Incremental cost and length of stay associated with postprocedure delirium in transcatheter and surgical aortic valve replacement patients in the United States

The Influence of Audiovisual Distraction on Pain Reduction During Transcatheter Aortic Valve Implantation Under Monitored Anesthesia Care: A Prospective Randomized Trial

OBJECTIVES

To investigate the effect of an audiovisual distraction system on the dose of remifentanil for perioperative sedation during transcatheter aortic valve implantation under monitored anesthesia care.

DESIGN

Single-center prospective randomized nonblinded study.

SETTING

Tertiary referral academic hospital.

PARTICIPANTS

Ninety patients who underwent transfemoral transcatheter aortic valve implantation between July 2019 and July 2021.

INTERVENTIONS

Patients were randomized to use either a novel audiovisual distraction system during the intervention (n = 45) or standard care without an audiovisual distraction system (n = 45).

MEASUREMENTS AND MAIN RESULTS

Standardized questionnaires were given to each patient at admission and before and after the intervention to assess their levels of anxiety. Primary endpoints were the average and peak infusion rates of remifentanil. All patients were considered for the final analysis according to an intention-to-treat design. No relevant differences in pre- and postinterventional anxiety status were observed between the groups. Similarly, there were no significant differences in reported pain scores (p = 0.364). The average infusion rate (p = 0.028) and peak infusion rate (p = 0.025) of remifentanil were lower in the group with an audiovisual distraction system.

CONCLUSIONS

Audiovisual distraction is a useful adjunct to reduce the dose of remifentanil under monitored anesthesia care during transcatheter aortic valve implantation. Larger studies are needed to evaluate potential positive effects on patient satisfaction, incidence of delirium, and possible economic benefits.

Progression of Frailty and Cardiovascular Outcomes Among Medicare Beneficiaries

Background

Frailty is associated with adverse cardiovascular outcomes independent of age and comorbidities, yet the independent influence of frailty progression remains uncertain.

Methods

Medicare Fee-for-service beneficiaries ≥ 65 years at cohort inception with continuous enrollment from 2003-2015 were included. Frailty trajectory was measured by annualized change in a validated claims-based frailty index (CFI) over a 5-year period. Linear mixed effects models, adjusting for baseline frailty, were used to estimate CFI change over a 5-year period. Survival analysis was used to evaluate associations of frailty progression and future health outcomes (major adverse cardiovascular and cerebrovascular events [MACCE], all-cause death, heart failure, myocardial infarction, ischemic stroke, and days alive at home [DAH] within the following calendar year).

Results

26.4 million unique beneficiaries were included (mean age 75.4 ± 7.0 years, 57% female, 13% non-White). In total, 20% had frailty progression, 66% had no change in frailty, and 14% frailty regression over median follow-up of 2.4 years. Compared to those without a change in CFI, when adjusting for baseline frailty, those with frailty progression had significantly greater risk of incident MACCE (hazard ratio [HR] 2.30, 95% confidence interval [CI] 2.30-2.31), all-cause mortality (HR 1.59, 95% CI 1.58-1.59), acute myocardial infarction (HR 1.78, 95% CI 1.77-1.79), heart failure (HR 2.78, 95% CI 2.77-2.79), and stroke (HR 1.78, 95% CI 1.77-1.79). There was also a graded increase in risk of each outcome with more rapid progression and significantly fewer DAH with the most rapid vs. the slowest progression group (270.4 ± 112.3 vs. 308.6 ± 93.0 days, rate ratio 0.88, 95% CI 0.87-0.88, p < 0.001).

Conclusions

In this large, nationwide sample of Medicare beneficiaries, frailty progression, independent of baseline frailty, was associated with fewer DAH and a graded risk of MACCE, all-cause mortality, myocardial infarction, heart failure, and stroke compared to those without progression.

