) and $28,893 (commercial payers). Trauma centers that were larger, metropolitan, located in the West, and associated with proprietary (investor-owned, for-profit) hospitals had higher trauma activation fees. Proprietary hospitals posted fees that were 60percent higher than those published by public, nonfederal hospitals. Unmerited variation in trauma activation fees may suggest that the current funding strategy is equitable neither for trauma centers nor for the severely injured patients who rely on them for lifesaving care.

Impact of insurance payer type (medicare vs. private) on the patient reported outcomes after shoulder arthroplasty

BackgroundThis study’s purpose is to determine if there is a difference in patient reported outcome measures (PROMs) following shoulder arthroplasty (SA) based upon payer insurance type with a secondary outcome of determining if any appreciable difference surpasses the minimal clinically important difference (MCID). MethodsSubjects undergoing anatomic and reverse total shoulder arthroplasty (aTSA and rTSA) were prospectively enrolled between March 2019 – March 2021. Subjects completed PROMIS Upper Extremity (P-UE), the American Shoulder and Elbow Score (ASES), and the Simple Shoulder Test (SST) preoperatively and at 2-weeks, 6-weeks, 3-months, 6-months, and 12-months postoperatively. Descriptive statistics of baseline patient characteristics and preoperative PROMs (ASES, SST, P-UE) were compared between insurance types. Results143 patients were identified who met the inclusion criteria for this study. There were 98 patients within the Medicare cohort and 45 patients with private insurance. Patients in the Medicare cohort were older (mean age 70.5 vs 61.3 years), with high proportion of smokers, diabetics, and rTSA compared to the private payor cohort. There were no significant differences between the two cohorts with respect to outcomes scores except for significantly better SST in the private insurance cohort (69.3 versus 79.4, p=0.02). No significant differences were noted for the achievement of MCID between cohorts [P-UE (p=1.0), ASES (p=0.25), SST (0.52)] and pre- to postoperative improvements for P-UE (p=0.62), ASES (p=0.4), or SST (0.66). ConclusionOur study demonstrates that, at a tertiary level academic institution in a metropolitan city, payor type does not have significant impact on achieving MCID or pre-to-postoperative improvements in PROMs after SA.

Financial Burden and Outcomes of Firearm Injuries in U.S. Hospitals, 2003–2020

Firearm-related injuries (FRIs) are serious but a preventable public health issue. The objective of this study was to describe FRI inpatient costs by (1) patient insurance payer type, and (2) hospital safety-net mix. FRIs were identified using International Classification of Disease diagnosis codes in the National Inpatient Sample. All admissions between 2003 and 2020 were included. The primary outcome was consumer-price index adjusted inpatient stay costs. Mixed effects generalized linear regressions, with a random intercept at the hospital level, were used to describe costs. Analyses were sample weighted and performed between 2023 and 2024. Among 538,795 FRIs, the median age was 27 years (interquartile range: 21 - 37 years). Injuries by payer type were highest among self-pay (280,161; 39%), followed by Medicaid (182,716; 34%), private (113,650; 21%), and Medicare (30,110; 6%). Inflation-adjusted costs of FRI stays totaled $15.2 billion, with $6.2 billion from Medicaid and $5 billion from the self-pay group. After 2014, FRI incidence declined among self-pay/no-charge patients and increased among Medicaid-covered patients - representing a 127% total increase in Medicaid costs from $169 million in 2003 to $753 million in 2020. Among moderate-high and high safety-net mix hospitals, costs increased from $257 million in 2003 to $567 million in 2020. The incidence and costs of FRIs among Medicaid-insured has substantially increased since 2003. Importantly, these increased costs are disproportionately placed on disadvantaged patients and safety-net hospitals.

Postoperative Complications and Readmission Rates in Robotic-Assisted Versus Manual Total Knee Arthroplasty: Large, Propensity Score-Matched Patient Cohorts.

