Inpatient Hospital Charge Variability of U.S. Hospitals

Pricing of hospital services: evidence from a thematic review

The management implications of pricing healthcare services, especially hospitals, have received insufficient scholarly attention. Additionally, disciplinary overlaps have led to scattered academic efforts in this domain. This study performs a thematic synthesis of the literature and applies retrospective analysis to hospital service pricing articles to address these issues. The study's inputs were sourced from well-known online repositories, using a structured search string and PRISMA flow chart to select the pertinent documents. Our thematic analysis of pricing literature encompasses: (a) comprehension of hospital service pricing nature; (b) pricing objectives, strategies and practices differentiation; (c) presentation of factors impacting hospital service pricing. We observe that hospital pricing is an intricate and unclear matter. The terms 'pricing strategies' and 'pricing practices' are often used interchangeably in academic literature. Hospital service pricing is influenced by costs, demand and supply factors, market structure, pricing regulation and third-party reimbursements. The study's findings provide policy implications for service pricing in hospitals, in addition to suggesting avenues for future research on hospital pricing.

Burden and Characteristics of Revision Total Knee Arthroplasty in China: a National Study Based on Hospitalized Cases

BACKGROUND

National epidemiological data in China are absent for revision total knee arthroplasty (TKA). This study aimed to investigate the burden and characteristics of revision TKA in China.

METHODS

We reviewed 4,503 revision TKA cases registered in the Hospital Quality Monitoring System in China between 2013 and 2018 using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Revision burden was determined by the ratio of the number of revision procedures to the total number of TKA procedures. Demographic characteristics, hospital characteristics, and hospitalization charges were identified.

RESULTS

The revision TKA cases accounted for 2.4% of all TKA cases. The revision burden showed an increasing trend from 2013 to 2018 (2.3 to 2.5%) (P for trend = 0.034). Gradual increases in revision TKA were observed in patients aged > 60 years. The most common causes for revision TKA were infection (33.0%) and mechanical failure (19.5%). More than 70% of the patients were hospitalized in provincial hospitals. A total of 17.6% patients were hospitalized in a hospital outside the province of their residence. The hospitalization charges continued to increase between 2013 and 2015 and remained roughly stable over the next three years.

CONCLUSIONS

This study provided epidemiological data for revision TKA in China based on a national database. There was a growing trend of revision burden during the study period. The focalized nature of operations in a few higher volume regions was observed and many patients had to travel to obtain their revision procedure.

Hospital Charges Are Not Associated With Episode-of-Care Costs or Complications After Total Joint Arthroplasty

BACKGROUND

The Centers for Medicare and Medicaid Services (CMS) now requires hospitals to publish charges for commonly performed procedures. This study aimed to evaluate compliance with the price transparency mandate and to determine if there is a correlation between hospital charges and episode-of-care claims costs and outcomes after total hip arthroplasty (THA) and total knee arthroplasty (TKA).

METHODS

We identified a consecutive series of 2476 Medicare patients who underwent primary THA or TKA from 2018 to 2019 at one of 18 hospitals. Each hospital website was explored to assess compliance with the new price transparency requirements. Demographics, comorbidities, complications, and readmissions were recorded. Ninety-day episode-of-care claims costs were calculated using CMS claims data. Multivariate regression was performed to determine whether hospital charges had any association with complications, readmissions, or episode-of-care costs.

RESULTS

There was no correlation between published hospital charges and inpatient costs (r = 0.087), postacute care costs (r = 0.126), or episode-of-care costs (r = 0.131). When controlling for demographics and comorbidities, there was no association between published charges and complications (P = .433) or readmissions (P = .141). All hospitals posted some shoppable services information online, but only 7 (39%) were fully compliant by publishing all price data. Of the 11 hospitals (61%) publishing hospital THA and TKA charges, the mean charge was $48,325 (range, $12,625-$79,531).

CONCLUSION

Published charges for TKA and THA had no correlation with episode-of-care claims costs and were not associated with clinical outcomes. Despite efforts by CMS to increase price transparency, few hospitals were fully compliant, and a wide range in published charges was found.

