Variation In Care Costs Research Articles

National Prevalence of Complications and Cost of Small Joint Arthroplasty for Hand Osteoarthritis and Post-Traumatic Arthritis

Osteoarthritis (OA) of the hand is commonly treated using implant arthroplasty. Despite the increasing prevalence of hand OA, population-based evidence regarding the complication profile and associated cost for patients undergoing proximal interphalangeal (PIP) joint and metacarpophalangeal (MCP) joint arthroplasty are lacking. Therefore, we aimed to evaluate the complication profiles and variation in cost of care for patients undergoing PIP and MCP joint arthroplasty. We analyzed insurance claims from 2009 to 2016 using the Truven MarketScan Databases for adult patients undergoing a PIP and MCP joint arthroplasty following OA or post-traumatic arthritis diagnosis. Multivariable logistic regression was performed to investigate the association of patient-level factors and complications at 2 years after surgery. Cumulative direct cost, defined as the cost of the index surgery and 2-year postoperative episode, and patient-level characteristics were examined. We analyzed a total of 2,859 patients who underwent MCP joint arthroplasty (36%) or PIP joint arthroplasty (64%). On average, these procedures have a 35% complication rate. However, patients undergoing PIP joint arthroplasty were more likely to suffer a prosthetic fracture than patients undergoing MCP joint arthroplasty (3.4% vs 1.5%, respectively). Each complication resulted in an additional cost of $1,076. This nationwide analysis provides a population estimate of the complication profile and associated costs of MCP and PIP joint arthroplasty for hand OA and post-traumatic arthritis.Minimizing postoperative complications after MCP and PIP joint arthroplasty is one avenue to decrease health care costs. Prognostic II.

Regional Variation in Standardized Costs of Care at Children's Hospitals.

(1) To evaluate regional variation in costs of care for 3 inpatient pediatric conditions, (2) assess potential drivers of variation, and (3) estimate cost savings from reducing variation. Retrospective cohort study of hospitalizations for asthma, diabetic ketoacidosis (DKA), and acute gastroenteritis (AGE) at 46 children<s hospitals from October 2014 to September 2015. Variation in trimmed standardized costs were assessed within and across regions. Linear mixed effects models were adjusted for patient- and encounter-level variables to assess drivers of variation. After adjusting for patient-level factors, variation remained. Using census division clusters, mean trimmed and adjusted total standardized costs were 120% higher for asthma ($1920 vs $4227), 46% higher for DKA ($7429 vs $10,881), and 150% higher for AGE ($3316 vs $8292) in the highest-cost compared with the lowest-cost region. Comparing hospitals in the same region, standardized costs were significantly different (P < 0.001) for each condition in each region. Drivers of variation were encounter-level variables including length of stay and intensive care unit utilization. For this cohort, annual savings from reducing variation would equal $69.1 million at the interregional level and $25.2 million at the intraregional level. Pediatric hospital costs vary between and within regions. Future studies should examine how much of this variation is avoidable. To the extent that less spending does not compromise outcomes, care models may be adjusted to eliminate unwarranted variation and reduce costs.

The Core Competencies in Hospital Medicine 2017 Revision. Section 3: Healthcare Systems.

BACKGROUNDThough regional variation in healthcare spending has received national attention, it has not been widely studied in pediatrics.OBJECTIVES(1) To evaluate regional variation in costs of care for 3 inpatient pediatric conditions, (2) assess potential drivers of variation, and (3) estimate cost savings from reducing variation.DESIGN/SETTING/PATIENTSRetrospective cohort study of hospitalizations for asthma, diabetic ketoacidosis (DKA), and acute gastroenteritis (AGE) at 46 children's hospitals from October 2014 to September 2015.INTERVENTION/MEASUREMENTSVariation in trimmed standardized costs were assessed within and across regions. Linear mixed effects models were adjusted for patient‐ and encounter‐level variables to assess drivers of variation.RESULTSAfter adjusting for patient‐level factors, variation remained. Using census division clusters, mean trimmed and adjusted total standardized costs were 120% higher for asthma ($1920 vs $4227), 46% higher for DKA ($7429 vs $10,881), and 150% higher for AGE ($3316 vs $8292) in the highest‐cost compared with the lowest‐cost region. Comparing hospitals in the same region, standardized costs were significantly different (P &lt; 0.001) for each condition in each region. Drivers of variation were encounter‐level variables including length of stay and intensive care unit utilization. For this cohort, annual savings from reducing variation would equal $69.1 million at the interregional level and $25.2 million at the intraregional level.CONCLUSIONSPediatric hospital costs vary between and within regions. Future studies should examine how much of this variation is avoidable. To the extent that less spending does not compromise outcomes, care models may be adjusted to eliminate unwarranted variation and reduce costs.