Update of the European Society of Anaesthesiology and Intensive Care Medicine evidence-based and consensus-based guideline on postoperative delirium in adult patients

Postoperative delirium (POD) remains a common, dangerous and resource-consuming adverse event but is often preventable. The whole peri-operative team can play a key role in its management. This update to the 2017 ESAIC Guideline on the prevention of POD is evidence-based and consensus-based and considers the literature between 01 April 2015, and 28 February 2022. The search terms of the broad literature search were identical to those used in the first version of the guideline published in 2017. POD was defined in accordance with the DSM-5 criteria. POD had to be measured with a validated POD screening tool, at least once per day for at least 3 days starting in the recovery room or postanaesthesia care unit on the day of surgery or, at latest, on postoperative day 1. Recent literature confirmed the pathogenic role of surgery-induced inflammation, and this concept reinforces the positive role of multicomponent strategies aimed to reduce the surgical stress response. Although some putative precipitating risk factors are not modifiable (length of surgery, surgical site), others (such as depth of anaesthesia, appropriate analgesia and haemodynamic stability) are under the control of the anaesthesiologists. Multicomponent preoperative, intra-operative and postoperative preventive measures showed potential to reduce the incidence and duration of POD, confirming the pivotal role of a comprehensive and team-based approach to improve patients' clinical and functional status.

Transcatheter Aortic Valve Replacement (TAVR) Versus Surgical Aortic Valve Replacement (SAVR): A Review on the Length of Stay, Cost, Comorbidities, and Procedural Complications

This review provides an in-depth analysis of the effect of length of stay (LOS), comorbidities, and procedural complications on the cost-effectiveness of transcatheter aortic valve replacement (TAVR) in comparison to surgical aortic valve replacement (SAVR). We found that the average LOS was shorter for patients undergoing TAVR, contributing to lower average costs associated with the procedure, although the LOS varied between patients due to the severity of illness and comorbidities present. TAVR has also been found to improve the quality of life for patients receiving aortic valve replacement compared to SAVR. Although TAVR has a lower rate of most post-operative complications caused by SAVR, such as bleeding and cardiac complications, TAVR shows an increased rate of permanent pacemaker (PPM) implantation due to mechanical trauma on the heart's conduction system. In addition, our findings suggest that the cost-effectiveness of each procedure varies based on the types of valve, the patient history of other medical conditions, and the procedural methods. Our findings show that TAVR is preferred over SAVR in terms of cost-effectiveness across a variety of patients with other coexisting medical conditions, including cancer, advanced kidney disease, cirrhosis, diabetes mellitus, and bundle branch block. TAVR also appears to be superior to SAVR with fewer post-operative complications. However, TAVR appears to have a higher rate of PPM implantation rates as compared to SAVR. The comorbidities of the valve recipient must be considered when deciding whether to use TAVR or SAVR as cost-effectiveness varies with the patient background.

Machine learning for prediction of delirium in patients with extensive burns after surgery

AIMS

Machine learning-based identification of key variables and prediction of postoperative delirium in patients with extensive burns.

METHODS

Five hundred and eighteen patients with extensive burns who underwent surgery were included and randomly divided into a training set, a validation set, and a testing set. Multifactorial logistic regression analysis was used to screen for significant variables. Nine prediction models were constructed in the training and validation sets (80% of dataset). The testing set (20% of dataset) was used to further evaluate the model. The area under the receiver operating curve (AUROC) was used to compare model performance. SHapley Additive exPlanations (SHAP) was used to interpret the best one and to externally validate it in another large tertiary hospital.

RESULTS

Seven variables were used in the development of nine prediction models: physical restraint, diabetes, sex, preoperative hemoglobin, acute physiological and chronic health assessment, time in the Burn Intensive Care Unit and total body surface area. Random Forest (RF) outperformed the other eight models in terms of predictive performance (ROC:84.00%) When external validation was performed, RF performed well (accuracy: 77.12%, sensitivity: 67.74% and specificity: 80.46%).

CONCLUSION

The first machine learning-based delirium prediction model for patients with extensive burns was successfully developed and validated. High-risk patients for delirium can be effectively identified and targeted interventions can be made to reduce the incidence of delirium.

