Obesity and hospital outcomes following traumatic injury: Associations in 9 years of patient data from a single metropolitan area

Traumatic injury is a leading cause of death and disability worldwide. Obesity may put trauma patients at risk for complications leading to negative clinical outcomes. Data on all hospital admissions due to traumatic injury in the Detroit metropolitan area between 2006 and 2014 were obtained from the Michigan State Inpatient Database. Generalized linear modelling was used to compare patients with and without obesity on three outcomes: mortality, length of hospital stay and total charges for care. Adjusting for demographics, patients with obesity had 26% longer hospitalization. Adjusting for demographics and length of stay, charges were 8% higher. Obesity was unrelated to mortality. Obesity had greater impact on length of stay among younger adults; its relationship with charges emerged only among older adults. Obesity has significant clinical implications for trauma care. Demands for trauma care resources, and the charges associated with providing care, are likely to increase as obesity rates rise.

Investigating the utility of intraoperative neurophysiological monitoring for anterior cervical discectomy and fusion: analysis of over 140,000 cases from the National (Nationwide) Inpatient Sample data set

OBJECTIVE

Intraoperative neurophysiological monitoring (IONM) is a useful adjunct in spine surgery, with proven benefit in scoliosis-correction surgery. However, its utility for anterior cervical discectomy and fusion (ACDF) is unclear, as there are few head-to-head comparisons of ACDF outcomes with and without the use of IONM. The authors sought to evaluate the impact of IONM on the safety and cost of ACDF.

METHODS

This was a retrospective analysis of data from the National (Nationwide) Inpatient Sample of the Healthcare Cost and Utilization Project from 2009 to 2013. Patients with a primary procedure code for ACDF were identified, and diagnosis codes were searched to identify cases with postoperative neurological complications. The authors performed univariate and multivariate logistic regression for postoperative neurological complications with use of IONM as the independent variable; additional covariates included age, sex, surgical indication, multilevel fusion, Charlson Comorbidity Index (CCI) score, and admission type. They also conducted propensity score matching in a 1:1 ratio (nearest neighbor) with the use of IONM as the treatment indicator and the aforementioned variables as covariates. In the propensity score-matched cohort, they compared neurological complications, length of stay (LOS), and hospital charges (in US dollars).

RESULTS

A total of 141,007 ACDF operations were identified. IONM was used in 9540 cases (6.8%). No significant association was found between neurological complications and use of IONM on univariate analysis (OR 0.80, p = 0.39) or multivariate regression (OR 0.82, p = 0.45). By contrast, age ≥ 65 years, multilevel fusion, CCI score > 0, and a nonelective admission were associated with greater incidence of neurological complication. The propensity score-matched cohort consisted of 18,760 patients who underwent ACDF with (n = 9380) or without (n = 9380) IONM. Rates of neurological complication were comparable between IONM and non-IONM (0.17% vs 0.22%, p = 0.41) groups. IONM and non-IONM groups had a comparable proportion of patients with LOS ≥ 2 days (19% vs 18%, p = 0.15). The use of IONM was associated with an additional $6843 (p < 0.01) in hospital charges.

CONCLUSIONS

The use of IONM was not associated with a reduced rate of neurological complications following ACDF. Limitations of the data source precluded a specific assessment of the effectiveness of IONM in preventing neurological complications in patients with more complex pathology (i.e., ossification of the posterior longitudinal ligament or cervical deformity).

The triad of diabetes ketoacidosis, hypertriglyceridemia and acute pancreatitis. How does it affect mortality and morbidity?: A 10-year analysis of the National Inpatient Sample

