Insurer costs of COVID-19 by disease severity and duration

OBJECTIVES

To analyze US commercial insurance payments associated with COVID-19 as a function of severity and duration of disease.

STUDY DESIGN

Retrospective database analysis.

METHODS

Patients with COVID-19 between April 1, 2020, and June 30, 2021, in the Merative MarketScan Commercial database were identified and stratified as having asymptomatic, mild, moderate (with and without lower respiratory disease), or severe/critical (S/C) disease based on the severity of the acute COVID-19 infection. Duration of disease (DOD) was estimated for all patients. Patients with DOD longer than 12 weeks were defined as having post-COVID-19 condition (PCC). Outcomes were all-cause payments (ACP) and disease-specific payments (DSP) for the entire DOD. Variables included demographic and comorbidities at the time of acute disease. Adjusted payments by disease severity were estimated using generalized linear models (γ distribution with log link).

RESULTS

A total of 738,339 patients were included (374,401 asymptomatic, 156,220 mild, 180,213 moderate, and 27,505 S/C cases). DSP increased from $217 (95% CI, $214-221) for asymptomatic cases to $2744 (95% CI, $2678-$2811) for moderate cases with lower respiratory disease and $28,250 (95% CI, $26,963-$29,538) for S/C cases. ACP increased from $505 (95% CI, $497-$512) for asymptomatic cases to $46,538 (95% CI, $44,096-$48,979) for S/C cases. The DSP and ACP further increased by $50,736 (95% CI, $45,337-$56,136) and $94,839 (95% CI, $88,029-$101,649), respectively, in S/C cases with PCC vs a DOD of fewer than 4 weeks.

CONCLUSIONS

COVID-19 payments for S/C cases were more than 10-fold greater than those of moderate cases and further increased by nearly $95,000 in S/C cases with PCC vs a DOD of fewer than 4 weeks.

Risk factors and healthcare costs associated with long bone fracture non-union: a retrospective US claims database analysis

BACKGROUND

Few contemporary US-based long bone non-union analyses have recently been published. Our study was designed to provide a current understanding of non-union risks and costs, from the payers' perspective.

METHODS

The Merative™ MarketScan® Commercial Claims and Encounters database was used. Patients with surgically treated long bone (femur, tibia, or humerus) fractures in the inpatient setting, from Q4 2015 to most recent, were identified. Exclusion criteria included polytrauma and amputation at index. The primary outcome was a diagnosis of non-union in the 12 and 24 months post-index. Additional outcomes included concurrent infection, reoperation, and total healthcare costs. Age, gender, comorbidities, fracture characteristics, and severity were identified for all patients. Descriptive analyses were performed. Crude and adjusted rates of non-union (using Poisson regressions with log link) were calculated. Marginal incremental cost of care associated with non-union and infected non-union and reoperation were estimated using a generalized linear model with log link and gamma distribution.

RESULTS

A total of 12,770, 13,504, and 4,805 patients with femoral, tibial, or humeral surgically treated fractures were identified, 74-89% were displaced, and 18-27% were comminuted. Two-year rates of non-union reached 8.5% (8.0%-9.1%), 9.1% (8.6%-9.7%), and 7.2% (6.4%-8.1%) in the femoral, tibial, and humeral fracture cohorts, respectively. Shaft fractures were at increased risk of non-union versus fractures in other sites (risk ratio (RR) in shaft fractures of the femur: 2.36 (1.81-3.04); tibia: 1.95 (1.47-2.57); humerus: 2.02 (1.42-2.87)). Fractures with severe soft tissue trauma (open vs. closed, Gustilo III vs. Gustilo I-II) were also at increased risk for non-union (RR for Gustilo III fracture (vs. closed) for femur: R = 1.96 (1.45-2.58), for tibia: 3.33 (2.85-3.87), RR for open (vs. closed) for humerus: 1.74 (1.30-2.32)). For all fractures, younger patients had a reduced risk of non-union compared to older patients. For tibial fractures, increasing comorbidity (Elixhauser Index 5 or greater) was associated with an increased risk of non-union. The two-year marginal cost of non-union ranged from $33K-$45K. Non-union reoperation added $16K-$34K in incremental costs. Concurrent infection further increased costs by $46K-$86K.