Association of general anesthesia exposure with risk of postoperative delirium in patients receiving transcatheter aortic valve replacement: a meta-analysis and systematic review

The aim of this meta-analysis was to assess the association of general anesthesia (GA) exposure with the risk of POD in this patient population. Databases including Medline, EMBASE, Cochrane library, and Google Scholar were searched from inception to December 2022. Analysis of 17 studies published between 2015 and 2021 involving 10,678 individuals revealed an association of GA exposure with an elevated risk of POD [odd ratio (OR) = 1.846, 95% CI 1.329 to 2.563, p = 0.0003, I2 = 68.4%, 10,678 patients]. Subgroup analysis of the diagnostic methods also demonstrated a positive correlation between GA exposure and POD risk when validated methods were used for POD diagnosis (OR = 2.199, 95% CI 1.46 to 3.31, p = 0.0002). Meta-regression analyses showed no significant impact of age, male proportion, and sample size on the correlation between GA and the risk of POD. The reported overall incidence of POD from the included studies regardless of the type of anesthesia was between 0.8 and 27%. Our meta-analysis showed a pooled incidence of 10.3% (95% CI 7% to 15%). This meta-analysis suggested an association of general anesthesia with an elevated risk of postoperative delirium, implying the necessity of implementing appropriate prophylactic strategies against this complication when general anesthesia was used in this clinical setting.

Postoperative delirium after transcatheter aortic valve replacement: An updated systematic review and meta-analysis

AIMS

To perform an updated systematic review and meta-analysis of postoperative delirium (POD) after transcatheter aortic valve replacement (TAVR).

METHODS

We conducted a systematic literature search of PubMed, Embase, and Cochrane Library databases from the time of the first human TAVR procedure in 2002 until December 24, 2021, which was supplemented by manual searches of bibliographies. Data were collected on incidence rates, risk factors, and/or associated mortality of POD after TAVR. Pooled analyses were conducted using random effects models to yield mean differences, odds ratios, hazard ratios, and risk ratios, with 95% confidence intervals.

RESULTS

A total of 70 articles (69 studies) comprising 413,389 patients were included. The study heterogeneity was substantial. The pooled mean incidence of POD after TAVR in all included studies was 9.8% (95% CI: 8.7%-11.0%), whereas that in studies using validated tools to assess for delirium at least once a day for at least 2 consecutive days after TAVR was 20.7% (95% CI: 17.8%-23.7%). According to the level of evidence and results of meta-analysis, independent preoperative risk factors with a high level of evidence included increased age, male sex, prior stroke or transient ischemic attack, atrial fibrillation/flutter, weight loss, electrolyte abnormality, and impaired Instrumental Activities of Daily Living; intraoperative risk factors included non-transfemoral access and general anesthesia; and acute kidney injury was a postoperative risk factor. POD after TAVR was associated with significantly increased mortality (pooled unadjusted RR: 2.20, 95% CI: 1.79-2.71; pooled adjusted RR: 1.62, 95% CI: 1.25-2.10), particularly long-term mortality (pooled unadjusted HR: 2.84, 95% CI: 1.91-4.23; pooled adjusted HR: 1.88, 95% CI: 1.30-2.73).

CONCLUSIONS

POD after TAVR is common and is associated with an increased risk of mortality. Accurate identification of risk factors for POD after TAVR and implementation of preventive measures are critical to improve prognosis.

Volatile Versus Total Intravenous Anesthesia on Postoperative Delirium in Adult Patients Undergoing Cardiac Valve Surgery: A Randomized Clinical Trial

BACKGROUND

The effect of anesthesia regimens on postoperative delirium after on-pump cardiac valve surgery is yet undetermined. This study aimed to evaluate the effect of volatile anesthesia compared with propofol-based total intravenous anesthesia (TIVA) on the occurrence of delirium after on-pump cardiac valve surgery.

METHODS

This randomized clinical trial was conducted at a university academic hospital in China, from February 2019 to January 2021. Patients scheduled for on-pump cardiac valve surgery or combined valve with coronary artery bypass grafting (CABG) surgeries were randomly assigned to receive anesthesia maintenance with either a volatile anesthetic (sevoflurane or desflurane) or propofol-based TIVA. The primary outcome was the incidence of delirium during the first 7 days after surgery, assessed using the confusion assessment method for the intensive care unit (ICU). The secondary outcomes included duration of delirium, subtypes of delirium, 30-day mortality, pain score, major morbidity (including cerebral infarction, respiratory failure, and pneumonia), duration of mechanical ventilation, and lengths of ICU and hospital stay. The statistical analysis of the primary outcome variable was by Pearson's χ 2 test.