Outpatient Operative Management of Pediatric Supracondylar Humerus Fractures: An Analysis of Frequency, Complications, and Cost From 2009 to 2018

BACKGROUND

In an effort to increase the value of health care in the United States, there has been increased focus on shifting certain procedures to an outpatient setting. While pediatric supracondylar humerus fractures (SCHFs) have traditionally been treated in an inpatient setting, recent studies have investigated the safety and efficiency of outpatient surgery for these injuries. This retrospective study aims to examine ongoing trends of outpatient surgical care for SCHFs, examine the safety and complication rates of these procedures, and investigate the potential cost-savings from this shift in care.

METHODS

Pediatric patients less than 13 years old who underwent surgery for closed SCHF from 2009 to 2018 were identified using International Classification of Diseases-9/10 Clinical Modification and Procedural Classification System codes in the New York Statewide Planning and Research Cooperative System (SPARCS) database. Linear regression was used to assess the shift in proportion of outpatient surgical management of these injuries over time. Multivariable Cox proportional hazards regression was used to compare return to emergency department (ED) visit, readmission, reoperation, and other adverse events. A 2-sample t test was performed on the average charge amount per claim for inpatient versus outpatient surgery.

RESULTS

A total of 8488 patients were included in the analysis showing there was a statistically significant shift towards outpatient management between 2009 (23% outpatient) and 2018 (59% outpatient) (P<0.0001). Relative to inpatient surgical management, outpatient surgical management had lower rates of return ED visits at 1 month (hazard ratio: 0.744, P=0.048). All other adverse events compared across inpatient and outpatient surgical management were not significantly different. The median amount billed per claim for inpatient surgeries was significantly higher than for outpatient surgeries ($16,097 vs. $9,752, P<0.0001). White race, female sex, and weekday ED visit were associated with increased rate of outpatient management.

CONCLUSIONS

This study demonstrates the trend of increasing outpatient surgical management of pediatric SCHF from 2009 to 2018. The increased rate of outpatient management has not been associated with elevated complication rates but is associated with significantly reduced health care charges.

LEVEL OF EVIDENCE

Level III-retrospective cohort.

Economic Implications of Chinese Diagnosis-Related Group-Based Payment Systems for Critically Ill Patients in ICUs

OBJECTIVES

To evaluate the economic implications of payments based on Chinese diagnosis-related groups for critically ill patients in ICUs in terms of total hospital expenditure, out-of-pocket payments, and length of stay.

DESIGN

A pre-post comparison of patient cohorts admitted to ICUs 1 year before and 1 year after Chinese diagnosis-related group reform was undertaken. Demographic characteristics, clinical data, and medical expenditures were collated from a health insurance database.

SETTING

Twenty-two public hospitals in Sanming, Southern China.

PATIENTS

All patients admitted to ICUs from January 1, 2017, to December 31, 2018.

INTERVENTION

The implementation of Chinese diagnosis-related group-based payments on January 1, 2018.

MEASUREMENTS AND MAIN RESULTS

Economic variables (total expenditures, out-of-pocket payments, and length of stay) were calculated for each patient from the day of hospital admission to the day of hospital discharge. Adjusted mean out-of-pocket payment estimates were 29.46% (p < 0.001) lower following reform. Adjusted mean out-of-pocket payments fell by 41.32% for patients in neonatal ICU, whereas there were no significant decreases in out-of-pocket payments for patients in PICU and adult ICU. Furthermore, adjusted mean out-of-pocket payments decreased by 55.74% in secondary hospitals, but there was no significant change in tertiary hospitals after Chinese diagnosis-related group reform. No significant changes were found in total expenditures and length of stay.

CONCLUSIONS

Chinese diagnosis-related group policy provided an opportunity for critically ill patients in ICUs to achieve at least short-term financial benefits in reducing out-of-pocket payments, without affecting the total expenditures and length of stay. Chinese diagnosis-related group-based payment significantly relieved financial burdens for patients with lower illness severities, such as patients in neonatal ICU. The results of this study can offer significant insights for policymakers in reducing the financial burden on critically ill patients, both in China and in other countries with similar systems.