The triad of acute pancreatitis (AP) coexisting with diabetes ketoacidosis (DKA) and hypertriglyceridemia (HTG) has been reported, but no impact on mortality has been found to date. We aim to assess if patients with this triad are at a higher inpatient mortality compared to patients with acute pancreatitis only.Retrospective cohort. The National Inpatient Sample (NIS) database from 2003 to 2013 was queried for patients with a discharge diagnosis of AP and presence of DKA and HTG was ascertained based on International Classification of Diseases, 9th revision (ICD9) codes. Adjusted for age, gender, race, Charlson comorbidity index (CCI), median income quartile, and hospital characteristics.Over 2.8 million AP patients were analyzed. When compared with patients with AP-only, patients with the triad of AP + DKA + HTG had higher inpatient mortality (aOR 2.8, P < .001; CI: 1.9 - 4.2), Acute Kidney Injury (AKI) (aOR 4.1, P < .001; CI: 3.6-4.6), Systemic Inflammatory Response Syndrome (SIRS) (aOR 4.9, P < .001), Shock (aOR 4.3, P < .001), Acute Respiratory Distress Syndrome (ARDS) (aOR 3.0, P < .001), sepsis (aOR 2.6, P < .001), ileus (aOR 2.1, P < .001), parenteral nutrition requirement (aOR 1.8, P < .001), inflation-adjusted hospital charges (US$ 17,704.1), and had longer length of stay (LOS) (aOR 2.0, P < .001; CI 1.8-2.3). Furthermore, when compared to AP-only, patients with AP + HTG had lower mortality, which is different from the current AP knowledge. Finally, it appears that the driving force for the increased in mortality of patients with the triad (AP, DKA, HTG) is the DKA rather than the HTG.Patients with the triad of AP, DKA, and HTG constitute a unique subgroup of patients that has higher inpatient mortality, multi-organ failure, hospital charges, and longer hospital length of stay. Therefore, hospital protocols targeting this subgroup of AP patients could improve mortality and outcomes.

Use of the burn intervention score to calculate the charges of the care of burns

BACKGROUND

To our knowledge this is the first published estimate of the charges of the care of burns in Sweden. The Linköping Burn Interventional Score has been used to calculate the charges for each burned patient since 1993. The treatment of burns is versatile, and depends on the depth and extension of the burn. This requires a flexible system to detect the actual differences in the care provided. We aimed to describe the model of burn care that we used to calculate the charges incurred during the acute phase until discharge, so it could be reproduced and applied in other burn centres, which would facilitate a future objective comparison of the expenses in burn care.

METHODS

All patients admitted with burns during the period 2010-15 were included. We analysed clinical and economic data from the daily burn scores during the acute phase of the burn until discharge from the burn centre.

RESULTS

Total median charge/patient was US$ 28 199 (10th-90th centiles 4668-197 781) for 696 patients admitted. Burns caused by hot objects and electricity resulted in the highest charges/TBSA%, while charges/day were similar for the different causes of injury. Flame burns resulted in the highest mean charges/admission, probably because they had the longest duration of stay. Mean charges/patient increased in a linear fashion among the different age groups.

CONCLUSION

Our intervention-based estimate of charges has proved to be a valid tool that is sensitive to the procedures that drive the costs of the care of burns such as large TBSA%, intensive care, and operations. The burn score system could be reproduced easily in other burn centres worldwide and facilitate the comparison regardless of the differences in the currency and the economic circumstances.

Trends in Drug Use-Associated Infective Endocarditis and Heart Valve Surgery, 2007 to 2017: A Study of Statewide Discharge Data

Background

Drug use-associated infective endocarditis (DUA-IE) is increasing as a result of the opioid epidemic. Infective endocarditis may require valve surgery, but surgical treatment of DUA-IE has invoked controversy, and the extent of its use is unknown.

Objective

To examine hospitalization trends for DUA-IE, the proportion of hospitalizations with surgery, patient characteristics, length of stay, and charges.

Design

10-year analysis of a statewide hospital discharge database.

Setting

North Carolina hospitals, 2007 to 2017.

Patients

All patients aged 18 years or older hospitalized for IE.

Measurements

Annual trends in all IE admissions and in IE hospitalizations with valve surgery, stratified by patients' drug use status. Characteristics of DUA-IE surgical hospitalizations, including patient demographic characteristics, length of stay, disposition, and charges.

Results

Of 22 825 IE hospitalizations, 2602 (11%) were for DUA-IE. Valve surgery was performed in 1655 IE hospitalizations (7%), including 285 (17%) for DUA-IE. Annual DUA-IE hospitalizations increased from 0.92 to 10.95 and DUA-IE hospitalizations with surgery from 0.10 to 1.38 per 100 000 persons. In the final year, 42% of IE valve surgeries were performed in patients with DUA-IE. Compared with other surgical patients with IE, those with DUA-IE were younger (median age, 33 vs. 56 years), were more commonly female (47% vs. 33%) and white (89% vs. 63%), and were primarily insured by Medicaid (38%) or uninsured (35%). Hospital stays for DUA-IE were longer (median, 27 vs. 17 days), with higher median charges ($250 994 vs. $198 764). Charges for 282 DUA-IE hospitalizations exceeded $78 million.

Limitation

Reliance on administrative data and billing codes.

Conclusion

DUA-IE hospitalizations and valve surgeries increased more than 12-fold, and nearly half of all IE valve surgeries were performed in patients with DUA-IE. The swell of patients with DUA-IE is reshaping the scope, type, and financing of health care resources needed to effectively treat IE.