Developing an Episode Based Payment Model for Acute Pancreatitis Hospitalizations

Introduction: The episode based payment model (EBP) is one approach being explored to incentivize pay for quality and performance. Acute pancreatitis hospitalizations (episodes) which involve multiple providers with marked variations in management is an ideal disease to explore this model of reimbursement. The aim of the study is to model the cost of care for acute pancreatitis hospitalizations using consensus guidelines (gold standard) to determine variations in cost of care. Methods: Patient encounters from a single health plan were retrospectively identified using a single ICD 9 code (577.0) for acute pancreatitis between 2011 and 2015 to derive an EBP model. Only acute care encounters were used in model building. To ensure the use of the best evidence available, we utilized the IAP/APA and ACG guidelines for the management of acute pancreatitis as a way to identify variations in care. Imaging utilization in the first 24 hours (abdominal computed tomography CT, abdominal ultrasonography), length of stay (LOS), location of care and cost (USD) were obtained. Results: There were 123 patients identified during the study period of which 65 patients (53%) received management in the acute care setting. The average age was 42 years old and the majority were female (54%). The mean LOS was 2 days and the average cost of an encounter was $6,131. Twenty- seven patients (42%) in the health plan sought care at neighboring, non-academic hospitals. Using multivariable linear regression, CT imaging ($1656, p = 0.018), prolonged LOS ($1765, p < 0.0001) and care outside of our institution ($1921, p = 0.007) were all shown to be significant linear predictors of higher cost (Figure 1). The overall EBP model was able to explain 60% of the variation in cost and was statistically significant (P < 0.0001). Conclusion: Practice guidelines are seldom used to determine how deviations affect cost. For acute pancreatitis, our preliminary EBP model suggests that LOS, CT imaging and care at an academic center (high volume) statistically impact inpatient costs. Clinical Implications- Incorporating clinical guidelines in episode based payment models may be a better way to inform clinicians how deviation from guidelines impact the overall cost of healthcare.Table 1: Optimized linear model of cost in all patients in the cohort

Regional variations in cost of trauma care in the United States

The study of regional variations in costs of care has been used to identify areas of savings for several diseases and conditions. This study investigates similar potential regional differences in the cost of adult trauma care using an all-payer, nationally representative sample. Trauma patients aged 18 to 64 years in the 2006-2008 Nationwide Inpatient Sample were identified using International Classification of Diseases, 9th Revision, Clinical Modification codes. Those with isolated diagnoses for five index conditions (ICs): blunt splenic injury, liver injury, tibia fracture, moderate traumatic brain injury, and pneumothorax/hemothorax were selected. Cost was estimated from charges using a cost-to-charge ratio. Generalized linear modeling was used to compare the mean cost for treating these ICs between US regions (Northeast, South, Midwest, and West), adjusting for hospital factors (size, teaching status, and location), patient demographics, injury severity, length of stay, Charlson comorbidity index, local wage index, and payer. Relative mean cost (RC) was calculated using Northeast as the reference, and sampling weights were applied to obtain regional estimates. Differences in adjusted mortality between regions were also assessed. Adjusted relative costs were estimated for 62,678 patients (South: 28,536; West: 12,975; Midwest: 11,450; and Northeast: 9,717). Mean costs for liver injury were 22%higher in the Midwest compared with the Northeast (RC: 1.22; 95%confidence interval [CI]: 1.10-1.35). Similarly higher costs were seen with other regions and ICs (RC for blunt splenic injury in the South: 1.18; 95% CI: 1.07-1.31; RC for pneumothorax/hemothorax in the West: 1.31; 95% CI: 1.22-1.41). No differences in adjusted mortality by region were noted overall. Even after controlling for factors known to influence medical care cost, as well as controlling for geographic differences in pricing, significant regional differences exist in the cost of trauma care. Exploring these variations may assist in identifying potential areas for cost savings.

