Clinical and economic comparison of laparoscopic versus open hepatectomy for primary hepatolithiasis: a propensity score-matched cohort study

BACKGROUND

It is unclear whether laparoscopic hepatectomy (LH) for hepatolithiasis confers better clinical benefit and lower hospital costs than open hepatectomy (OH). This study aim to evaluate the clinical and economic value of LH versus OH.

METHODS

Patients undergoing OH or LH for primary hepatolithiasis at Yijishan Hospital of Wannan Medical College between 2015 and 2022 were divided into OH group and LH group. Propensity score matching (PSM) was used to balance the baseline data. Deviation-based cost modelling and weighted average median cost (WAMC) were used to assess and compare the economic value.

RESULTS

A total of 853 patients were identified. After exclusions, 403 patients with primary hepatolithiasis underwent anatomical hepatectomy (OH n=143; LH n=260). PSM resulted in 2 groups of 100 patients each. Although LH required a longer median operation duration compared with OH (285.0 versus 240.0 min, respectively, P<0.001), LH patients had fewer wound infections, fewer pre-discharge overall complications (26 versus 43%, respectively, P=0.009), and shorter median postoperative hospital stays (8.0 versus 12.0 days, respectively, P<0.001). No differences were found in blood loss, major complications, stone clearance, and mortality between the two matched groups. However, the median overall hospital cost of LH was significantly higher than that of OH (CNY¥52,196.1 versus 45,349.5, respectively, P=0.007). Although LH patients had shorter median postoperative hospital stays and fewer complications than OH patients, the WAMC was still higher for the LH group than for the OH group with an increase of CNY¥9,755.2 per patient undergoing LH.

CONCLUSION

The overall clinical benefit of LH for hepatolithiasis is comparable or even superior to that of OH, but with an economic disadvantage. There is a need to effectively reduce the hospital costs of LH and the gap between costs and diagnosis-related group reimbursement to promote its adoption.

The impact of electric scooters in Melbourne: data from a major trauma service

BACKGROUND

The proliferation of electric scooters globally has been associated with an increase in related injuries and consequent economic burden. This study aims to assess the injury patterns and the economic impact associated with electric scooter use in Melbourne, Australia.

METHODS

A retrospective cohort study was conducted using hospital and registry data from January 2022 to January 2023. Data collected included demographic details, alcohol and helmet use, injury type and severity, operative treatment provided, and direct medical costs. The economic impact (in AUD) of the patient's emergency presentation and hospital admission was calculated.

RESULTS

During the study period, 256 electric scooter related injuries were recorded, comprising 247 riders and nine pedestrians. The majority of patients were males (69%) with a median age of 29.5 (15-78). Alcohol use was reported by 34% and helmet use by 33%. Injuries most commonly affected the upper limb (53%) and head (50%), with abrasions (75%) and fractures (48%) being the most common type of injury sustained. The total hospital cost was $1 911 062, and the median cost was $1321.66 per patient (IQR: $479.37-$5096.65).

CONCLUSION

Electric scooter usage, as observed through patient presentations to the Royal Melbourne Hospital, is associated with a considerable number of injuries, primarily among young males, and an ensuing substantial economic burden. The findings underscore the urgent need for improved safety measures to minimize electric scooter-related injuries and their clinical and economic repercussions.

Risk Factors for Increased Hospital Costs for Primary Total Hip Arthroplasty

BACKGROUND

Patient medical complexity increases the cost of primary total hip arthroplasty (THA). The goal of this study was to quantify the impact of specific medical comorbidities on the real hospital cost of primary THA.

METHODS

This study consisted of a retrospective analysis of 1,222 patient encounters for Current Procedural Terminology code 27130 (primary THA) between January 2017 and March 2020 at a high-volume urban academic medical center. Patient demographics, comorbidities, and admission data were collected, and univariate and multivariate gamma regression analyses were performed to identify associations with increased costs incurred during THA admission.

RESULTS

The median total cost for THA was $30,580. Univariate analysis showed increased cost for body mass index (BMI) > 35 versus BMI < 35 ($31,739 versus 30,071; P < .05), American Society of Anesthesiologists (ASA) score 3 to 4 versus ASA 1 to 2 ($32,268 versus 30,045; P < .05), prevalence of diabetes ($31,523 versus 30,379; P < .05), congestive heart failure ($34,814 versus 30,584; P < .05), peripheral vascular disease (PVD) ($35,369 versus 30,573; P < .05), chronic pulmonary disease (CPD) ($34,625 versus 30,405; P < .05), renal disease ($31,973 versus 30,352; P < .05), and increased length of stay (r = 0.424; P < .05). Multivariate gamma regression showed that BMI > 35 (relative risk [RR] = 1.05), ASA 3 to 4 (RR = 1.07), PVD (RR = 1.29), CPD (RR = 1.13), and renal disease (RR = 1.09) were independently associated with increased THA hospital cost (P < .01). Increased costs seen in BMI > 35 versus BMI < 35 patients were largely due to hospital room and board ($6,345 versus 5,766; P = .01) and operating room costs ($5,744 versus 5,185; P < .05).

CONCLUSIONS

A BMI > 35, PVD, CPD, renal disease, and ASA 3 to 4 are associated with higher inpatient hospital costs for THA.