Primary Funding Source

National Institutes of Health.

Influence of Intraoperative Neuromonitoring on the Outcomes of Surgeries for Pediatric Scoliosis in the United States

BACKGROUND

Intraoperative neuromonitoring (IONM) is used to detect impending neurologic damage during complex spinal surgeries. Although IONM is increasingly used during pediatric scoliosis surgeries in the United States, the effect of IONM on the outcomes of such surgeries at a national level is unclear.

METHODS

Using National Inpatient Sample (NIS) from 2009 to 2012, 32,305 spinal fusions performed in children 18 years old or younger of age with scoliosis were identified using ICD-9 procedure and diagnosis codes. IONM was identified using the ICD-9 procedure code 00.94. The effects of IONM use on length of stay (LOS), discharge disposition, hospital charges, and in-hospital complications were assessed using multivariate regression analysis adjusting for patient and hospital characteristics.

RESULTS

IONM was used in 5,706 (18%) of the surgeries. IONM was associated with increased home discharge (adjusted odds ratio [AOR] = 1.25 [95% confidence interval 1.10-1.40], p = .001). There was no difference in LOS (p = .096) and hospital charges (p = .750). Neurologic complications were noted in 52 (0.9%) surgeries using IONM and 368 (1.4%) surgeries without IONM (p = .005). Although IONM use trended toward lower risk of neurologic complications in multivariate analysis, it failed to achieve statistical significance (AOR = 0.77 [0.57-1.04], p = .084).

CONCLUSIONS

Reported use of IONM in this database was significantly less compared with other databases, suggesting that IONM might be underreported in the NIS database. Nevertheless, in this database, IONM was significantly associated with increased home discharge. Hospital charges and LOS were not affected by IONM. There was a trend toward lower risk of neurologic complications with IONM use, though this finding was not statistically significant.

Inpatient Cost of Stroke in Beijing: A Descriptive Analysis

BACKGROUND

Stroke has been the leading cause of death in China and contributed almost one-third to stroke deaths worldwide. The rising cost of stroke treatment is of great concern, but has not been thoroughly studied. This study aimed to analyze stroke in-hospital charges by subtypes, age, and sex and investigate potential factors associated with the cost of per stay.

METHODS

The research was a retrospective observational study based on patients with a primary diagnosis of stroke from 31 hospitals in Beijing. Characteristics of total treatment cost and cost of per stay were analyzed. The potential influences on hospital charges were explored using a stepwise multiple regression model.

RESULTS

A total of 16,111 stroke in-patient admissions were identified among which 8.3% was subarachnoid hemorrhage, 22.4% intracerebral hemorrhage, and 69.1% cerebral infarction. The average length of stay (LoS) was 14.5 (11.9) days. The cost of per stay was USD 4,423.9 (6,684.4) among which the out-of-pocket expenses were USD 1,640.2 (3,118.0). Stroke type, age, medical insurance, treatment results, and hospital level were significantly associated with the cost of stroke (p < 0.001).

CONCLUSION

Hospitalization cost of stroke was substantial. These findings provide health policymakers and healthcare professionals with evidence to help guide future spending.

Association of Inpatient Palliative Care with Health Care Utilization and Postdischarge Outcomes among Medicare Beneficiaries with End Stage Kidney Disease

BACKGROUND AND OBJECTIVES

Palliative care may improve quality of life and reduce the cost of care for patients with chronic illness, but utilization and cost implications of palliative care in ESKD have not been evaluated. We sought to determine the association of inpatient palliative care with health care utilization and postdischarge outcomes in ESKD.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

In analyses stratified by whether patients died during the index hospitalization, we identified Medicare beneficiaries with ESKD who received inpatient palliative care, ascertained by provider specialty codes, between 2012 and 2013. These patients were matched to hospitalized patients who received usual care using propensity scores. Primary outcomes were length of stay and hospitalization costs. Secondary outcomes were 30-day readmission and hospice enrollment.