There is a paucity of research comparing postoperative complication rates between manual total knee arthroplasty (M-TKA) and robotic-assisted total knee arthroplasty (RA-TKA). This study aims to compare 90-day postoperative complication, readmission, and emergency department rates between RA-TKA and M-TKA. A retrospective review of a multihospital database identified patients who underwent TKA between January 2016 and May 2023. Surgeons who used the robotic-assisted surgery technique in <10% or >90% of their cases annually were excluded. This resulted in 15,999 cases (8,853 RA-TKAs; 7,146 M-TKAs) from 282 surgeons. RA-TKA and M-TKA cohorts were one-to-one matched based on patient sex, age, body mass index, hospital setting, surgeon experience, primary payer, and anesthesia type. Each cohort consisted of 7,146 patients (N = 14,292). 90-day revisits, specifically readmissions, readmissions with >23 hours of observation, and ED visit rates were compared between cohorts. Complications were classified according to the Clinical Classification Software schema and compared between cohorts. Mann-Whitney U, chi-squared, and Fisher exact tests, along with Bonferroni correction, were used to statistically compare cohorts. All-cause 90-day readmission rates were 2.4% for RA-TKA and 2.6% for M-TKA (P = 0.36). RA-TKA had fewer revisits (RA-TKA: 7.8%; M-TKA: 8.8%, P = 0.027) and rates of readmission with >23 hours of observation (RA-TKA: 1.4%; M-TKA: 2.0%, P = 0.003). RA-TKA had fewer hospital revisits due to joint stiffness (RA-TKA: 17 revisits; M-TKA: 42 revisits, P = 0.002) and chronic pain (RA-TKA: 1 revisit; M-TKA: 8 revisits, P = 0.039). Fewer readmissions were observed for acute injuries (lower extremity muscle/tendon strains) in the RA-TKA cohort (RA-TKA: 1; M-TKA: 9, P = 0.021). RA-TKA had fewer ED visits due to hematomas (RA-TKA: 0 visits; M-TKA: 7 visits, P = 0.016). In this retrospective matched cohort analysis, RA-TKA was associated with markedly fewer revisits and readmissions with >23 hours of observation compared with M-TKA. No differences in all-cause 90-day readmission were observed between cohorts. Level III. Retrospective review.

Tracking 5-Year Trends in the Workforce Prescribing Psychotropics and Medications for Opioid Use Disorder: A Cross-Sectional Study.

Although there is increased demand for behavioral health services, there is limited national data on the workforce prescribing psychotropics and/or medications for opioid use disorder (MOUD), and many current estimates are based on self-reported data or clinician rosters. To describe trends in the workforce prescribing psychotropics (i.e., antidepressants, antipsychotics, antianxiety medications, mood stabilizers) and/or MOUD from 2017 to 2021. Cross-sectional analysis of 2017-2021 IQVIA Xponent retail prescription claims data. Clinicians who prescribed more than ten total prescriptions for psychotropics and/or MOUD in a calendar year. We analyzed the number of prescriptions and prescribers by year, month, drug type, specialty type, payor type, and clinician county rurality. There was a 2.7% increase in the number of prescribers between 2017 and 2021, with the highest growth among psychiatric nurse practitioners (44.7%), nurse practitioners (25.5%), and physician assistants (6.5%). Primary care physicians (PCPs) and advanced practice clinicians (APCs) made up more than half of the workforce but prescribed 3.5 times fewer prescriptions on average compared to psychiatric and addiction medicine specialists. PCPs and APCs in rural areas wrote the most prescriptions collectively for psychotropics and MOUD per month. Using prescription data, a proxy for being active in the workforce, goes beyond specialty designation to identify the full workforce prescribing psychotropics and MOUD, including the growing role of APCs and PCPs.

Cancer Rehabilitation: Impact on Breast Cancer Survivors' Work Ability and Health-Related Quality of Life.

Breast cancer survivors (BCSs) report persistent, diminished ability to work, and decreased health-related quality of life (HRQoL). Cancer rehabilitation interventions (physical therapy or occupational therapy [PT/OT]) aim to improve these outcomes, but little is known about their impact in the community. This retrospective, pre-post, uncontrolled study examined cases of younger BCSs (age <65 years) who attended cancer-specialized PT/OT over a 2-year period. Outcomes and covariates (age, race, US region, payer type, number of visits, length of care [weeks]) were extracted from electronic medical records. Patient-reported outcomes were overall-Work Ability Score (WASoverall), physical-WAS (WASphysical), and mental-WAS (WASmental) and PROMIS Global Physical Health (GPH), Global Mental Health (GMH), Physical Function (PF), and Ability to Participate in Social Roles and Activities (SRA). We used linear mixed effect models to examine pre- to post-rehabilitation change overall, and separately, while controlling for covariates. PT/OT cases (NPT=758; NOT=140) had a mean [SD] age of 51.39 [8.49] years and attended approximately 12 visits (IQR, 8.0-19.0) over 10.71 weeks (IQR, 6.14-17.00). Overall, work ability outcomes (WASoverall: +1.79; WASphysical: +0.78; WASmental: +0.47; all P<.001) and HRQoL outcomes improved significantly (GPH: +5.38; GMH: +2.90; PF: +5.17; SRA: +5.83; all P<.001), and average change on each HRQoL outcome exceeded the minimal important change (2 points). Outcome scores were similar at each timepoint for both PT and OT cases (all P>.05) and both groups improved significantly (all P<.01). In this large study of the impact of cancer-specialized, community-based PT and OT, younger BCSs reported significant improvement in ability to work and HRQoL. Although more research is needed, these findings suggest improved access to PT/OT could improve work ability and HRQoL for younger BCSs.