CONCLUSIONS

Non-union affects 7-10% of surgically treated long bone fracture cases. Shaft and complex fractures were at increased risk for non-union.

Health care costs of COVID-19 vs influenza and pneumonia

OBJECTIVES

To estimate payments for the treatment of COVID-19 compared with that of influenza or viral pneumonia (IP), from the perspective of the US payer.

STUDY DESIGN

Retrospective cohort analysis.

METHODS

Patients with COVID-19 during the period from October 1, 2020, to February 1, 2021, or IP during the period from October 1, 2018, to February 1, 2019, in the IBM MarketScan databases were identified. The index was defined as the date of the first COVID-19 or IP diagnosis. Patients with COVID-19 were stratified by severity. Variables for all patients included demographics and comorbidities at the time of index and duration of disease. IP and COVID-19 cohorts were matched using propensity scores, and inflation-adjusted all-cause payments (ACP), and disease-specific payments (DSP) for IP vs COVID-19 were estimated using generalized linear models.

RESULTS

Matched cohorts included 6332 Medicare (female, 58.5%; mean [SD] age, 75.3 [7.6] years), and 397,532 commercially insured patients (female, 57.6%; mean [SD] age, 34.7 [16.7] years). ACP and DSP were significantly higher in the COVID-19 cohort vs IP cohort. Payments for severe/critical COVID-19 were significantly greater than those for IP, with adjusted marginal incremental DSP and ACP of $24,852 (95% CI, $21,573-$28,132) and $50,325 (95% CI, $43,932-$56,718), respectively. IP was significantly less expensive than moderate COVID-19 for commercial payers but not Medicare. IP was more expensive than mild COVID-19 for all payers.

CONCLUSIONS

Payments associated with severe/critical COVID-19 significantly exceeded those associated with IP. For Medicare, IP was more expensive than mild or moderate COVID-19. For commercial payers, IP was less expensive than moderate COVID-19 but more expensive than mild COVID-19.

Longitudinal rates, risk factors, and costs of superficial and deep incisional surgical-site infection (SSI) after primary and revision total knee arthroplasty: A US retrospective claims database analysis

OBJECTIVE

We evaluated longitudinal rates, risk factors, and costs of superficial and deep incisional surgical-site infection (SSI) 6 months after primary total knee arthroplasty (pTKA) and revision total knee arthroplasty (rTKA).

METHODS

Patients were identified from January 1, 2016 through March 31, 2018, in the IBM MarketScan administrative claims databases. Kaplan-Meier survival curves evaluated time to SSI over 6 months. Cox proportional hazard models evaluated SSI risk factors. Generalized linear models estimated SSI costs up to 12 months.

RESULTS

Of the 26,097 pTKA patients analyzed (mean age, 61.6 years; SD, 9.2; 61.4% female; 60.4% commercial insurance), 0.65% (95% CI, 0.56%-0.75%) presented with a deep incisional SSI and 0.82% (95% CI, 0.71%-0.93%) with a superficial incisional SSI. Also, 3,663 patients who had rTKA (mean age, 60.9 years; SD, 10.1; 60.6% female; 53.0% commercial insurance), 10.44% (95% CI, 9.36%-11.51%) presented with a deep incisional SSI and 2.60% (95% CI, 2.07%-3.13%) presented with a superficial incisional SSI. Infections were associated with male sex and multiple patient comorbidities including chronic pulmonary disease, pulmonary circulatory disorders, fluid and electrolyte disorders, malnutrition, drug abuse, and depression. Adjusted average all-cause incremental commercial cost ranged from $14,298 to $29,176 and from $41,381 to 59,491 for superficial and deep incisional SSI, respectively.

CONCLUSIONS

SSI occurred most frequently following rTKA and among patients with pulmonary comorbidities and depression. The incremental costs associated with SSI following TKA were substantial.

Total knee arthroplasty in the outpatient vs inpatient settings: impact of site of care on early postoperative economic and clinical outcomes

BACKGROUND

The incidence of total knee arthroplasty (TKA) surgery performed in the outpatient setting has increased as a result of improved perioperative recovery protocols, bundled payments, and challenges brought by the coronavirus disease of 2019 (COVID-19) pandemic on health systems. This study evaluates early postoperative clinical and economic outcomes of patients treated in the inpatient vs outpatient setting using the Attune Knee System (AKS).