RESULTS

Inpatient palliative care occurred in <1% of hospitalizations lasting >2 days. Among the decedent cohort (n=1308), inpatient palliative care was associated with a 21% shorter length of stay (-4.2 days; 95% confidence interval, -5.6 to -2.9 days) and 14% lower hospitalization costs (-$10,698; 95% confidence interval, -$17,553 to -$3843) compared with usual care. Among the nondecedent cohort (n=5024), inpatient palliative care was associated with no difference in length of stay (0.4 days; 95% confidence interval, -0.3 to 1.0 days) and 11% higher hospitalization costs ($4275; 95% confidence interval, $1984 to $6567) compared with usual care. In the 30-day postdischarge period, patients who received inpatient palliative care had higher likelihood of hospice enrollment (hazard ratio, 8.3; 95% confidence interval, 6.6 to 10.5) and lower likelihood of rehospitalization (hazard ratio, 0.8; 95% confidence interval, 0.7 to 0.9).

CONCLUSIONS

Among patients with ESKD who died in the hospital, inpatient palliative care was associated with shorter hospitalizations and lower costs. Among those who survived to discharge, inpatient palliative care was associated with no difference in length of stay and higher hospitalization costs but markedly higher hospice use and fewer readmissions after discharge.

Higher mortality and hospital charges in patients with cirrhosis and acute respiratory illness: a population-based study

Both cirrhosis and acute respiratory illness (ARI) carry substantial disease and financial burden. To compare hospitalized patients with cirrhosis with ARI to cirrhotic patients without ARI, a retrospective cohort study was conducted using the California Office of Statewide Health Planning and Development database. To balance the groups, propensity score matching (PSM) was used. We identified a total of 46,192 cirrhotic patients during the three study periods (14,049, 15,699, and 16,444 patients, respectively). Among patients hospitalized with cirrhosis, the ARI prevalence was higher in older age groups (p < 0.001), the Asian population (p = 0.002), non-Hispanic population (p = 0.001), and among Medicare patients (p < 0.001). Compared to controls, patients with ARI had 53.8% higher adjusted hospital charge ($122,555 vs. $79,685 per patient per admission, p < 0.001) and 35.0% higher adjusted in-hospital mortality (p < 0.001). Older patients, patients with alcoholic liver disease or liver cancer were at particularly higher risk (adjusted hazard ratio = 2.94 (95% CI: 2.26-3.83), 1.22 (95% CI: 1.02-1.45), and 2.17 (95% CI: 1.76-2.68) respectively, p = 0.028 to <0.001). Mortality rates and hospital charges in hospitalized cirrhotic patients with ARI were higher than in cirrhotic controls without ARI. Preventive efforts such as influenza and pneumococcal vaccination, especially in older patients and those with liver cancer, or alcoholic liver disease, would be of value.

Decreasing Resource Utilization without Compromising Care through Minimizing Preoperative Laboratories

Approximately 18 billion dollars is spent annually on preoperative testing. The purpose of this study was to determine whether implementation of an algorithm aimed at minimizing preoperative tests resulted in decreased costs without compromising care. We performed a pre-post trial comparing January 2016 to April 2016 with May 2016 to July 2017. In May 2016, an algorithm was instituted in which laboratories were canceled based on an algorithm that incorporated patient and procedural factors. Total number of laboratories canceled before orthopedic, urologic, or general surgical procedures was documented. Case cancellations during this time were recorded. There were 22,175 laboratories during the study time frame. There was a significant decrease of 2.4 per cent in expected laboratories in the post-intervention group. There was an overall cost savings of $33,032.00. The per cent of patients who were seen in preoperative testing clinic and still needed medical optimization decreased after algorithm implementation (3.3% vs 2.1% P < 0.01). No cases were canceled because of lack of laboratory information. An algorithm for selective preoperative laboratory testing provides overall cost savings. Decreasing the number of unnecessary laboratories ordered reduced case cancellations. Instituting an algorithm for preoperative laboratory testing is cost-effective without compromising care.

[ESTIMATION OF EFFICIENCY OF HOSPITAL PAYMENT METHODS IN THE REPUBLIC OF KAZAKHSTAN]

Purpose - to evaluate the methods of payment for medical aid in the medical organizations of the Republic of Kazakhstan. The materials of the study were statistical and financial indicators of the activity of medical organizations of the Republic of Kazakhstan for 2010-2017. The research is based on methods of organizational and economic research: theoretical analysis, economic and statistical analysis. With the implementation of the system of "global budget" at the Regional Oncologic Dispensary main target indicators of the memorandum was reached with the year 2011-2015. With the introduction of the system, the beds were reduced by 33.3%, but due to the increase in beds in the day hospital, the number of patients treated increased by 55.8%. In the Tayinshinsky Central District Hospital, the increase in funding by 26.7% and wages of medical workers by 24.9%. Thus, the application in the domestic practice of global budget systems and payment for diagnosis-related groups in a hospital environment showed its effectiveness, proving that the payment system is designed to stimulate efficiency gains and to prevent the provision of unnecessary services. At the same time, a number of negative aspects of payment methods can be identified, which requires a further revision of the diagnosis-related groups in order to improve the efficiency of using budget funds. Payment of medical services for the global budget system, in particular oncological services also require a number of changes on the part of the regulatory normative legal acts.