Community-Level Disadvantage of Adults With Firearm- vs Motor Vehicle–Related Injuries

Motor vehicle crash (MVC) and firearm injuries are 2 of the top 3 mechanisms of adult injury-related deaths in the US. To understand the differing associations between community-level disadvantage and firearm vs MVC injuries to inform mechanism-specific prevention strategies and appropriate postdischarge resource allocation. This multicenter cross-sectional study analyzed prospectively collected data from the American College of Surgeons (ACS) Firearm Study. Included patients were treated either for firearm injury between March 1, 2021, and February 28, 2022, or for MVC-related injuries between January 1 and December 31, 2021, at 1 of 128 participating ACS trauma centers. Community distress. Odds of presenting with a firearm as compared with MVC injury based on levels of community distress, as measured by the Distressed Communities Index (DCI) and categorized in quintiles. A total of 62 981 patients were included (mean [SD] age, 42.9 [17.7] years; 42 388 male [67.3%]; 17 737 Black [28.2%], 9052 Hispanic [14.4%], 36 425 White [57.8%]) from 104 trauma centers. By type, there were 53 474 patients treated for MVC injuries and 9507 treated for firearm injuries. Patients with firearm injuries were younger (median [IQR] age, 31.0 [24.0-40.0] years vs 41.0 [29.0-58.0] years); more likely to be male (7892 of 9507 [83.0%] vs 34 496 of 53 474 [64.5%]), identified as Black (5486 of 9507 [57.7%] vs 12 251 of 53 474 [22.9%]), and Medicaid insured or uninsured (6819 of 9507 [71.7%] vs 21 310 of 53 474 [39.9%]); and had a higher DCI score (median [IQR] score, 74.0 [53.2-94.8] vs 58.0 [33.0-83.0]) than MVC injured patients. Among admitted patients, the odds of presenting with a firearm injury compared with MVC injury were 1.50 (95% CI, 1.35-1.66) times higher for patients living in the most distressed vs least distressed ZIP codes. After controlling for age, sex, race, ethnicity, and payer type, the DCI components associated with the highest adjusted odds of presenting with a firearm injury were a high housing vacancy rate (OR, 1.11; 95% CI, 1.04-1.19) and high poverty rate (OR, 1.17; 95% CI, 1.10-1.24). Among patients sustaining firearm injuries patients, 4333 (54.3%) received no referrals for postdischarge rehabilitation, home health, or psychosocial services. In this cross-sectional study of adults with firearm- and motor vehicle-related injuries, we found that patients from highly distressed communities had higher odds of presenting to a trauma center with a firearm injury as opposed to an MVC injury. With two-thirds of firearm injury survivors treated at trauma centers being discharged without psychosocial services, community-level measures of disadvantage may be useful for allocating postdischarge care resources to patients with the greatest need.

Telemedicine appointments are more likely to be completed than in-person healthcare appointments: a retrospective cohort study.

Missed appointments can lead to treatment delays and adverse outcomes. Telemedicine may improve appointment completion because it addresses barriers to in-person visits, such as childcare and transportation. This study compared appointment completion for appointments using telemedicine versus in-person care in a large cohort of patients at an urban academic health sciences center. We conducted a retrospective cohort study of electronic health record data to determine whether telemedicine appointments have higher odds of completion compared to in-person care appointments, January 1, 2021, and April 30, 2023. The data were obtained from the University of South Florida (USF), a large academic health sciences center serving Tampa, FL, and surrounding communities. We implemented 1:1 propensity score matching based on age, gender, race, visit type, and Charlson Comorbidity Index (CCI). The matched cohort included 87376 appointments, with diverse patient demographics. The percentage of completed telemedicine appointments exceeded that of completed in-person care appointments by 9.2 points (73.4% vs 64.2%, P < .001). The adjusted odds ratio for telemedicine versus in-person care in relation to appointment completion was 1.64 (95% CI, 1.59-1.69, P < .001), indicating that telemedicine appointments are associated with 64% higher odds of completion than in-person care appointments when controlling for other factors. This cohort study indicated that telemedicine appointments are more likely to be completed than in-person care appointments, regardless of demographics, comorbidity, payment type, or distance. Telemedicine appointments are more likely to be completed than in-person healthcare appointments.