RESULTS

Among the 684 patients analyzed (mean age, 53.8 years; 381 [55.7%] women), 676 were assessed for the primary outcome. Postoperative delirium occurred in 63 of 337 (18.7%) patients receiving volatile anesthesia versus 76 of 339 (22.4%) patients receiving propofol-based TIVA (relative risk, 0.80; 95% confidence interval [CI], 0.55-1.16; P = .231). There were no significant differences between the groups in any of the secondary outcomes.

CONCLUSIONS

Among patients undergoing on-pump cardiac valve surgery, anesthesia maintenance with a volatile agent did not result in significantly fewer occurrences of postoperative delirium than propofol-based TIVA.

Incremental medical cost of delirium in elderly patients with cognitive impairment: analysis of a nationwide administrative database in Japan

OBJECTIVES

Delirium is a neuropsychiatric disorder that commonly occurs in elderly patients with cognitive impairment. The economic burden of delirium in Japan has not been well characterised. In this study, we assessed incremental medical costs of delirium in hospitalised elderly Japanese patients with cognitive impairment.

DESIGN

Retrospective, cross-sectional, observational study.

SETTING

Administrative data collected from acute care hospitals in Japan between April 2012 and September 2020.

PARTICIPANTS

Hospitalised patients ≥65 years old with cognitive impairment were categorised into groups-with and without delirium. Delirium was identified using a delirium identification algorithm based on the International Classification of Diseases 10^th Revision codes or antipsychotic prescriptions.

OUTCOME MEASURES

Total medical costs during hospitalisation were compared between the groups using a generalised linear model.

RESULTS

The study identified 297 600 hospitalised patients ≥65 years of age with cognitive impairment: 39 836 had delirium and 257 764 did not. Patient characteristics such as age, sex, inpatient department and comorbidities were similar between groups. Mean (SD) unadjusted total medical cost during hospitalisation was 979 907.7 (871 366.4) yen for patients with delirium and 816 137.0 (794 745.9) yen for patients without delirium. Adjusted total medical cost was significantly greater for patients with delirium compared with those without delirium (cost ratio=1.09, 95% CI: 1.09 to 1.10; p<0.001). Subgroup analyses revealed significantly higher total medical costs for patients with delirium compared with those without delirium in most subgroups except patients with hemiplegia or paraplegia.

CONCLUSIONS

Medical costs during hospitalisation were significantly higher for patients with delirium compared with those without delirium in elderly Japanese patients with cognitive impairment, regardless of patient subgroups such as age, sex, intensive care unit admission and most comorbidities. These findings suggest that delirium prevention strategies are critical to reducing the economic burden as well as psychological/physiological burden in cognitively impaired elderly patients in Japan.

Hospitalisation costs and health related quality of life in delirious patients: a scoping review

INTRODUCTION

Delirium is a common condition of a global disturbance of cognition, triggered by underlying diseases. The objective of this study is to review the current evidence in the literature on direct healthcare costs and health-related quality of life (HRQOL) associated with delirium.

METHODS

A systematic search was conducted in PubMed and Embase for relevant studies published between January 1, 2010 and November 4, 2021. Studies for inclusion reported estimates on healthcare costs or HRQOL, adjusted for relevant confounding factors.

RESULTS

Fourteen studies on healthcare costs and eleven studies on HRQOL were included. Delirium resulted in (adjusted) increased costs ranging from $1,532 to $22,269 depending on included cost categories, the country and the type of hospital department. Increased length of stay for delirious patients ranged from 2.5 days to 10.4 days and had the largest contribution to overall, direct incremental costs. Heterogeneity was observed in HRQOL outcomes.

CONCLUSION

The analysis indicates that the presence of a delirium episode may lead to increased costs of hospitalisation. Changes in HRQOL due to delirium are not well demonstrated and more research is needed to determine the effect of delirium on HRQOL.