Cost Analysis of Direct Oral Anticoagulants Compared with Warfarin in Patients with Blunt Traumatic Intracranial Hemorrhages

Direct oral anticoagulants (DOACs) are rapidly gaining popularity as alternatives to warfarin in the prevention of stroke or systemic embolic events because of the simplicity of their dosing and lack of monitoring requirement. Many physicians feared that these novel agents would be cost-prohibitive not only in their administration but also in their sequelae of bleeding, given the few reversal agents available. Whereas the medication itself is more expensive than traditional warfarin, the total cost of a hospital admission has not been compared between patients on DOACs and warfarin who have sustained a blunt traumatic intracranial hemorrhage (ICH). We conducted a retrospective review of our hospital's trauma database from June 2011 through September 2015 at our Level II trauma center of patients who suffered from an ICH who were anticoagulated at the time of their trauma. Patients who died during their hospital admission or were exclusively on antiplatelet agents were excluded. Of the 136 patients studied, 79 were on warfarin and 57 were on a DOAC at the time of their presentation for a traumatic ICH. The average charged cost for the hospital stay of a patient with an ICH was significantly higher for patients on warfarin compared with DOACs [$70,384.08 vs $49,226.66 (P = 0.02)]. The average reimbursement rate for the hospital was also significantly higher for those patients on warfarin as compared with those on DOACs [$23,922.93 vs $14,705.77 (P = 0.02)]. DOACs are associated with a significant cost benefit in patients admitted for blunt traumatic ICHs when compared with those on warfarin.

A Calculated Risk: Performing Laparoscopic Cholecystectomy for Acute Cholecystitis on Patients with End Stage Renal Disease

End-stage renal disease (ESRD) is a multifactorial disease linked to socioeconomic status and associated with worse surgical outcomes. We explore intraoperative and postoperative outcomes in patients with cholecystitis undergoing laparoscopic cholecystectomy (LC). The Nationwide Inpatient Sample from 2005 to 2012 was used to identify patients undergoing LC for cholecystitis using ICD-9 codes. Outcomes of interest were mortality, common bile duct injury, conversion to open, intraoperative complications, postoperative complications, length of stay (LOS), and total charge. Univariate analysis was performed using t test for continuous variables and chi-squared test for categorical variables. Multivariable models were created that adjusted for age, demographics, year of admission, comorbidities, and presence of ESRD. Of 225,058 patients that underwent LC, 2,115 had ESRD. On univariate analysis, the ESRD cohort had a higher incidence of mortality and complications: intraoperative, mechanical wound, respiratory, cardiovascular, and postoperative infections. ESRD patients had higher median LOS and total charge. Multivariate analysis showed ESRD as an independent risk factor for mortality, mechanical wound complications, and intraoperative complications. Negative binomial regression analysis showed that ESRD patients had LOS 50.4 per cent longer than non-ESRD patients. Linear regression analysis showed that, after adjustment, ESRD patients had total charge 6.82 per cent higher than non-ESRD patients. In this large retrospective analysis, we find that after adjusting for clinical, socioeconomic, and demographic variables, ESRD is an independent risk factor for increased mortality, intraoperative complications, mechanical wound complications, increased LOS, and cost for patients undergoing LC. Prospective studies exploring risk optimization strategies for patients with ESRD are warranted.

Early Blood Transfusions in Sepsis: Unchanged Survival and Increased Costs

BACKGROUND

Early red blood cell transfusions are a common treatment for adults hospitalized for sepsis without shock. However, their utility and association with mortality and costs have not been well studied.

OBJECTIVES

To examine early transfusion rates for patients with sepsis treated outside intensive care units, and to find a correlation between transfusion rates and survival rates and costs.

METHODS

Data were obtained from hospital members of the Premier Healthcare Alliance that admitted at least 50 adults with sepsis between January 1, 2006, and December 31, 2010. Early transfusion rates at each hospital were calculated as the observed incidence of allogeneic red blood cells administered by hospital day 2. A multivariable logistic regression model was constructed to estimate the expected or risk-adjusted transfusion rates, mortality rates, and costs.