Estimation of healthcare-related charges in women with BRCA mutations and breast cancer

Background

Breast cancer costs were estimated at $16.5 billion in 2010 and were higher than other cancer costs. There are limited studies on breast cancer charges and costs by BRCA mutations and receptor status. We examined overall health care and breast cancer-related charges by BRCA status (BRCAm vs. BRCAwt), receptor status (HER2+ vs. HER2-), and treatment setting (neoadjuvant vs. adjuvant).

Methods

Retrospective cohort study of charge data from 1995-2014 in an academic medical center. Facilities, physician, pharmacy, and diagnosis-related charges were presented as mean and median charges with standard deviation (SD) and interquartile ranges (25%-75%). Wilcoxon rank-sum test was used to assess statistically significant differences in charges between comparators.

Results

Total median breast-cancer related charges were $65,414 for BRCAm and $54,635 for BRCAwt (p=0.19); however all-cause charges were higher for BRCAm patients ($145,066 vs. $119,119, p<0.001). HER2+ status was associated with higher median breast cancer charges ($152,159 vs. $44,087, p<0.0001) that was driven by the charges for biological agents. Patients initially seen in the neoadjuvant setting had higher mean breast cancer charges than in the adjuvant setting ($117,922 vs. $80,061, p<0.0001).

Conclusion

BRCA mutation status was not associated with higher breast cancer charges but HER2+ status had significantly higher charges, due to charges for biological agents. Patients who initially received neoadjuvant treatment had significantly higher overall treatment charges than adjuvant therapy patients. With the advent of novel therapies for BRCAm, the economic impact of these treatments will be important to consider relative to their survival benefits.

A Systematic Review of Medical Costs Associated with Heart Failure in the USA (2014-2020)

BACKGROUND

Heart failure presents a growing clinical and economic burden in the USA. Robust cost data on the burden of illness are critical to inform economic evaluations of new therapeutic interventions.

OBJECTIVES

This systematic literature review of heart failure-related costs in the USA aimed to assess the quality of the published evidence and provide a narrative synthesis of current data.

METHODS

Four electronic databases (MEDLINE, EMBASE, EconLit, and the Centre for Reviews and Dissemination York Database, including the NHS Economic Evaluation Database and Health Technology Assessment Database) were searched for journal articles published between January 2014 and March 2020. The review, registered with PROSPERO (CRD42019134201), was restricted to cost-of-illness studies in adults with heart failure events in the USA.

RESULTS

Eighty-seven studies were included, 41 of which allowed a comparison of cost estimates across studies. The annual median total medical costs for heart failure care were estimated at $24,383 per patient, with heart failure-specific hospitalizations driving costs (median $15,879 per patient). Analyses of subgroups revealed that heart failure-related costs are highly sensitive to individual patient characteristics (such as the presence of comorbidities and age) with large variations even within a subgroup. Additionally, differences in study design and a lack of standardized reporting limited the ability to compare cost estimates. The finding that costs are higher for patients with heart failure with reduced ejection fraction compared with patients with preserved ejection fraction highlights the need for differentiating among different heart failure types.

CONCLUSIONS

The review underpins the conclusion drawn in earlier reviews, namely that hospitalization costs are the key driver of heart failure-related costs. Analyses of subgroups provide a clearer understanding of sources of heterogeneity in cost data. While current cost estimates provide useful indications of economic burden, understanding the nuances of the data is critical to support its application.