Impact of Body Mass Index on Delirious Patients Outcomes: A Nation-Wide Analysis

Background: Delirium is a common serious health problem characterized by abrupt changes in consciousness and cognitive function. It leads to poor prognosis, especially among older adults. Low body mass index (BMI) is an independent risk factor for intensive care unit and postoperative delirium, though the impact of body mass index on the prognosis of delirium has not been well studied. This study aims to examine the correlation of BMI on outcomes of delirium patients. Methods: This cross-sectional study utilized national inpatient sample (NIS) database to examine the association of low BMI (&lt;= 19 kg/m2) termed underweight with patient outcomes among patients admitted with delirium diagnosis between January 1, 2020, and December 31, 2020. This study included adult patients (&gt;18 years old) with delirium as primary and underweight (Z68.1) as secondary diagnosis using International Classification of Diseases (ICD) 10 codes. The study variables included gender, age, race, Charlson Comorbidity Index (CCI), insurance, median household income, hospital region, hospital bed size, teaching hospital status and dementia. We compared baseline characteristics and outcomes for delirium hospitalization. Primary outcome was in-hospital mortality. Hospital length of stay (LOS) and total hospital charges were secondary outcomes. Main determinant variable was BMI status (underweight vs non-underweight). Values were presented as percentages or as mean±standard deviations. Recommended discharge and hospital weights were included to construct national estimates for every analysis. Univariate and multivariate regression analyses were used to find odds ratio and adjusted mean differences. Variables with univariate test with a p &lt; 0.20 was included in multivariable model, along with other variables of known clinical importance. STATA version 18.0 (StataCorp LLC, Texas, USA) was used for statistics, and p &lt; 0.05 was considered statistically significant. Results: About 130,805 patients were hospitalized with delirium as primary diagnosis with 6,605 (5.05%) being underweight patients. Overall, in-hospital mortality among the delirium hospitalization group was 2.2%. Most underweight delirium patients were females (63.1%), mean age of 74 years, Caucasian (71.04%), with a low median household income (29.4%) and Medicare payer type (81.2%). Hospital characteristics for most of these admissions include large bed size (49.5%), urban teaching hospitals (70.9%) and located in southern part of United States (38.4%). In multivariate regression analysis, underweight delirium patients had statistically significant increased risk of in-hospital mortality (adjusted odds ratio, [AOR] 2.03; p &lt; 0.001), higher average LOS (additional 2.28 days; p &lt; 0.001) and higher total hospital charges per stay (additional $10,295.26; p &lt; 0.003) when compared to non-underweight patients after controlling for patient and hospital characteristics, CCI and dementia. Conclusions: Underweight is an independent risk factor for in-hospital mortality, longer LOS, and higher costs among adult delirium patients. This study aims to create awareness about this special subgroup of delirium patients for improving their outcome.

2024 Update of The Society of Thoracic Surgeons Short-term Esophagectomy Risk Model: More Inclusive and Improved Calibration

BackgroundThe Society of Thoracic Surgeons General Thoracic Surgery Database (STS-GTSD) previously reported short-term risk models for esophagectomy for esophageal cancer. We sought to update existing models using more inclusive contemporary cohorts, with consideration of additional risk factors based on clinical evidence. MethodsThe study population consisted of adult patients in the STS-GTSD who underwent esophagectomy for esophageal cancer between January 2015 and December 2022. Separate esophagectomy risk models were derived for 3 primary end points: operative mortality, major morbidity, and composite morbidity or mortality. Logistic regression with backward selection was used, with predictors retained in models if P < .10. All derived models were validated using 9-fold cross-validation. Model discrimination and calibration were assessed for the overall cohort and specified subgroups. ResultsA total of 18,503 patients from 254 centers underwent esophagectomy for esophageal cancer. Operative mortality, morbidity, and composite morbidity or mortality rates were 3.4%, 30.5%, and 30.9%, respectively. Novel predictors of short-term outcomes in the updated models included body surface area and insurance payor type. Overall discrimination was similar or superior to previous STS-GTSD models for operative mortality (C statistic = 0.72) and for composite morbidity or mortality (C statistic = 0.62), Model discrimination was comparable across procedure- and demographic-specific subcohorts. Model calibration was excellent in all patient subgroups. ConclusionsThe newly derived esophagectomy risk models showed similar or superior performance compared with previous models, with broader applicability and clinical face validity. These models provide robust preoperative risk estimation and can be used for shared decision making, assessment of provider performance, and quality improvement.