RESULTS

A total of 256 396 adults were hospitalized with sepsis without major bleeding or surgery at 364 US hospitals. Approximately 84% of all patients admitted with sepsis, without vasopressor therapy, were treated outside the intensive care unit (by day 2). The mean institutional early transfusion rate was 6.9%. After risk standardization, the median (interquartile range) transfusion rate was 6.7% (5.8%-7.6%), mortality rate was 15.5% (13.1%-18.1%), and costs were $13 333 ($11 939-$14 986). Early transfusion rates were not correlated with mortality but were modestly positively correlated with costs (Spearman ρ = 0.157; P = .003).

CONCLUSIONS

Early transfusion rates during hospitalization for sepsis without shock varied widely across the hospitals. Transfusion rates were associated with increased costs but not with mortality rates.

Distribution and predictors of hospital charges for haemorrhagic stroke patients in Beijing, China, March 2012 to February 2015: a retrospective study

OBJECTIVES

The purpose of this study is to analyse hospital charges for patients with haemorrhagic stroke in China and investigate potential factors associated with inpatient charges.

METHODS

The study participants were in-hospital patients with a primary diagnosis of haemorrhagic stroke from all the secondary and tertiary hospitals in Beijing during the period from 1 March 2012 to 28 February 2015. Distribution characteristics of detailed hospital charges were analysed. The influence of potential factors on hospital charges was researched using a stepwise multiple regression model.

RESULTS

A total of 34 890 patients with haemorrhagic stroke of mean age 61.19±14.37 years were included in the study, of which 37.2% were female. Median length of hospital stay (LOHS) was 15 days (IQR 9-23) and median hospital cost was 18 577 Chinese yuan (CNY) (IQR 10 442-39 784). The hospital costs for patients in Western medicine hospitals (median 19 651 CNY) were significantly higher (P<0.01) than those in traditional Chinese medicine hospitals (median 14 560 CNY), and were significantly higher (P<0.01) for Level 3 hospitals (median 20 029 CNY) than for Level 2 hospitals (median 16 095 CNY). The proportion of medicine fees and bed fees within total hospital charges showed a decreasing trend during the study period. With stepwise multiple regression, the major factors associated with hospital charges were LOHS, surgery, pulmonary infection, ventilator usage, hospital level, occupation, hyperlipidaemia, hospital type, in-hospital death, sex and age.

CONCLUSION

We conclude that medicines form the largest part of hospital charges but are showing a decreasing trend, and LOHS is strongly associated with patient charges for haemorrhagic stroke in China. This implies that the cost structure is very unreasonable in China and medical technology costs fail to be fully manifested. A reasonable decrease in medicine charges and shortening LOHS may be effective ways to reduce hospital charges.

Trauma Surgeons Save Lives-Scribes Save Trauma Surgeons!

With the advent of the electronic medical record, the documentation burden of the trauma surgeon has become overwhelming. To help, our trauma division added scribes to the rounding team. We hypothesized that scribe utilization would improve our documentation efficiency and offer a financial benefit to the institution. A review of trauma surgeon documentation and billing was performed at a Level I trauma center over two time periods: January to May 2014 (no scribes) and January to May 2015 (scribes). The number of notes written by trauma surgeons was obtained, as were documentation charges. Documentation efficiency was determined by noting both the hour of the day in which inpatient progress notes were written and the number of notes written after patient discharge. In the 2014 period, a total of 9726 notes were written by trauma attendings. In the 2015 period, 10,933 were written. Despite having 407 fewer trauma patient-days in the 2015 period, the group wrote 343 notes/week versus 298 notes/week (P = 0.008). More inpatient progress notes were written earlier in the working day and fewer were written in the evening. Fewer notes were written after patient discharge (12.7 vs 8.4%). A total of 1,664 hours of scribe time were used over the 5-month period, generating an expense of $32,787. The additional notes generated by scribes resulted in $191,394 in charges. Conservatively, assuming a 20 per cent charge reimbursement, the cost of the scribes was covered. The addition of scribes to the daily trauma rounding team improved note efficiency and increased charge capture at our center.

Management trends of infantile hemangioma: A national perspective

INTRODUCTION

The primary management of infantile hemangioma (IH) has changed since 2008, with the initiation of propranolol. The change that propranolol has affected on resource utilization is unknown.

MATERIALS AND METHODS

The Kids' Inpatient Database (KID) in 2003, 2006, 2009, and 2012 was queried for ICD-9 codes for IH in children under age three. The number of patients undergoing the following procedures of interest: tracheostomy, tracheoscopy and laryngoscopy with biopsy, and excision of skin lesion were evaluated. Data was analyzed for demographics and details on the admission. Trends were identified. Weighted statistical analyses were performed with SAS 9.4.