Vascular Complications Increase Hospital Charges and Mortality in Adult Patients on Extracorporeal Membrane Oxygenation in the United States

Patients on extracorporeal membrane oxygenation (ECMO) who suffer vascular complications frequently accrue additional procedures and costs. We sought to evaluate the effect of ECMO-related vascular complications on hospital charges and in-hospital mortality. Adult discharges involving ECMO from 2004 to 2013 in the National Inpatient Sample were examined. There were 12,636 patients in the cohort. Vascular complications, focusing on arterial complications were identified using ICD-9-CM diagnosis and procedure codes. A multivariable survey linear regression model using median hospital charges was used to model the effect of vascular complications on charges. We used multivariable survey logistic regression to evaluate the effect of vascular complications on in-hospital mortality. Of the 12,636 patients examined, 6467 (51.2%) had ECMO-related vascular complications. Median charges in patients with vascular complications were $ 477,363 (interquartile range: 258,660-875,823) and were $ 282,298 (interquartile range: 130,030-578,027) without vascular complications. On multivariable analysis, patients with vascular complications had 24% higher median charges than patients without vascular complications (Ratio: 1.24; 95% confidence interval [CI]: 1.16-1.33; P < 0.0001) and 34% higher odds of experiencing in-hospital mortality than patients without vascular complications (adjusted odds ratio: 1.34; 95% CI:1.08-1.66; P = 0.009). Vascular complications occur in over half of ECMO patients and are associated with an increased risk of high hospital charges and in-hospital mortality. These findings support the need for identification and modification of risk factors for ECMO-related vascular complications. Furthermore, the standardization of protocols using evidence-based measures to mitigate vascular complications may improve overall ECMO outcomes.

Inpatient Versus Outpatient Treatment of Gartland Type II Supracondylar Humerus Fractures: A Cost and Safety Comparison

BACKGROUND

In an effort to increase health care value, there has been a recent focus on the transition of traditionally inpatient procedures to an outpatient setting. We hypothesized that in the treatment of Gartland extension type II supracondylar humerus fractures (SCHF), outpatient surgery can be performed safely and with similar clinical and radiographic outcomes compared with urgent inpatient treatment with an overall reduction in cost.

METHODS

We compared a prospective cohort of Gartland type II SCHF treated primarily as outpatients (postprotocol) to a retrospective cohort treated primarily as urgent inpatients (preprotocol), excluding patients with preoperative neurovascular injury, open fracture, additional ipsilateral upper extremity fracture, and prior ipsilateral SCHF. Inpatient versus outpatient treatment was also compared. Outcomes including perioperative factors, complications, readmission, reoperation, postoperative radiographic measurements, and direct hospital costs underwent univariate and multivariate analyses.

RESULTS

A total of 220 patients in the postprotocol cohort (88 inpatients and 132 outpatients) and 129 in the preprotocol cohort (97 inpatients and 32 outpatients) were analyzed. There were no differences in operative times, number of pins, conversion to open reductions, readmissions, or reoperations between cohorts or groups, and no cases developed postoperative neurovascular injuries or compartment syndromes. Total complications did not differ between the preprotocol and postprotocol cohorts; however, were higher in the inpatient group (3.8% vs. 0%; P=0.016) in the univariate, but not multivariate analysis. There were no differences in Baumann angle or humerocondylar angle. Significantly more inpatients' anterior humeral line fell outside of the middle third of the capitellum in the univariate, but not multivariate analysis. There were significant reductions in total cost per patient between the preprotocol and postprotocol cohorts (marginal effect, -$215; P<0.0001) and between the inpatient and outpatient groups (marginal effect, -$444; P<0.0001).

CONCLUSIONS

Delayed treatment of Gartland type II SCHF in the outpatient setting can be performed safely and with similar clinical and radiographic outcomes to those treated urgently as inpatients with a significant cost reduction.

LEVEL OF EVIDENCE

Therapeutic level III-retrospective comparative study.

The increasing cost of pediatric otolaryngology care

INTRODUCTION

Defining the costs associated with healthcare is vital to determining and understanding ways to reduce costs and improve quality of healthcare delivery. The objective of the present study was to identify the current public health burden of inpatient admissions for conditions commonly treated by pediatric otolaryngologists and compare trends in healthcare utilization with other common surgical diagnoses.