Research progress on risk factors of delirium in burn patients: A narrative review

Delirium, an acute brain dysfunction, is a common and serious complication in burn patients. The occurrence of delirium increases the difficulty of patient treatment, is associated with various adverse outcomes, and increases the burden on the patient's family. Many scholars have studied the factors that cause delirium, but the causes, pathogenesis, and treatment of delirium in burn patients have not been fully revealed. There is no effective pharmacological treatment for delirium, but active preventive measures can effectively reduce the incidence of delirium in burn patients. Therefore, it is necessary to study the relevant factors affecting the occurrence of delirium in burn patients. This study was conducted on December 20, 2021 by searching the PubMed database for a narrative review of published studies. The search strategy included keywords related to "burns," "delirium," and "risk factors." We reviewed the characteristics of delirium occurrence in burn patients and various delirium assessment tools, and summarized the risk factors for the development of delirium in burn patients in terms of personal, clinical, and environmental factors, and we found that although many risk factors act on the development of delirium in burn patients, some of them, such as clinical and environmental factors, are modifiable, suggesting that we can estimate the exposure of burn patients to risk factors by assessing their likelihood of delirium occurring and to make targeted interventions that provide a theoretical basis for the prevention and treatment of burn delirium.

Length of Stay in Older Patients Undergoing Transcatheter Aortic Valve Replacement: Value of a Geriatric Approach

BACKGROUND

For patients with transcatheter aortic valve replacement (TAVR), increased length of stay (LOS) is associated with increased long-term mortality. The main objective of our study was to analyze the association between geriatrics factors and the hospital LOS for older patients undergoing TAVR for severe aortic stenosis.

METHODS

This retrospective single-center study included all patients aged ≥75 who underwent TAVR between January 2018 and January 2019. Hospital LOS and postoperative complications were analyzed regarding the geriatric factors recorded during a systematic preoperative, comprehensive geriatric assessment (CGA). The individualized-care plans established after the preoperative CGA were also analyzed.

RESULTS

median LOS of the 196 patients included was 6 days (interquartile range: 4-8), and 29% of patients had prolonged LOS. In a multivariable analysis, the preoperative factors associated with a prolonged hospital LOS were EuroSCORE I (p value = 0.02), prior major neurocognitive disorders (p value = 0.01), femoral access (p value <0.001), all complications (p value <0.001), and discharge in a rehabilitation center (p value <0.001). One-fourth (27%) of the patients had at least 1 geriatric complication. After CGA, 69 patients did not need any geriatric recommendation, whereas for the 127 other patients, an individualized-care plan was established but only 46 (36%) of them were followed up.

CONCLUSION

Our results favor the preoperative screening for major neurocognitive disorders in order to reduce LOS. Furthermore, the proposed individual-care plans after CGA were poorly followed. Practitioners may perceive the preoperative CGA as a screening tool, but its primary objective is to develop an individualized-care plan as a prehabilitation plan in order to optimize the physical, functional, and social issues.

Validation of E-PRE-DELIRIC in cardiac surgical ICU delirium: A retrospective cohort study

BACKGROUND

The early prediction model for delirium in intensive care units (ICUs)-E-PRE-DELIRIC-has been created to predict delirium development during the length of stay in ICUs. However, there have been few early predictive models for delirium in the cardiac surgical ICU (CSICU), and the predictive ability of the E-PRE-DELIRIC among patients following cardiac surgeries is still unknown.

AIMS AND OBJECTIVES

To validate the performance of E-PRE-DELIRIC in CSICU.

DESIGN

A retrospective cohort study.

METHODS

Data were retrospectively extracted from the electronic records for patients admitted in CSICU from January 2018 to December 2018 in a tertiary teaching hospital in China. Adult patients were included following the criteria of the E-PRE-DELIRIC model. Predictors, including age, history of cognitive impairment, history of alcohol abuse, urgent admission, use of corticosteroids, respiratory failure, blood urea nitrogen, and mean arterial pressure, at the time of ICU admission were retrieved, and delirium was assessed twice a day using the Confusion Assessment Method for the ICU. The performance of the E-PRE-DELIRIC model was evaluated by area under receiver operator characteristic curve, precision-recall curve (AUPRC), Hosmer-Lemeshow (HL) test, and calibration belt.