Social tipping and climate change: The moderating role of social capital in bridging the gap between awareness and action

AbstractBridging the gap between awareness and action on environmental issues such as climate change often requires understanding the moderating roles of individual trust, institutional trust and civic engagement. This paper explores how social capital, through generalaised trust, trust in institutions and civic engagement, can either strengthen or weaken the agency on climate change on environmental behaviour. Linking climate change awareness to environmental behaviour through the mediation of perceived changes in quality of life is the chosen approach to explore the role of social capital. The results suggest that low levels of trust, whether interpersonal or institutional, reduce an individual's sense of agency by firstly reducing the impact of climate change awareness on quality of life, changing perceptions and consequently reducing environmental behaviour. Greater trust in institutions produces a stronger effect of climate change awareness on willingness to pay. On the other hand, civic engagement shows a significant effect when taxes are considered. The study suggests that the impact of social capital on environmental payments varies according to the type of payment (voluntary vs. mandatory). The mapping of the role of social capital in reducing the agency of climate change awareness in quality‐of‐life changes should be further explored, as the latter has proven to be a promising way to address climate change in developed and developing countries.

Військові виплати: поняття та адміністративна проблематика воєнного часу

This article examines the system of military benefits in Ukraine, focusing on their structure, scope, and impact on military personnel and their families. In particular, the different types of military payments, such as salaries, allowances for special conditions of service, disability compensation and pensions, are examined. Changes in legislation on military benefits and their compliance with international standards are also analyzed. It emphasizes the importance of adequate financial support for the military to maintain their combat readiness and morale. A detailed analysis reveals what factors influence the level of military payments, including budgetary constraints, the economic situation in the country, and the army’s need for modern weapons and equipment. The article also examines the effectiveness of the system of payments in providing social protection to military personnel and their families, as well as the possibility of ensuring an adequate standard of living after retirement. Finally, the article concludes with a discussion of what improvements can be made to the military pay system to make military careers more attractive and ensure stability in the military. The article also analyzes the role of military payments in maintaining military discipline and motivation of personnel. In particular, the article discusses the timeliness and regularity of payments, their correspondence to the actual living expenses of the military, as well as the possibility of receiving additional incentives for length of service, military ranks or special tasks. Finally, the article highlights the prospects for further development of the military pay system in Ukraine and the importance of improving this system in order to ensure national security and defense capability. The article also addresses the urgent problem of social security for military personnel in the context of armed conflict. The author analyzes the current state of payments to military personnel, including salaries, additional remuneration and compensation. The main focus is on legislative changes that have taken place in recent years and their impact on the welfare of the military. Particular attention is paid to the analysis of recent legislative initiatives aimed at improving the social protection of military personnel. The provisions of the new laws and regulations governing payments, as well as their effectiveness and impact on the motivation of the military are examined in detail. The article also analyzes the problems of implementing these laws in practice, including bureaucratic obstacles and insufficient funding. The article concludes that the military pay system needs to be further improved, emphasizing the importance of timely and fair financial support for military personnel as one of the key factors in maintaining the army’s combat capability and morale. The author offers recommendations on possible areas for reforming the payment system, including the introduction of new mechanisms for controlling and ensuring transparency of financial flows. The article is important for researchers in the field of social policy, military experts, and those involved in the process of formulating and implementing state policy in the field of defense. It contributes to a deeper understanding of the problems and prospects for the development of the social security system for military personnel in Ukraine, which is an important aspect of ensuring national security and stability of the state.