METHODS

A retrospective cohort study using the Kids' Inpatient Database for pediatric discharges in the United States from 2000 to 2012. A list of the top 500 admission diagnoses was identified and subsequently grouped into surgical diagnoses typically managed by otolaryngologists and those managed by any other surgical discipline with the top 10 in each category included. Database analyses generated national estimates of summary statistics and comparison of trends over the twelve-year period.

RESULTS

Of the top pediatric admission diagnoses, the most common conditions managed by surgical specialties involved inflammatory or infectious causes. Hospital charges significantly increased during this time across all diagnoses. On average, the charges for otolaryngologic diagnoses increased by 37.13% while costs increased by almost 12%. In comparison, the charges for non-otolaryngologic diagnoses increased by 35.87% and the costs by 10.43%.

CONCLUSIONS

The public health impact and rising costs of healthcare are substantial. It is of critical significance that the healthcare system be aware of opportunities and lessons that may be learned across specialties to identify the primary drivers of healthcare cost while maintaining high quality standards for patient care.

Hidden Costs of Hospitalization After Firearm Injury: National Analysis of Different Hospital Readmission

OBJECTIVE

To compare the risk factors and costs associated with readmission after firearm injury nationally, including different hospitals.

BACKGROUND

No national studies capture readmission to different hospitals after firearm injury.

METHODS

The 2013 to 2014 Nationwide Readmissions Database was queried for patients admitted after firearm injury. Logistic regression identified risk factors for 30-day same and different hospital readmission. Cost was calculated. Survey weights were used for national estimates.

RESULTS

There were 45,462 patients admitted for firearm injury during the study period. The readmission rate was 7.6%, and among those, 16.8% were readmitted to a different hospital. Admission cost was $1.45 billion and 1-year readmission cost was $131 million. Sixty-four per cent of those injured by firearms were publicly insured or uninsured. Readmission predictors included: length of stay >7 days [odds ratio (OR) 1.43, P < 0.01], Injury Severity Score >15 (OR 1.41, P < 0.01), and requiring an operation (OR 1.40, P < 0.01). Private insurance was a predictor against readmission (OR 0.81, P < 0.01). Predictors of readmission to a different hospital were unique and included: initial admission to a for-profit hospital (OR 1.52, P < 0.01) and median household income ≥$64,000 (OR 1.48, P < 0.01).

CONCLUSIONS

A significant proportion of the national burden of firearm readmissions is missed by not tracking different hospital readmission and its unique set of risk factors. Firearm injury-related hospitalization costs $791 million yearly, with the largest fraction paid by the public. This has implications for policy, benchmarking, quality, and resource allocation.

Variation in hospital charges in patients with external ventricular drains: comparison between the intensive care and surgical floor settings

OBJECTIVE

Placement of an external ventricular drain (EVD) is a common and potentially life-saving neurosurgical procedure, but the economic aspect of EVD management and the relationship to medical expenditure remain poorly studied. Similarly, interinstitutional practice patterns vary significantly. Whereas some institutions require that patients with EVDs be monitored strictly within the intensive care unit (ICU), other institutions opt primarily for management of EVDs on the surgical floor. Therefore, an ICU burden for patients with EVDs may increase a patient's costs of hospitalization. The objective of the current study was to examine the expense differences between the ICU and the general neurosurgical floor for EVD care.

METHODS

The authors performed a retrospective analysis of data from 2 hospitals within a single, large academic institution-the University of Washington Medical Center (UWMC) and Seattle Children's Hospital (SCH). Hospital charges were evaluated according to patients' location at the time of EVD management: SCH ICU, SCH floor, or UWMC ICU. Daily hospital charges from day of EVD insertion to day of removal were included and screened for days that would best represent baseline expenses for EVD care. Independent-samples Kruskal-Wallis analysis was performed to compare daily charges for the 3 settings.