RESULTS

Of the 725 patients included, 120 (16.6%) developed delirium. The AUROC was 0.54 (95% confidence interval [CI], 0.48-0.59), and the AUPRC was 0.18 (95% CI, 0.12-0.20). The HL test showed a significant difference between predicted probability and delirium occurrence (χ² = 17.326, P = .027), and the overestimation chance of the E-PRE-DELIRIC score was 0.24 to 0.43.

CONCLUSION

The E-PRE-DELIRIC model has poor-to-fair predictive value in this study; thus, its application among the CSICU patients is limited. Development of reliable and validated tools for early prediction of delirium in CSICU is required.

RELEVANCE TO CLINICAL PRACTICE

Early prediction of delirium risk at CSICU admission is of vital importance and could provide timely information to caregivers. However, the E-PRE-DELIRIC model should be applied cautiously in the CSICU because of the significant probability of over-estimating the risk of developing delirium.

Implementation of the "awakening and breathing trials, choice of drugs, delirium management, and early exercise/mobility" bundle in the pediatric intensive care unit of tertiary hospitals in southwestern China: a cross-sectional survey

Objective

To investigate management and implementation of the “awakening and breathing trials, choice of drugs, delirium management, and early exercise/mobility” (ABCDE) bundle in the pediatric intensive care unit (PICU) in southwestern China

Methods

A self-designed questionnaire for determining implementation of the ABCDE bundle was distributed to healthcare professionals in the PICU. Multiple linear regression was used to analyze results.

Results

A total of 270 questionnaires were collected. There was no significant difference in the awareness of the ABCDE bundle rate among Sichuan, Guizhou, and Yunnan workers. Only dynamic adjustment of drug dose accounted for more than half (55.5%) of “frequent implementation” and “general implementation”, followed by implementation of sedation assessment, pain assessment, and spontaneous breathing trials (46.4%, 39.3%, and 35.6%, respectively). A total of 80.4% of healthcare professionals never performed screening of delirium. Multivariate analysis showed that the healthcare professionals’ scores of ABCDE bundle behavior significantly differed regarding awareness of the ABCDE bundle, years of work at the hospital, the region of hospitals, and occupational category.

Conclusion

Implementation of the ABCDE bundle in the PICU in southwestern China is not sufficient. Existing problems need to be identified and a standardized sedation and analgesia management model needs to be established.

Incidence, Risk Factors and Impact on Long-Term Outcome of Postoperative Delirium After Transcatheter Aortic Valve Replacement

Background: The aim of the present study was to analyze incidence, risk factors, and association with long-term outcome of postoperative delirium (POD) after transcatheter aortic valve replacement (TAVR).

Methods: Six hundred and sixty one consecutive patients undergoing TAVR were prospectively enrolled from January 2016 to December 2017. POD was assessed regularly during ICU-stay using the CAM-ICU test.

Results: The incidence of POD was 10.0% (n = 66). Patients developing POD were predominantly male (65%), had higher EuroSCORE II (5.4% vs. 3.9%; P = 0.041) and were more often considered frail (70% vs. 26%; P < 0.001). POD was associated with more peri-procedural complications including vascular complications (19.7 vs. 9.4; P = 0.017), bleeding (12.1 vs. 5.4%; P = 0.0495); stroke (4.5 vs. 0.7%; P = 0.025), respiratory failure requiring ventilation (16.7% vs. 1.8%; P < 0.001), and pneumonia (34.8% vs. 7.1%; P < 0.001). Consequently, patients with POD had significantly longer ICU- (7.9 vs. 3.2 days P < 0.001) and hospital-stay (14.9 vs. 9.0 days; P < 0.001), and higher in-hospital mortality (6.1 vs. 2.1%; P = 0.017). Logistic regression analysis identified male sex (odds ratio (OR) 2.2 [95% confidence interval (CI) 1.2–4.0); P = 0.012], atrial fibrillation [OR 3.0 (CI 1.6–5.6); P < 0.001], frailty [OR 4.3 (CI 2.4–7.9); P < 0.001], pneumonia [OR 4.4 (CI 2.3–8.7); P < 0.001], stroke [OR 7.0 (CI 1.2–41.6); P = 0.031], vascular complication [OR 2.9 (CI 1.3–6.3); P = 0.007], and general anesthesia [OR 2.0 (CI 1.0–3.7); P = 0.039] as independent predictors of POD. On Cox proportional hazard analysis POD emerged as a significant predictor of 2-year mortality [HR 1.89 (CI 1.06–3.36); P = 0.030].