RESULTS

The number of qualified admissions significantly increased over the years (9271 in 2003-12029 in 2012, OR 1.042 per year increase, p < 0.001). The mean age at admission ranged from 26 to 28 days but did not vary over time (p = 0.54). The percentage undergoing tracheostomy significantly decreased from 1.05% in 2003 to 0.27% in 2012 (p = 0.0055), and the percentage undergoing tracheoscopy and laryngoscopy with biopsy significantly decreased from 7.29% in 2003 to 4.20% in 2012 (p = 0.011) among those with IH of unspecified or other sites. The percentage undergoing skin lesion excision also significantly decreased from 1.87% in 2003 to 1.03%, in 2012 (p = 0.0038) among those with IH of skin and subcutaneous tissue. These findings suggest a potential impact of propranolol. After adjusting for inflation, the total hospital charges increased from a mean of $17,838 in 2003 to an adjusted mean of $41,306 in 2012 (p < 0.0001).

CONCLUSIONS

Total admissions and hospital charges in children with IH has increased from 2003 to 2012. The percentage of patients undergoing tracheostomy, tracheoscopy and laryngoscopy with biopsy, and skin lesion excision significantly decreased in 2012 compared to 2003, suggesting a potential impact of propranolol. Further studies are needed to examine these changes more closely.

Practice Patterns for Cholecystectomy After Endoscopic Retrograde Cholangiopancreatography for Patients With Choledocholithiasis

BACKGROUND & AIMS

Cholecystectomy (CCY) after an episode of choledocholithiasis requiring endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction reduces recurrent biliary events compared to expectant management. We studied practice patterns for performance of CCY after ERCP for choledocholithiasis using data from 3 large states and evaluated the effects of delaying CCY.

METHODS

We conducted a retrospective cohort study using the ambulatory surgery, inpatient, and emergency department databases from the states of California (years 2009-2011), New York (2011-2013), and Florida (2012-2014). We collected data from 4516 patients hospitalized with choledocholithiasis who underwent ERCP. We compared outcomes of patients who underwent CCY at index admission (early CCY), elective CCY within 60 days of discharge (delayed CCY), or did not undergo CCY (no CCY), calculating rate of recurrent biliary events (defined as an emergency department visit or unplanned hospitalization due to symptomatic cholelithiasis, cholecystitis, choledocholithiasis, cholangitis, or biliary pancreatitis), mortality, and cost by CCY cohort. We also evaluated risk factors for not undergoing CCY. The primary outcome measure was the rate of recurrent biliary events in the 365 days after discharge from index admission.

RESULTS

Of the patients who underwent ERCP for choledocholithiasis, 41.2% underwent early CCY, 10.9% underwent delayed CCY, and 48.0% underwent no CCY. Early CCY reduced relative risk of recurrent biliary events within 60 days by 92%, compared with delayed or no CCY (P < .001). After 60 days following discharge from index admission, patients with early CCY had an 87% lower risk of recurrent biliary events than patients with no CCY (P < .001) and patients with delayed CCY had an 88% lower risk of recurrent biliary events than patients with no CCY (P < .001). A strategy of delayed CCY performed on an outpatient basis was least costly. Performance of early CCY was inversely associated with low facility volume. Hispanic race, Asian race, Medicaid insurance, and no insurance associated inversely with performance of delayed CCY.

CONCLUSIONS

In a retrospective analysis of >4500 patients hospitalized with choledocholithiasis, we found that CCY was not performed after ERCP for almost half of the cases. Although early and delayed CCY equally reduce the risk of subsequent recurrent biliary events, patients are at 10-fold higher risk of recurrent biliary event while waiting for a delayed CCY compared with patients who underwent early CCY. Delayed CCY is a cost-effective strategy that must be balanced against the risk of loss to follow-up, particularly among patients who are ethnic minorities or have little or no health insurance.

Effect of Abdominal Ultrasound on Clinical Care, Outcomes, and Resource Use Among Children With Blunt Torso Trauma: A Randomized Clinical Trial

IMPORTANCE

The utility of the focused assessment with sonography for trauma (FAST) examination in children is unknown.

OBJECTIVE

To determine if the FAST examination during initial evaluation of injured children improves clinical care.