RESULTS

Data from a total of 261 hospital days for 23 patients were included in the analysis. Ten patients were cared for in the UWMC ICU and 13 in the SCH ICU and/or on the SCH neurosurgical floor. The median values for total daily hospital charges were $19,824.68 (interquartile range [IQR] $12,889.73-$38,494.81) for SCH ICU care, $8,620.88 (IQR $6,416.76-$11,851.36) for SCH floor care, and $10,002.13 (IQR $8,465.16-$12,123.03) for UWMC ICU care. At SCH, it was significantly more expensive to provide EVD care in the ICU than on the floor (p < 0.001), and the daily hospital charges for the UWMC ICU were significantly greater than for the SCH floor (p = 0.023). No adverse clinical event related to the presence of an EVD was identified in any of the settings.

CONCLUSIONS

ICU admission solely for EVD care is costly. If safe EVD care can be provided outside of the ICU, it would represent a potential area for significant cost savings. Identifying appropriate patients for EVD care on the floor is multifactorial and requires vigilance in balancing the expenses associated with ICU utilization and optimal patient care.

Hospital Charges for Urologic Surgery Episodes of Care Are Rising Despite Declining Costs

OBJECTIVE

To investigate the temporal relationship of hospital charges relative to recorded costs for surgical episodes of care.

PATIENTS AND METHODS

This retrospective cohort study selected individuals who underwent any of 8 index urologic surgical procedures at 392 unique institutions from January 1, 2005, through December 31, 2015. For each surgical encounter, cost and charge data reported by hospitals were extracted and adjusted to 2016 US dollars. Trend analysis and multivariable logistic regression modeling were used to assess outcomes. The primary outcome was trend in median charge and cost. Secondary outcomes consisted of hospital characteristics associated with membership in the highest quartile of institutional charge-to-cost ratio.

RESULTS

Cohort-level median cost per encounter trended down from $6824 in 2005 to $5586 in 2015 (P for trend<.001), and charges increased from $20,210 to $25,773 during the same period (P for trend<.001). Hospitals in the highest quartile of institutional charge-to-cost ratio were more likely to be safety net, nonteaching, urban, lower surgical volume, smaller, and located outside the Midwest (P<.001 for each characteristic).

CONCLUSION

The pricing trends shown herein could indicate some success in cost-containment for surgical episodes of care, although higher hospital charges may be increasingly used to bolster reimbursement from third-party payers and to compensate for escalating costs in other areas.

Cesarean delivery rates, costs and readmission of childbirth in the new cooperative medical scheme after implementation of an episode-based bundled payment (EBP) policy

BACKGROUND

In the past decade, the rate of cesarean delivery increased dramatically in rural China under the fee-for-service (FFS) system. In September 2011, the New Cooperative Medical Scheme (NCMS) agency in Yong'an county in Fujian province of China adopted a policy of reforming payment for childbirth by transforming the FFS payment into episode-based bundled payment (EBP), which made the cesarean deliveries less profitable. Thus, this study was conducted to determine the effect of EBP policy on reducing cesarean use and controlling delivery costs for rural patients in the NCMS.

METHODS

Data from the inpatient information database of the NCMS agency from January 2010 to March 2013 was collected, in which Yong'an county was employed as a reform county and 2 other counties as controls. We investigated the effects of EBP on cesarean delivery rate, costs of childbirth and readmission for rural patients in the NCMS using a natural experiment design and difference in differences (DID) analysis method.

RESULTS

The EBP reform was associated with 33.97% (p<0.01) decrease in the probability of cesarean delivery. The EBP reform, on average, reduced the total spending per admission, government reimbursement expenses per admission, and out-of-pocket (OOP) payments per admission by ¥ 649.61, ¥ 575.01, and ¥ 74.59, respectively. The OOP payments had a net decrease of 14.24% (p<0.01); whereas the OOP payments as a share of total spending had a net increase of 8.72% (p<0.01). There was no evidence of increase in readmission rates.

CONCLUSIONS

These results indicate that the EBP policy has achieved at least a short-term success in lowering the increase of cesarean delivery rate and costs of childbirth. Considering both the cesarean rate and the OOP payments as a share of total spending after the reform were still high, China still has a long way to go to achieve the ideal level of cesarean rate and improve the benefits of deliveries for rural population.