Conclusion: POD is a frequent finding after TAVR and is significantly associated with reduced 2-year survival. Predictors of delirium include not only peri-procedural parameters like stroke, pneumonia, vascular complications and general anesthesia but also baseline characteristics as male sex, atrial fibrillation and frailty.

The economic cost of delirium: A systematic review and quality assessment

INTRODUCTION

This review aims to systematically identify and appraise the methodological quality of claims on the cost of delirium; and discuss challenges and opportunities for improvements in the precision of the estimates.

METHODS

Searches of scientific papers and gray literature were performed up until June 2020. The Larg and Moss checklist was used to assess the methodological quality of the included studies.

RESULTS

After deduplication, the search identified 317 potentially relevant articles, of which 17 articles were eligible for inclusion. After adjusting for inflation and common currency, the cost of delirium ranged between $806 and $24,509 (in 2019 US$).

DISCUSSION

This review found significant variation among the cost estimates and methodological quality. There has been limited focus on dementia as a sequela of delirium in terms of economic implications, but recent evidence suggests cost implications of delirium may be 52% higher when dementia is considered.

Delirium diagnostic tool-provisional (DDT-Pro) scores in delirium, subsyndromal delirium and no delirium

OBJECTIVE

To evaluate whether the Delirium Diagnostic Tool-Provisional (DDT-Pro), a 0-9 point scale with three items each representing symptoms from delirium's three core domains, differentiates subsyndromal delirium (SSD) from delirium and no delirium.

METHODS

We applied cluster analyses of DDT-Pro scores from 200 consecutive inpatients using three reference standards for delirium diagnosis to determine DDT-Pro cutoff values for delirium, SSD and no delirium groups. Clinical validators and DDT-Pro item scores were compared among groups.

RESULTS

DDT-Pro SSD range was 6-7 (n = 54), with no delirium having higher scores (n = 98) and delirium lower (n = 48). Dementia prevalence in the SSD group (40.7%) was intermediate between no delirium (20.4%) and delirium (66.7%). SSD and delirium groups were more affected than no delirium regarding medical comorbidities, hospital stay (no delirium <1 week, SSD and delirium >1 week) and mortality (SSD = 7.4%, delirium = 18.8%, no delirium = 1%). Values for motor subtypes, frontal lobe signs, and DRS-R98 in the SSD group were intermediate between no delirium and delirium, as well as for the DDT-Pro items (all p < 0.05).

CONCLUSIONS

All DDT-Pro items, which represent the three delirium core domains, are important for SSD diagnosis. Patients scoring in the SSD 6-7 range have significant clinical and prognostic features and deserve clinical attention.

The Association of Economic Outcome and Geriatric Syndromes among Older Adults with Transcatheter Aortic Valve Replacement (TAVR)

BACKGROUND

The association of geriatric syndromes and economic outcomes among patients who are undergoing transcatheter aortic valve replacement (TAVR) remains unknown.