ВИЗНАННЯ ЗАБЕЗПЕЧЕНЬ У ВІТЧИЗНЯНІЙ І МІЖНАРОДНІЙ ПРАКТИЦІ ОБЛІКУ І ЗВІТНОСТІ

Introduction. Provisioning is the process of setting aside an amount that may be necessary to settle a possible obligation when neither the amount nor the date of the obligation can be estimated with certainty. The objective of accounting and reporting in this area is to establish provisions and to choose the best option for making such provisions. Due to their dynamic nature, liabilities significantly affect the solvency of a business entity, require effective cash flow management and control over the actual status of settlements. The purpose of this article is to study the main aspects of recognising collateral, covering domestic and international accounting and reporting practices. Methods. In the course of the study, the following methods were used: monographic method for studying the literature on the recognition of collateral; method of regulatory support for assessing the established rules and regulations on collateral; analytical method for analytical assessment of the justification of collateral. Results. The creation of collateral is a necessity determined by current legislation and regulations. However, the list of collateral provided in National Accounting Standards 11 is not exhaustive, as an entity should create collateral to reimburse any future expenses (of course, subject to the recognition conditions). Taking into account the specifics of the entities' business, various circumstances may arise that will lead to the emergence and recognition of provisions, which in turn requires careful analysis and justification. Conclusions. Based on the study of the conditions for the formation of collateral in the accounting system and the tasks of accounting and management of enterprises, it is advisable to involve qualified specialists and managers to justify the recognition of collateral. Also, the order on accounting policy should reflect information on the types of payments for which a specific provision is formed. It is recommended to improve the wording of the criteria for recognising collateral in accounting, which will facilitate the convergence of National Accounting Standards 11 and IAS 37.

Integration of dental therapists in safety net practice increases access to oral health care in Minnesota.

This study evaluates the impact of introducing dental therapists (DTs) into Children's Dental Services (CDS), a large non-profit organization in Minnesota. The aim is to assess the effect of DTs in improving access and reducing dental care costs in Minnesota by analyzing the trends in dental care delivery and procedures performed by CDS dentists and therapists. Using 2009 to 2021 data from CDS, the study compares trends in patient volume, types of procedures, salary data and payments by dentists, DTs, and registered dental hygienists (RDH). Return on investment (ROI) trends are calculated using salary and revenues for each provider type. After introducing DTs at CDS and implementing mobile clinics, the number of patients served and volume increased steadily, demonstrating increased access. DTs provided an increasing proportion of fluorides, sealants, and extractions through 2020. Interestingly 2021, there was a decrease for DTs, possibly due to Covid related workforce shortages. ROI analysis showed that DTs' ROI dramatically rose, eventually surpassing dentists, while RDHs maintained a constant ROI. Dentists' ROI also initially increased after adopting DTs in the practice. Integrating DTs at CDS improved access by expanding mobile clinics, increasing patient volume, and redistributing procedures, while demonstrating a positive return on investment. Results suggest that adopting the DT model may be a promising practice for other organizations seeking to improve access to dental care, increase operational efficiency, and boost the dental care team's ROI.

Burn Center Verification and Safety-net Status: Are There Differences in Discharge to Inpatient Rehabilitation?

Discharge to acute rehabilitation following major burn injury is crucial for patient recovery and quality of life. However, barriers to acute rehabilitation, including race and payor type impede access. The effect of burn center organizational structure on discharge disparities remains unknown. This study aims to investigate associations between patient demographics, burn center factors, and discharge to acute rehabilitation on a population level. Using the California Healthcare Access and Information Database, 2009-2019, all inpatient encounters at verified and non-verified burn centers were extracted. The primary outcome was the proportion of patients discharged to acute rehabilitation. Key covariates included age, race, burn center safety net status, diagnosis related group, American Burn Association (ABA) verification status, and American College of Surgeons (ACS) Level 1 trauma center designation. Logistic regression and mixed-effects modeling were performed, with Bonferroni adjustment for multiple testing. Among 27,496 encounters, 0.8% (228) were discharged to inpatient rehabilitation. By race/ethnicity, the proportion admitted to inpatient rehabilitation was 0.9% for White, 0.6% for Black, 0.7% for Hispanic, and 1% for Asian. After adjusting for burn severity and age, notable predictors for discharge to inpatient rehabilitation included Medicare as payor (OR 0.30-0.88, p=0.015) compared to commercial insurance, trauma center status (OR 1.45-3.43, p<.001), ABA verification status (OR 1.16-2.74, p=0.008), and safety-net facility status (OR 1.09-1.97, p=0.013). Discharge to inpatient rehabilitation varies by race, payor status, and individual burn center. Verified and safety-net burn centers had more patients discharge to inpatient rehabilitation adjusted for burn severity and demographics.