DESIGN, SETTING, AND PARTICIPANTS

A randomized clinical trial (April 2012-May 2015) that involved 975 hemodynamically stable children and adolescents younger than 18 years treated for blunt torso trauma at the University of California, Davis Medical Center, a level I trauma center.

INTERVENTIONS

Patients were randomly assigned to a standard trauma evaluation with the FAST examination by the treating ED physician or a standard trauma evaluation alone.

MAIN OUTCOMES AND MEASURES

Coprimary outcomes were rate of abdominal computed tomographic (CT) scans in the ED, missed intra-abdominal injuries, ED length of stay, and hospital charges.

RESULTS

Among the 925 patients who were randomized (mean [SD] age, 9.7 [5.3] years; 575 males [62%]), all completed the study. A total of 50 patients (5.4%, 95% CI, 4.0% to 7.1%) were diagnosed with intra-abdominal injuries, including 40 (80%; 95% CI, 66% to 90%) who had intraperitoneal fluid found on an abdominal CT scan, and 9 patients (0.97%; 95% CI, 0.44% to 1.8%) underwent laparotomy. The proportion of patients with abdominal CT scans was 241 of 460 (52.4%) in the FAST group and 254 of 465 (54.6%) in the standard care-only group (difference, -2.2%; 95% CI, -8.7% to 4.2%). One case of missed intra-abdominal injury occurred in a patient in the FAST group and none in the control group (difference, 0.2%; 95% CI, -0.6% to 1.2%). The mean ED length of stay was 6.03 hours in the FAST group and 6.07 hours in the standard care-only group (difference, -0.04 hours; 95% CI, -0.47 to 0.40 hours). Median hospital charges were $46 415 in the FAST group and $47 759 in the standard care-only group (difference, -$1180; 95% CI, -$6651 to $4291).

CONCLUSIONS AND RELEVANCE

Among hemodynamically stable children treated in an ED following blunt torso trauma, the use of FAST compared with standard care only did not improve clinical care, including use of resources; ED length of stay; missed intra-abdominal injuries; or hospital charges. These findings do not support the routine use of FAST in this setting.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01540318.

Increase in spinal deformity surgery in patients age 60 and older is not associated with increased complications

BACKGROUND CONTEXT

Surgical treatment for adult spinal deformity improves patient quality of life; however, trends in surgical utilization in the elderly, who may be at higher risk for complications, remain unclear.

PURPOSE

To identify trends in the utilization of adult deformity and determine complication rates among older patients.

STUDY DESIGN

This is a retrospective database analysis.

PATIENT SAMPLE

The Nationwide Inpatient Sample database was queried from 2004 to 2011 to identify adult patients who underwent spinal fusion of eight or more levels using International Classification of Diseases, Ninth Revision (ICD-9) coding.

OUTCOME MEASURES

Incidence of surgery, complication rates, length of stay, and total hospital charges.

METHODS

The incidence of surgery was normalized to United States census data by age group. Trends in complications, length of stay, and inflation-adjusted hospital charges were determined using linear regression and Cochran-Armitage trend testing.

RESULTS

An estimated 29,237 patients underwent adult spinal deformity surgery with an increase from 2,137 to 5,030 cases per year from 2004 to 2011. Surgical incidence among patients 60 years and older increased from 1.9 to 6.5 cases per 100,000 people from 2004 to 2011 (p<.001), whereas utilization in patients younger than 60 increased from 0.59 to 0.93. Linear regression revealed that the largest increase in surgical utilization was for patients aged 65-69 years with an increase of 0.68 patients per 100,000 people per year (p<.001), followed by patients aged 70-74 years with a rate of 0.56 patients per 100,000 people per year (p=.001). Overall complication rates were 22.5% in 2004 and 26.7% in 2011. Although complication risk increased with age (≥60 vs. <60: relative risk 1.91 [1.83, 1.99], p<.001), within-age group rates were stable over time. Mean length of stay was 9.6 days in 2004 and 9.0 days in 2011. Inflation-adjusted mean hospital charges increased from $171,517 in 2004 to $303,479 in 2011 (p<.001).

CONCLUSIONS

Operative management of adult spinal deformity increased 3.4-fold among patients ≥60 years from 2004 to 2011, with an associated 1.8-fold increase in hospital charges. Although the exact reasons for the striking increase in hospital charges remain unclear, some of the increase is likely related to decreasing reimbursement of charges by payors over the same period of time. The large majority of cases were performed in large academic centers, and growth in deformity trained spine specialists in these centers may have contributed to this trend. Despite the increased utilization of surgery for adult spinal deformity, in-hospital complications remained stable across all ages.