The Effects of Patient Function and Dependence on Costs of Care in Alzheimer's Disease

To estimate incremental effects of patients' dependence and function on costs of care during the early stages of Alzheimer's disease (AD) and to compare strengths of their relationships with different cost components. Multicenter, cross-sectional, observational study. Three university hospitals in the United States. One hundred seventy-nine community-living patients with probable AD, with modified Mini-Mental State Examination scores of 30 or higher. Patients' dependence was measured using the Dependence Scale (DS). Functional capacity was measured using the Blessed Dementia Rating Scale (BDRS). Total cost was measured by summing direct medical costs and informal costs. Direct medical costs included costs of hospitalization, outpatient treatment and procedures, assistive devices, and medications. Informal costs were estimated from time spent helping with basic and instrumental activities of daily living for up to three caregivers per patient using national average hourly earnings as wage rate. DS and BDRS were associated with higher total cost; a 1-point increase in DS was associated with a $1,832 increase in total cost, and a 1-point increase in BDRS was associated with a $3,333 increase. Examining component costs separately identified potential differences between DS and BDRS. A 1-point increase in BDRS was associated with a $1,406 increase in direct medical cost. A 1-point increase in DS was associated with a $1,690 increase in informal cost. Patients' dependence and function related differently to direct medical and informal cost, suggesting that measures of function and dependence provided unique information for explaining variations in cost of care for patients with AD, highlighting the value in measuring both constructs.

Cost of AIDS Care in Mexico: What Are its Main Individual Predictors?

The Mexican government is offering universal access to antiretroviral (ARV) drugs. The cost of doing so, despite aggressive price negotiation with the pharmaceutical industry, remains high. Even with a low prevalence, about 150,000 Mexicans are estimated to be living with HIV and will require ARV treatment. Estimating the resources needed to fund this gap should consider how patient and provider characteristics affect health care costs. Using a sample of patients from 11 facilities in three Mexican cities representing a large proportion of AIDS patients in the country, we developed a fixed-effect model, which by controlling the facilities and individual heterogeneity estimates predicted costs using patient demographic and socioeconomic characteristics as well as physician training. The estimated model explains about 45% of the variation in costs. Additional education is significantly and positively associated with cost. Increasing age is also associated with higher costs. Socioeconomic status and demographic characteristics explain an important proportion of variation in care costs for AIDS, despite AIDS being such a heterogeneous disease. Such characteristics will need to be taken into account when resource needs are estimated. A priority-setting process considering the principles of equity in the fair distribution of resources is needed to help reduce the social burden of HIV/AIDS in Mexico.

Cost of care for individuals with cystic fibrosis: a regression approach to determining the impact of recombinant human DNase.

We estimated direct medical costs of care and important determinants of the costs in patients with cystic fibrosis (CF), including therapy with recombinant human DNase (rhDNase). Costs were estimated with resource use data from the Epidemiologic Study of Cystic Fibrosis. Ordinary least squares regression was used to determine the effect of clinical and demographic variables on individual cost of care. The estimated cost of caring for 303 patients in Alberta was $2,279,801 in 1996. The mean cost of care was $7524 (range $386-92,376)/patient. Regression results indicated that age and forced expiratory volume predicted had a negative association with costs. Being female, receiving rhDNase, and having Pseudomonas aeruginosa or Burkholderia cepacia were all associated with high costs. Our estimates indicated large interindividual variation in cost of care for patients with CF.

A competitive bidding approach to physician payment.

Prologue: For the most part, efforts to reform the way Medicare pays physicians have focused on administrative fee-setting approaches: fee schedules, adjustments of fees to reflect geographic variation in costs of care, rebasing the Medicare Economic Index, and other strategies. The rationale for administered pricing centers on the pervasive view that to continue the current style of paying physicians under Medicare will merely drive prices higher. One voice in the crowd, however, has suggested an alternative approach to meeting the goals of physician payment reform: competitive bidding. In this article, economist Jeff McCombs advocates retaining market-driven physician payment; his proposal draws heavily on the competitive bidding model used in setting payments for durable medical equipment and outpatient clinical laboratories under Medicare. His approach keeps the task of setting prices in the hands of providers, who, he contends, know best what it costs to provide health care services. While similar to...