Potential financial impact of restriction in “never event” and periprocedural hospital-acquired condition reimbursement at a tertiary neurosurgical center: a single-institution prospective study

Object

The Centers for Medicare and Medicaid Services (CMS) have moved to limit hospital augmentation of diagnosis-related group billing for “never events” (adverse events that are serious, largely preventable, and of concern to the public and health care providers for the purpose of public accountability) and certain hospital-acquired conditions (HACs). Similar restrictions may be applied to physician billing. The financial impact of these restrictions may fall on academic medical centers, which commonly have populations of complex patients with a higher risk of HACs. The authors sought to quantify the potential financial impact of restrictions in never events and periprocedural HAC billing on a tertiary neurosurgery facility.

Methods

Operative cases treated between January 2008 and June 2008 were reviewed after searching a prospectively maintained database of perioperative complications. The authors assessed cases in which there was a 6-month lag time to allow for completion of hospital and physician billing. They speculated that other payers would soon adopt the present CMS restrictions and that procedure-related HACs would be expanded to cover common neurosurgery procedures. To evaluate the impact on physician billing and to directly contrast physician and hospital billing impact, the authors focused on periprocedural HACs, as opposed to entire admission HACs. Billing records were compiled and a comparison was made between individual event data and simultaneous cumulative net revenue and net receipts. The authors assessed the impact of the present regulations, expansion of CMS restrictions to other payers, and expansion to rehospitalization and entire hospitalization case billing due to HACs and never events.

Results

A total of 1289 procedures were completed during the examined period. Twenty-five procedures (2%) involved patients in whom HACs developed; all were wound infections. Twenty-nine secondary procedures were required for this cohort. Length of stay was significantly higher in patients with HACs than in those without (11.6 ± 11.5 vs 5.9 ± 7.0 days, respectively). Fifteen patients required readmission due to HACs. Following present never event and HAC restrictions, hospital and physician billing was minimally affected (never event billing as percent total receipts was 0.007% for hospitals and 0% for physicians). Nonpayment for rehospitalization and reoperation for HACs by CMS and private payers yielded greater financial impact (CMS only, percentage of total receipts: 0.14% hospital, 0.2% physician; all payers: 1.56% hospital, 3.0% physician). Eliminating reimbursement for index procedures yielded profound reductions (CMS only as percentage of total receipts: 0.62% hospital, 0.8% physician; all payers: 5.73% hospital, 8.9% physician).

Conclusions

The authors found potentially significant reductions in physician and facility billing. The expansion of never event and HACs reimbursement nonpayment may have a substantial financial impact on tertiary care facilities. The elimination of never events and reduction in HACs in current medical practices are worthy goals. However, overzealous application of HACs restrictions may remove from tertiary centers the incentive to treat high-risk patients.

Laser spectroscopy of niobium fission fragments: first use of optical pumping in an ion beam cooler buncher

A new method of optical pumping in an ion beam cooler buncher has been developed to selectively enhance ionic metastable state populations. The technique permits the study of elements previously inaccessible to laser spectroscopy and has been applied here to the study of Nb. Model independent mean-square charge radii and nuclear moments have been studied for ;{90,90 m,91,91 m,92,93,99,101,103}Nb to cover the region of the N=50 shell closure and N approximately 60 sudden onset of deformation. The increase in mean-square charge radius is observed to be less than that for Y, with a substantial degree of beta softness observed before and after N=60.

Salivary gland cancer: an exploratory analysis of dietary factors

This study was an exploratory analysis of dietary and other risk factors for primary salivary gland cancer in a population-based case-control study in Ontario, Canada. Cases were men and women diagnosed between 1995 and 1996 with a first primary cancer of the salivary gland, identified through the Ontario Cancer Registry. Controls were an age-matched random sample of the population of Ontario, identified through property assessment files. Cases (n = 91) and controls (n = 1897) completed a self-administered questionnaire with information on diet, smoking, height and weight, and other lifestyle and socio-demographic factors. Multivariate logistic regression was used to estimate odds ratios (ORs) and corresponding 95% confidence intervals (CIs). Among dietary variables, high relative to low intakes of alcohol (OR: 1.26; 95% CI: 0.68-2.35), fruits (OR: 1.26; 95% CI: 0.68-2.33), sweets (OR: 1.66; 95% CI: 0.85-3.25), dairy (OR: 1.41; 95% CI: 0.77-2.58), and starchy foods (OR: 1.78; 95% CI: 0.96-3.3) were associated with non-statistically significant increased risk of salivary gland cancer; whereas vegetables and meats were linked with non-statistically significant decreased risks of the disease. Among non-diet factors, male sex, obese BMI, exposure to occupational radiation, family history of cancer, and household income were suggestive of increased disease risk. Future work with larger numbers of cases are needed to further explore these associations.

Determinants of burden in those who care for someone with dementia

OBJECTIVES

Caregiver burden is a key measure in caregiver research and is frequently used as a baseline measure in intervention studies. Previous research has found numerous factors associated with caregiver burden such as the relationship quality between carer and patient, the patient's cognitive ability, behavioural and psychological symptoms displayed by the patient, caregiver gender, adverse life events to name a few. Many studies have investigated these factors singularly however current thought suggests a multi-factorial role and inter-dependence of these factors. Based on this it was decided to investigate factors associated with caregiver burden using a multiple regression analysis in order to ascertain the predictive quality of these factors of caregiver burden.

METHOD

Cross-sectional study using validated measures of a patient's cognitive ability, ability to carry out day-to-day tasks and behavioural and psychological symptoms. Caregiver outcomes used are caregiver burden, relationship quality, caregiver confidence, experience of adverse life events, neuroticism, age and gender. Interviews and questionnaires were carried out on 74 patients diagnosed with dementia and their main caregivers from the Midlands of England.