METHODS

Patients with an elective, primary TKA implanted with the AKS, from Q4 2015 to Q1 2021, were identified within the Premier Healthcare Database. The index was defined as the admission date for inpatient cases and the service day for outpatient procedures. Inpatient and outpatient cases were matched on patient characteristics. Outcomes included 90-day all-cause readmissions, 90-day knee reoperations, and index- and 90-day costs of care. Generalized linear models were used to evaluate outcomes (Reoperation: binomial distribution; costs: Gamma distribution with log link).

RESULTS

Before matching, 39,337 inpatient and 9,365 outpatient cases were identified, with greater comorbidities in the inpatient cohort. The outpatient cohort had a lower average Elixhauser Index (EI) compared to the inpatient cohort (1.94 (standard deviation (SD): 1.46) vs 2.17 (SD: 1.53), p < 0.001), and the rates for each individual comorbidities were also slightly lower in the outpatient compared to the inpatient cohorts. Post-match, 9,060 patients were retained in each cohort [mean age: ~ 67, EI = 1.9 (SD: 1.5), 40% male]. Post-match comorbidity rates were similar between inpatient and outpatient cohorts (outpatient EI: 1.94 (SD: 1.44)-inpatient EI: 1.96 (SD: 1.45), p = 0.3516): in both, 54.1% of patients had an EI between 1 and 2, and 5.1% had an EI ≥ 5. No differences were observed in 3-month reoperation rates (0.6% in outpatient, 0.7% in inpatient cohort). Index and post-index 90-day costs were lower in the outpatient vs inpatient cases [(savings for index-only costs: $2,295 (95% CI: $1,977-$2,614); 90 days post-index knee-related care only: $2,540 (95% CI: $2,205-$2,876); 90 days post-index all-cause care: $2,679 (95% CI: $2,322-$3,036)].

CONCLUSIONS

Compared to matched inpatient cases, outpatient TKA cases treated with AKS showed similar 90-day outcomes, at lower cost.

Outcomes of surgical versus nonsurgical treatment for multiple rib fractures: A US hospital matched cohort database analysis

BACKGROUND

Treatment for multiple rib fractures includes surgical stabilization of rib fractures (SSRF) or nonoperative management (NOM). Meta-analyses have demonstrated that SSRF results in faster recovery and lower long-term complication rates versus NOM. Our study evaluated postoperative outcomes for multiple rib fracture patients following SSRF versus NOM in a real-world, all-comer study design.

METHODS

Multiple rib fracture patients with inpatient admissions in the PREMIER hospital database from October 1, 2015, to September 30, 2020, were identified. Outcomes included discharge disposition, and 3- and 12-month lung-related readmissions. Demographics, comorbidities, concurrent injuries at index, Abbreviated Injury Scale and Injury Severity Scores, and provider characteristics were determined for all patients. Patients were excluded from the cohort if they had a thorax Abbreviated Injury Scale score of <2 (low severity patient) or a Glasgow Coma Scale score of ≤8 (extreme high severity patient). Stratum matching between SSRF and NOM patients was performed using fine stratification and weighting so that all patient data were kept in the final analysis. Outcomes were analyzed using generalized linear models with quasinormal distribution and logit links.

RESULTS

A total of 203,450 patients were included, of which 200,580 were treated with NOM and 2,870 with SSRF. Compared to NOM, patients with SSRF had higher rates of home discharge (62% SSRF vs. 58% NOM) and lower rates of lung-related readmissions (3 months, 3.1% SSRF vs. 4.0% NOM; 12 months, 6.2% SSRF vs. 7.6% NOM). The odds ratio (OR) for home or home health discharge in patients with SSRF versus NOM was 1.166 (95% confidence interval [CI], 1.073-1.266; p = 0.0002). Similarly, ORs for lung-related readmission at 3- and 12-month were statistically lower in the patients treated with SSRF versus NOM (OR [3 months], 0.764 [95% CI, 0.606-0.963]; p = 0.0227 and OR [12 months], 0.799 [95% CI, 0.657-0.971]; p = 0.0245).