Same-Hospital Re-Admission Rate Is Not Reliable for Measuring Post-Operative Infection-Related Re-Admission

BACKGROUND

Post-operative infections cause morbidity, consume resources, and are an important quality measure in assessing and comparing hospitals. Commonly used metrics do not account for re-admission to a different hospital. The Nationwide Readmissions Database (NRD) tracks re-admissions across United States (US) hospitals. Infection-related re-admission across US hospitals has not been studied previously.

PATIENTS AND METHODS

The 2013 NRD was queried for admissions with a primary International Classification of Diseases and Related Health Problems, 9th revision, Clinical Modification code for the most frequently performed operations. Non-elective all-cause, infection-related, and different hospital 30-day re-admission rates were calculated, using All Patient Refined Diagnosis Related Groups codes. Multi-variable logistic regression identified risk factors for re-admission.

RESULTS

Of 826,836 surviving to discharge, 39,281 (4.8%) had an unplanned re-admission within 30 days, occurring at a different hospital 20.5% of the time. The most common reason for re-admission was infection (25.1%). Orthopedic and spinal procedures were at highest risk for all-cause and infection-related different hospital re-admission. Infection-related different hospital re-admission risk factors included: Length of stay >30 days (odds ratio [OR] 2.28 [1.62-3.21], p < 0.01), age ≥65 years (OR 1.56 [1.38-1.76], p < 0.01), and Charlson Comorbidity Index >1 (OR 1.14 [1.01-1.28], p < 0.01) and differed from predictors of same-hospital infectious re-admission. Non-elective surgical procedure (OR 0.79 [0.72-0.87], p < 0.01) and initial hospitalization at a large hospital (OR 0.66 [0.59-0.74], p < 0.01) were protective.

CONCLUSION

A substantial proportion of post-operative re-admissions are missed by same-hospital re-admission data. All-cause and infection-related post-operative re-admissions to a different hospital are affected by unique patient and institution-specific factors. Re-admission reduction programs, quality metrics, and policy based on same hospital re-admission data should be updated to incorporate different hospital re-admission.

Risk factors and costs associated with nationwide nonelective readmission after trauma

BACKGROUND

Most prior studies of readmission after trauma have been limited to single institutions, whereas multi-institutional studies have been limited to single states and an inability to distinguish between elective and nonelective readmissions. The purpose of this study was to identify the risk factors and costs associated with nonelective readmission after trauma across the United States.

METHODS

The Nationwide Readmission Database was queried for all patients with nonelective admissions in 2013 and 2014 with a primary diagnosis of trauma. Univariate and multivariate logistic regression identified risk factors for 30-day nonelective same- and different-hospital readmission. The diagnosis groups on readmission were evaluated, and the total cost of readmissions was calculated.

RESULTS

There were 1,180,144 patients admitted for trauma, the 30-day readmission rate was 9.4%, and 26.4% of readmissions occurred at a different hospital. The median readmission cost for patients readmitted to the same hospital was $8,298 (interquartile range, $4,899-$14,911), whereas the median readmission cost for patients readmitted to a different hospital was $8,568 (interquartile range, $4,935-$16,078; p < 0.01). Multivariate regression revealed that patients discharged against medical advice were at increased risk of readmission (odds ratio, 2.79; p < 0.01) and readmission to a different facility (odds ratio, 1.58; p < 0.01). Home health care was associated with a decreased risk of readmission to a different hospital (odds ratio, 0.74; p < 0.01). Septicemia and disseminated infections were the most common diagnoses on readmission (8.4%) and readmission to a different hospital (8.6%).

CONCLUSIONS

A significant portion of US readmissions occur at different hospitals with implications for continuity of care, quality metrics, cost, and resource allocation. Home health care reduces the likelihood of nonelective readmission to a different hospital. Infection was the most common reason for readmission, with ramifications for outcomes research and quality improvement.

LEVEL OF EVIDENCE

Care management/epidimeological, level IV.