Supply chain fraud prediction with machine learning and artificial intelligence

As businesses undergo digital transformation, supply chain fraud poses an increasing threat, necessitating more sophisticated detection and prevention methods. This paper explores the application of machine learning (ML) and artificial intelligence (AI) in detecting and preventing supply chain fraud. The research design involves analyzing a dataset of supply chain operations and employing various ML algorithms to detect consumer-based fraud within the supply chain, which occurs when consumers partake in deceptive practices during the order process of e-commerce transactions. We analyzed 180,000 transactions from an international company recorded between 2015 and 2018. This study emphasises the necessity of human oversight in interpreting the results generated by these technologies. The implications of supply chain fraud on financial stability, legal standing, and reputation are discussed, along with the potential for ML technology to identify irregularities indicative of fraud. Descriptive findings highlight the prevalence of fraudulent transactions in specific payment types. The AI sequential and the CatBoost classifiers were the top-performing algorithms across all performance metrics. The top features to detect unusual orders are delivery status, payment type, and late delivery risks. The discussion emphasises the promising predictive capabilities of the ML and AI models and their implications for detecting supply chain fraud.

Impact of Program Region and Prestige on Industry Supplemental Earnings for Pediatric Orthopedic Surgery Fellowships in the United States: A Retrospective Analysis

Introduction: With the passage of the Physician Payment Sunshine Act, there has been increased transparency regarding the industrial financial relations that physicians have. Orthopedic surgeons have been highly studied in this domain with approximately 50% of all orthopedic surgeons engaging in industrial financial relationships. Furthermore, an increasing number of orthopedic surgeons are seeking fellowship training with pediatric fellowship programs gaining popularity in recent years. The purpose of this study is to evaluate the impact various pediatric orthopedic fellowship programs have on industry earnings and academic productivity. Methods: Pediatric orthopedic fellowship programs were identified via the Orthopedic Society of North America (POSNA) website. Information on individual fellowship programs was obtained from their respective websites. Academic productivity was measured via an aggregate of all employed physicians’ H-index at a specific fellowship as found on the Scopus website. The Open Payments Database (OPD) website was used to assess lifetime industry earnings. Other variables such as Newsweek or Doximity ranking were taken directly from relevant websites. Statistical analysis was performed using a Kruskal–Wallis test with Bonferroni correction and Mann–Whitney U-test. Results: A total of 43 pediatric orthopedic surgery fellowships in the United States were identified with a total of 392 physicians as fellowship faculty. Complete OPD and H-index information were available for 336 of those physicians (85.7%). On average, there were 7.81 ± 5.18 physicians and 1.56 ± 0.93 fellows per program. The mean combined physician H-index was 117.23 ± 122.51, and the mean combined physician lifetime supplemental earnings in dollars was $646,684.37 ± $1,159,507.17. There was no significant relationship between region of pediatric orthopedic fellowship, Newsweek ranking of affiliated hospital, Doximity ranking of affiliated hospital, presence of MBA program, type of program (public, private, mixed), and the lifetime industry earnings or academic productivity of program graduates. Conclusions: Despite the observed lack of statistical significance, there were clear trends observed with fellowship programs in the northeast and west coast regions being the highest earning and fellowship programs with top 10 Newsweek ranking of affiliated hospital having by far the greatest industry earnings. Sample size limitations likely prevented the detection of statistical significance. Future studies should examine if any relation exists when accounting for type of industry payment received and case volume per fellowship program.

Trends in Veteran hospitalizations and associated readmissions and emergency department visits during the MISSION Act era.

To examine changes in hospitalization trends and healthcare utilization among Veterans following Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act implementation. VA Corporate Data Warehouse and Centers for Medicare and Medicaid Services datasets. Retrospective cohort study to compare 7- and 30-day rates for unplanned readmission and emergency department visits following index hospital stays based on payor type (VHA facility stay, VA-funded stay in community facility [CC], or Medicare-funded community stay [CMS]). Segmented regression models were used to compare payors and estimate changes in outcome levels and slopes following MISSION Act implementation. Veterans with active VA primary care utilization and ≥1 acute hospitalization between January 1, 2016 and December 31, 2021. Monthly index stays increased for all payors until MISSION Act implementation, when VHA and CMS admissions declined while CC admissions accelerated and overtook VHA admissions. In December 2021, CC admissions accounted for 54% of index admissions, up from 25% in January 2016. From adjusted models, just prior to implementation (May 2019), Veterans with CC admissions had 47% greater risk of 7-day readmission (risk ratio [RR]: 1.47, 95% confidence interval [CI]: 1.43, 1.51) and 20% greater risk of 30-day readmission (RR: 1.20, 95% CI: 1.19, 1.22) compared with those with VHA admissions; both effects persisted post-implementation. Pre-implementation CC admissions were also associated with higher 7- and 30-day ED visits, but both risks were substantially lower by study termination (RR: 0.90, 95% CI: 0.88, 0.91) and (RR: 0.89, 95% CI: 0.87, 0.90), respectively. MISSION Act implementation was associated with substantial shifts in treatment site and federal payor for Veteran hospitalizations. Post-implementation readmission risk was estimated to be higher for those with CC and CMS index admissions, while post-implementation risk of ED utilization following CC admissions was estimated to be lower compared with VHA index admissions. Reasons for this divergence require further investigation.