CONCLUSION

Surgical stabilization of rib fractures results in greater odds of home discharge and lower rates of lung-related readmissions compared with NOM at 12 months of follow-up.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Longitudinal Rates, Patient Risk Factors, and Economic Impact of Superficial and Deep Incisional Surgical Site Infection After Primary and Revision Total Hip Arthroplasty: A U.S. Retrospective Commercial Claims Database Analysis

Background: Longitudinal rates, risk factors, and costs of superficial and deep incisional surgical site infection (SSI) were evaluated six months after primary total hip arthroplasty (pTHA) and revision total hip replacement (rTHA). Patients and Methods: Patients who had pTHA or rTHA between January 1, 2016 and March 31, 2018 were identified using the IBM^® MarketScan^® administrative claims databases. Kaplan-Meier survival curves evaluated time to SSI over six months. Cox proportional hazard models evaluated SSI risk factors. Generalized linear models estimated SSI costs up to 12 months. Results: The total cohort included 17,514 pTHA patients (mean [standard deviation] age 59.6 [10.1] years, 50.2% female; 66.4% commercial insurance), and 2,954 rTHA patients (61.2 [12.0] years, 52.0% female; 48.6% commercial insurance). Deep and superficial post-operative SSI at six months affected 0.30% (95% confidence interval [CI], 0.22%-0.39%) and 0.67% (95% CI, 0.55%-0.79% of patients in the pTHA, and 8.9% (95%CI: 7.8%-10.0%) and 4.8% (95% CI, 4.0%-5.6%) of patients in the rTHA cohorts. Hazards for SSI were related to patient comorbidities that included diabetes mellitus, obesity, renal failure, pulmonary or circulatory disorders, and depression. The adjusted average all-cause incremental commercial costs associated with post-operative infection ranged from $21,434 to $42,879 for superficial incisional SSI and $53,884 to $76,472 for deep incisional SSI, over a 12-month post-operative assessment period. Conclusions: The SSI rate after revision total hip arthroplasty (rTHA) was nearly 9% compared with 1.0% after pTHA. The risk of infection was influenced by several comorbid risk factors. The incremental cost associated with SSIs was substantial.

Incidence, costs and post-operative complications following ankle fracture - A US claims database analysis

BACKGROUND

The epidemiology and payer costs for ankle fractures are not well documented. This study evaluated: (1) the incidence of ankle fracture and ankle surgery following fracture in the US population; and (2) the clinical presentation of patients presenting with ankle fractures requiring surgery, their complication rates, and payer costs.

METHODS

Patients in the IBM® MarketScan® Commercial and Medicare Supplemental databases with an inpatient/outpatient diagnosis of ankle fracture from 2016 to 2019 were stratified by age group and gender, and rates of fracture per 10,000 enrollees were estimated. Surgically-treated patients between January 2016 - October 2021 were further analyzed. One-year post-surgical outcomes evaluated complication rates (e.g., infection, residual pain), reoperations, and 1-year payments. Standard descriptive statistics were calculated for all variables and outcomes. Generalized linear models were designed to estimate payments for surgical care and incremental payments associated with postoperative complications.

RESULTS

Fracture cases affected 0.14% of the population; 23.4% of fractures required surgery. Pediatric and elderly patients were at increased risk. From 3 weeks to 12 months following index ankle surgery, 5.5% (5.3% - 5.7%) of commercially insured and 5.9% (5.1% - 6.8%) of Medicare patients required a new surgery. Infection was observed in 4.4% (4.2% - 4.6%) commercially insured and 9.8% (8.8% - 10.9%) Medicare patients, and residual pain 3 months post-surgery was observed in 29.5% (28.7% - 30.3%) commercially-insured and 39.3% (36.0% - 42.6%) Medicare patients. Commercial payments for index surgery ranged from $9,821 (95% CI: $9,697 - $9,945) in the ambulatory surgical center to $28,169 (95% CI: $27,780 - $28,559) in the hospital inpatient setting, and from $16,775 (95% CI: $16,668 - $16,882) in patients with closed fractures, to $41,206 (95% CI: $38,795 - $43,617) in patients with Gustilo III fractures. Incremental commercial payments for pain and infection averaged $5,200 (95% CI: $4,261 - $6,139) and $27,510 (95% CI: $21,759 - $33,261), respectively.

CONCLUSION

Ankle fracture has a high incidence and complication rate. Residual pain affects more than one-third of all patients. Ankle fracture thus presents a significant societal impact in terms of patient outcomes and payer burden.