RESULTS

Multiple regression analysis showed that caregiver overload, carer-patient relationship quality, the experience of adverse life events, caregiver gender, caregivers' level of neuroticism, caregiver role captivity and the level of caregiver confidence accounted for over 80% of the variance in caregiver burden.

CONCLUSION

These results confirm previous correlational research on caregiver burden. Furthermore, due to the use of multiple regression analysis the findings also show factors that are clear predictors of caregiver burden and we offer possible suggestions from these findings on future clinical practice interventions on caregiver burden.

Enzymic pathways of hyaluronan catabolism

The enzymic degradation of hyaluronan in mammalian tissues takes place in two phases, encompassing breakdown of the polysaccharide to its monosaccharide constituents and subsequent utilization of the monosaccharide products. Degradation to the monosaccharide components is effected by the concerted action of three enzymes, hyaluronidase, beta-D-glucuronidase and beta-N-acetyl-D-hexosaminidase. The relative contributions of hyaluronidase and the two exoglycosidases to the physiological catabolism of hyaluronan are not yet known but consideration of the kinetic properties of the three enzymes clearly indicates that hyaluronidase is best suited for the initial attack on the polysaccharide, inasmuch as its Km for hyaluronan is 1000- to 10,000-fold lower than that estimated for beta-D-glucuronidase. Recent investigations in the authors' laboratories have been focused on the catabolism of hyaluronan and other complex carbohydrates in liver, since the sinusoidal endothelial cells in this organ are the main sites for degradation of circulating hyaluronan. Assay of ten lysosomal hydrolases in isolated rat liver cells showed considerably higher activities in Kupffer cells and endothelial cells than in hepatocytes for nine of the enzymes, including beta-D-glucuronidase and beta-N-acetyl-D-hexosaminidase. The activity of N-acetylglucosamine-6-phosphate deacetylase, a key enzyme in the metabolism of the N-acetylglucosamine released by the lysosomal degradation of hyaluronan and other complex carbohydrates, has also been determined. High deacetylase activities were observed in both Kupffer cells and endothelial cells but, surprisingly, virtually no activity was detected in hepatocytes. This finding implies that N-acetylglucosamine cannot be degraded in hepatocytes and must be largely reutilized in the synthesis of new macromolecules. Further studies of the enzymes involved in hyaluronan degradation and N-acetylglucosamine utilization in the liver are under way.

Metal ion levels in a triathlete with a metal-on-metal resurfacing arthroplasty of the hip

A prospective study of serum and urinary ion levels was undertaken in a triathlete who had undergone a metal-on-metal resurfacing arthroplasty of the hip four years previously. The one month study period included the final two weeks of training, the day of the triathlon, and the two weeks immediately post-race. Serum cobalt and chromium levels did not vary significantly throughout this period, including levels recorded on the day after the 11-hour triathlon. Urinary excretion of chromium increased immediately after the race and had returned to pre-race levels six days later. The clinical implications are discussed.

Architectures of somatic genomic rearrangement in human cancer amplicons at sequence-level resolution

For decades, cytogenetic studies have demonstrated that somatically acquired structural rearrangements of the genome are a common feature of most classes of human cancer. However, the characteristics of these rearrangements at sequence-level resolution have thus far been subject to very limited description. One process that is dependent upon somatic genome rearrangement is gene amplification, a mechanism often exploited by cancer cells to increase copy number and hence expression of dominantly acting cancer genes. The mechanisms underlying gene amplification are complex but must involve chromosome breakage and rejoining. We sequenced 133 different genomic rearrangements identified within four cancer amplicons involving the frequently amplified cancer genes MYC, MYCN, and ERBB2. The observed architectures of rearrangement were diverse and highly distinctive, with evidence for sister chromatid breakage-fusion-bridge cycles, formation and reinsertion of double minutes, and the presence of bizarre clusters of small genomic fragments. There were characteristic features of sequences at the breakage-fusion junctions, indicating roles for nonhomologous end joining and homologous recombination-mediated repair mechanisms together with nontemplated DNA synthesis. Evidence was also found for sequence-dependent variation in susceptibility of the genome to somatic rearrangement. The results therefore provide insights into the DNA breakage and repair processes operative in somatic genome rearrangement and illustrate how the evolutionary histories of individual cancers can be reconstructed from large-scale cancer genome sequencing.

Genome-wide association scan identifies a colorectal cancer susceptibility locus on chromosome 8q24

Using a multistage genetic association approach comprising 7,480 affected individuals and 7,779 controls, we identified markers in chromosomal region 8q24 associated with colorectal cancer. In stage 1, we genotyped 99,632 SNPs in 1,257 affected individuals and 1,336 controls from Ontario. In stages 2-4, we performed serial replication studies using 4,024 affected individuals and 4,042 controls from Seattle, Newfoundland and Scotland. We identified one locus on chromosome 8q24 and another on 9p24 having combined odds ratios (OR) for stages 1-4 of 1.18 (trend; P = 1.41 x 10(-8)) and 1.14 (trend; P = 1.32 x 10(-5)), respectively. Additional analyses in 2,199 affected individuals and 2,401 controls from France and Europe supported the association at the 8q24 locus (OR = 1.16, trend; 95% confidence interval (c.i.): 1.07-1.26; P = 5.05 x 10(-4)). A summary across all seven studies at the 8q24 locus was highly significant (OR = 1.17, c.i.: 1.12-1.23; P = 3.16 x 10(-11)). This locus has also been implicated in prostate cancer.