METHODS AND RESULTS

A retrospective observational study using the National Inpatient Sample (NIS) from 2011 to 2014 was conducted with 7078 patients who were 65 years or older and underwent TAVR. The average hospital cost was US$58 703 (± SD 29 777) and length of stay (LOS) was 8.1 days (±7.20). The rates of delirium, dementia, and frailty were 8.0%, 6.1%, and 10.5%, respectively. From a multivariable generalized linear regression, delirium increased the cost by 31.5% (95% CI 25.41~37.92) and LOS by 70.3% (95% CI 60.20~83.38). Frailty increased the cost by 7.4% (95% CI 3.44~11.53) and the LOS by 22.6% (95% CI 15.15~30.55). Dementia had no significant association with either outcome. When the interactions of the geriatric syndromes were tested for association with the outcomes, delirium in the absence of dementia but presence of frailty showed the strongest association with cost (increase by 45.1%, 95% CI 26.45~66.45), and delirium in the absence of both dementia and frailty showed the strongest association with LOS (increase by 74.5%, 95% CI 62.71~87.13). When the average hospital cost and LOS were predicted using the model with interaction terms, patients with delirium and frailty (but without dementia) had the highest value (total hospital cost US$86 503 and LOS 14.9 days).

CONCLUSION

Among TAVR patients, delirium was significantly associated with increased hospital cost and LOS, and the association was significantly higher in the absence of dementia. The results of this study will be a great asset for health care providers and administrators in planning for efficient care strategy to lower health care expenditure in the hospital for older adults who underwent TAVR.

Economic Burden of Postoperative Neurocognitive Disorders Among US Medicare Patients

IMPORTANCE

Postoperative neurocognitive disorders (PNDs) after surgical procedures are common and may be associated with increased health care expenditures.

OBJECTIVE

To quantify the economic burden associated with a PND diagnosis in 1 year following surgical treatment among older patients in the United States.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used claims data from the Bundled Payments for Care Improvement Advanced Model from 4285 hospitals that submitted Medicare Fee-for-service (FFS) claims between January 2013 and December 2016. All Medicare patients aged 65 years or older who underwent an inpatient hospital admission associated with a surgical procedure, did not experience a PND before index admission, and were not undergoing dialysis or concurrently enrolled in Medicaid were included. Data were analyzed from October 2019 and May 2020.

EXPOSURES

PND, defined as an International Classification of Diseases, Ninth or Tenth Revision, diagnosis of delirium, mild cognitive impairment, or dementia within 1 year of discharge from the index surgical admission.

MAIN OUTCOMES AND MEASURES

The primary outcome was total inflation-adjusted Medicare postacute care payments within 1 year after the index surgical procedure.

RESULTS

A total of 2 380 473 patients (mean [SD] age, 75.36 (7.31) years; 1 336 736 [56.1%] women) who underwent surgical procedures were included, of whom 44 974 patients (1.9%) were diagnosed with a PND. Among all patients, most were White (2 142 157 patients [90.0%]), presenting for orthopedic surgery (1 523 782 patients [64.0%]) in urban medical centers (2 179 893 patients [91.6%]) that were private nonprofits (1 798 749 patients [75.6%]). Patients with a PND, compared with those without a PND, experienced a significantly longer hospital length of stay (mean [SD], 5.91 [6.01] days vs 4.29 [4.18] days; P < .001), were less likely to be discharged home (9947 patients [22.1%] vs 914 925 patients [39.2%]; P < .001), and had a higher incidence of mortality at 1 year after treatment (4580 patients [10.2%] vs 103 767 patients [4.4%]; P < .001). After adjusting for patient and hospital characteristics, the presence of a PND within 1 year of the index procedure was associated with an increase of $17 275 (95% CI, $17 058-$17 491) in cost in the 1-year postadmission period (P < .001).

CONCLUSIONS AND RELEVANCE

The findings of this cohort study suggest that among older Medicare patients undergoing surgical treatment, a diagnosis of a PND was associated with an increase in health care costs for up to 1 year following the surgical procedure. Given the magnitude of this cost burden, PNDs represent an appealing target for risk mitigation and improvement in value-based health care.

Costs of postoperative delirium with transcatheter aortic valve replacement: Improved yet still present

Transcatheter aortic valve replacement (TAVR) is associated with a lower risk of postoperative delirium (PD) than surgical aortic valve replacement (SAVR) in patients aged ≥80, based on billing codes. Postoperative delirium remains a frequent problem after both SAVR and TAVR in clinical series and is costly. Improved pre-procedural prediction of PD risk would improve targeting of clinical care and allow testing of preventative and management strategies.