Demographic and clinical profile of patients treated with proximal femoral nails - a 10-year analysis of more than 40,000 Cases

Background

Hip fractures are common in elderly populations and can be life threatening. Changes in healthcare delivery and outcomes for patients with hip fracture treated with intramedullary nails are not well characterized. The objectives of our study were: 1) the characterization of patients treated with the Trochanteric Fixation Nail -Advanced™(TFNA) Proximal Femoral Nailing System or comparable nails (index) and estimate 12-month all-cause readmissions (ACR) and reoperations following index; and 2) the evaluation of 10-year healthcare utilization (HCU) trends for treatment of femoral fractures with femoral nails.

Methods

This is a retrospective database analysis using the Premier hospital database. All adults with femoral fracture treated with an intramedullary nail, from 2010 to Q3 2019, in the inpatient setting, were identified. Exclusion criteria included patients with bilateral hip surgery and presence of breakage at time of initial surgery. The primary outcome was ACR and reoperation, the secondary outcomes were healthcare utilization metrics. Variables included demographics, comorbidities (Elixhauser Index (EI)), surgical intervention variables and hospital characteristics.

Results

Forty-one thousand one hundred four patients were included in the study, of which 14,069 TFNA patients, with average age 77.9 (Standard deviation (SD): 12.0), more than 60% with 3 or more comorbidities (more than 64% for TFNA), 40% with severe or extreme disease severity and one third with severe or extreme risk for mortality. ACR reached 60.1% (95% confidence interval (CI): 59.6%-60.5%) – for TFNA: 60.0% (95%CI: 59.2%-60.8%). The reoperation rate was 4.0% (95%CI: 3.8%-4.2%) – for TFNA: 3.8% (95%CI: 3.5%-4.1%). Length of stay (LOS) averaged 5.8 days (SD: 4.8), and 12-month hip reoperation was 4.0% (3.8%-4.2%), in TFNA cohort: 3.8% (3.5%-4.1%). From 2010 to 2019: the percentage patients operated within 48 h of admission significantly increased, from 75.2% (95%CI: 74.3%-76.1%) to 84.3% (95%CI: 83.9%-84.6%); LOS significantly decreased, from 6.2 (95%CI: 6.0–6.4) to 5.6 (95%CI: 5.5–5.7) days; discharge to skilled nursing facilities (SNF) increased from 56.0% (95%CI: 54.8%-57.2%) to 61.5% (95%CI: 60.8%-62.2%); ACR rates decreased but reoperation rates remained constant.

Conclusions

ACR and reoperation rates were similar across device types and averaged 60.1% and 4.0%, respectively. Ten-year analyses showed reductions in hospital HCU and greater reliance on SNF.

Trends in Posterior Cervical Fusion for Deformity in the United States from 2000 to 2017

BACKGROUND

Posterior cervical decompression and fusion (PCF) is a common treatment for cervical spondylotic myelopathy. Treatment paradigms are shifting from simple decompression and fusion to correcting cervical deformities.

OBJECTIVE

To identify trends in PCF with an emphasis on cervical deformity and surgical complexity.

METHODS

Adults who underwent PCF from 2000 to 2017 were retrospectively identified in the Premier Healthcare Database (PHD) using International Classification of Disease Codes (ICD) 9 and 10. Patients were dichotomized into those with or without deformity diagnosis. PCF complexity was defined by adjunct surgical codes, including anterior cervical fusion, extension to thoracic levels, and osteotomy. Patient characteristics, including demographics, functional comorbidity index (FCI), and hospital characteristics, were extracted and annual procedures were projected to the US population.

RESULTS

A total of 68 415 discharges for PCF were identified. Compound annual growth rate (CAGR) of PCF from 2000 to 2017 for nondeformity cases was 9.7% and 16.5% for deformity. The demographics with the greatest growth were deformity patients aged 65 to 74 yr (15.1%). The CAGR of anterior cervical fusion and extension to thoracic levels was higher for deformity patients compared to nondeformity patients, 13.6% versus 3.9% and 20.4% versus 16.6%, respectively.

CONCLUSION

Rates of PCF for deformity are increasing at a greater rate than nondeformity PCF. The most growth was seen among deformity patients aged 65 to 74 yr. Surgical complexity is also changing with increasing use of anterior cervical fusion and extension of PCF to include thoracic levels.