State variations in insertion of long-acting reversible contraception during delivery hospitalization

ObjectivesThis study aimed to describe immediate postpartum long-acting reversible contraception (IPP LARC) insertion rates during delivery hospitalizations at the state level and by payor type. Study designThis is a cross-sectional study of 26 states and District of Columbia using 2020 State Inpatient Database. ResultsIn 2020, IPP LARC insertion rates varied widely by states, ranging from 2.55 to 637.25 per 10,000 deliveries. Rates were higher for deliveries with Medicaid as primary expected payor than with private insurance in all states but District of Columbia. ConclusionsRates of IPP LARC insertion varied in 2020 by state and were higher for deliveries with Medicaid as primary expected payor.

Real-world cost of disease progression (PD) after frontline (1L) R-CHOP in diffuse large B-cell lymphoma (DLBCL): An analysis of a large US claims database.

e19036 Background: Previous studies on the cost of PD in DLBCL do not reflect evolving standards of care and contain limited data on novel therapies in the relapsed/refractory setting. Here, we evaluated the cost of DLBCL PD after 1L therapy using recently available data from a US healthcare database of largely commercial health plan claims. Methods: Using previously published methods (Burke, et al. 2023), this retrospective cohort study analyzed data from IQVIA PharMetrics Plus. Patients (pts) with DLBCL receiving 1L therapy with R-CHOP between October 2016 and March 2021 were included. Index date was defined as a ≥60-day gap in treatment or initiation of new agents. Pts who received non-R-CHOP therapy after 1L were assigned to the ‘PD cohort’ and those not receiving second-line (2L) treatment for ≥2 years to the ‘no PD’ cohort. All pts had continuous enrollment in medical and pharmacy benefits from R-CHOP initiation to ≥2 years post index date, allowing time for post-1L relapse. Unadjusted all-cause healthcare costs per-patient-per-month (PPPM) and 3-year cumulative costs (2023 USD) were compared between cohorts. Generalized linear models were used to adjust for baseline characteristics including age, gender, US region, payer type, Charlson Comorbidity Index (CCI), index year, and healthcare costs 1 year before index date. Results: Overall, 824 pts were included (PD cohort, n=156; no PD cohort, n=668); mean follow-up was 41.6 months. In the overall cohort: 41% were female; and at index mean (SD) age was 58.6 (11.8) years and CCI (non-cancer comorbidity) was 2.5 (3.0). Baseline characteristics were generally similar between cohorts. In the PD cohort, 76 pts (48.7%) had multiple relapse events (3L+), 67 (42.9%) received stem-cell transplant, and 27 (17.3%) received chimeric antigen T-cell therapy (CAR-T). Adjusted mean PPPM cost was higher among the PD than no PD cohort ($11,432 vs $1,698, respectively; p&lt;0.001). A major cost driver was inpatient cost (40.1% and 21.6% of total cost for PD and no PD cohort, respectively). Treatments with CAR-T in the PD cohort were associated with an 18-fold increase in PPPM cost vs the no PD cohort ($29,794 vs $1,689, respectively; p&lt;0.001), and a 4-fold increase vs pts with PD who did not receive CAR-T ($7,829; p&lt;0.001). Adjusted 3-year cumulative costs were higher in the PD ($456,045) vs no PD ($60,519) cohort. Conclusions: Compared with a previous analysis on cost of PD after 1L R-CHOP in DLBCL (2010–2018; Burke, et al. 2023), this updated analysis indicates the cost is considerable, especially among pts receiving CAR-T in later lines, and is increasing, likely due to increasing utilization of novel, more expensive therapies. 1L treatments that prevent or delay relapse could thus reduce the economic burden of PD. Our findings are of use in determining the economic value of emerging 1L options that can successfully reduce the risk of relapse.