LEVEL OF EVIDENCE

Level III; Retrospective cohort study.

Healthcare Quality Received by Insured Patients in Two Indonesian Regional Public Hospitals

Background: Hospitals are required to improve the quality of health services provided to patients. Purpose: Evaluating and comparing the healthcare quality received by insured patients hospitalized in two Indonesian regional public hospitals. Methods: Secondary data analysis used the 2019 and 2020 Indonesian National Health Insurance e-claim databases of Hospital A and Hospital B. Descriptive and crosstabs analyses were used to determine INA-CBGs diagnoses that were categorized as high volume, high risk, and high cost. Results: The admissions that caused financial loss at the Hospital A were 21.1% in 2019 and 19.8% in 2020, while 30.3% in 2019 and 27.5% at the Hospital B. More than 60% of these admissions were placed in the 3rd class of inpatient wards of the two hospitals. Of these admissions, < 5% at the Hospital A and >5% at the Hospital B were readmitted within 30 days, although more than 90% were previously discharged based on physicians' approval. Conclusions: Inadequate healthcare quality received by insured patients. Hence, an integrated clinical pathways based professional nursing practice model is highly recommended to increase patient outcomes and decrease 30 days hospital readmission rates.

Cost Analysis of Intranatal Care Services at a Tertiary Care Public Sector Hospital in Rajasthan, India

Introduction India is responsible for the second-highest maternal deaths and the greatest burden of stillbirths worldwide. The cost of intranatal services is an important determining factor, especially in developing countries like India. Most studies report the cost of delivery from the patient's perspective, but there is a lack of studies from the health system's perspective. This present study aimed to bridge this gap by estimating the overall and unit costs of various types of deliveries at a tertiary-level hospital in Rajasthan, India. Methods The cost estimation of intranatal services was conducted in a tertiary-level teaching hospital in Jaipur, Rajasthan. This cost analysis undertook the health system's perspective, using bottom-up costing methodology. Data on all the resources (capital/recurrent) used for the delivery of intranatal care from April 2020 to March 2021 were collected. Sensitivity analysis was done to account for any variability in cost components on overall intranatal service cost. Results The annual cost of intranatal care services at the tertiary care hospital was INR 149,011,957 (USD 1,988,152). The unit cost per vaginal delivery was INR 8,244.4 (USD 109.9) and the unit cost per cesarean section was INR 10,696.2 (USD 142.7). Among various heads of expenditure, 'human resource' costs were predominant, accounting for 47.7% of the total costs, followed by 'building/space' and 'overhead' costs, accounting for 30.59% and 11.1%, respectively. Conclusion The results may help plan and manage intra-natal care services in Rajasthan. Apart from the judicious utilization of resources, the findings of the study may also serve as a basis for future health economic studies.

The impact of price transparency and competition on hospital costs: a research on all-payer claims databases

Background

Public reporting has been considered effective in reducing health care costs by mitigating information asymmetry in the market as payers have incorporated publicly available information mandates into pay-for-performance programs and value-based purchasing. Therefore, hospitals have faced increasing pressures to provide price transparency. Despite the widespread promotion of healthcare transparency, the effectiveness of public reporting has not yet been sufficiently understood. This study analyzed the impact of transparency policy and competition on hospital costs by taking the state operations of all-payer claims databases (APCDs) as a case of interest.

Methods

We employed a fixed-effects regression, which allows the generation of hospital-specific effects, in accordance with the suggestion by the Hausman test. The study samples comprise nonprofit and for-profit general acute care hospitals in the United States for 2011–2017. The finalized dataset ranges from 3547 observations in 2011 to 3405 observations in 2015 after removing missing values.

Results

We found that hospitals in the states with APCDs tend to bear higher average operating expenses than those without APCDs, which may indicate that states maintaining higher healthcare expenditures are more attentive to a price transparency initiative and tend to adopt APCDs. With regard to competition, the results showed that weak market competition is significantly associated with higher operating costs, supporting the traditional competition theory. However, the combined effect of APCDs and competition did not indicate a significant association with operating expenses. Further investigation showed a continued tendency for a weak intensity of competition to be linked to lower hospital operating costs in states without APCDs. For those located in non-APCD adopted states, market consolidation helped hospitals coordinate care more effectively, economize operating costs, and enjoy economies of scale due to their large size. Similar trends did not appear in APCD-adopted states except for in 2015.

Conclusions

This study observed limited evidence of the impact of APCDs and market competition. Our findings suggest that states need to make multifaceted efforts to contain hospital costs, not solely depending on the rollout of cost information or market competition. Market concentration may lead to coordinated care or cost economization in some cases. Still, the existing literature also demonstrates some potentially harmful impacts of increased concentration in the healthcare market, such as inefficient use of resources, unilateral market power, and deterrence of innovation. The introduction of a price transparency tool may require additional policy actions that take market competition into consideration.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08711-x.

Efficiency of the Japanese Hospitalist System for Patients with Urinary Tract Infection: A Propensity-matched Analysis

Objective The hospitalist system in the United States has been considered successful in terms of the quality of care and cost effectiveness. In Japan, however, its efficacy has not yet been extensively examined. This study examined the impact of the hospitalist system on the quality of care and healthcare economics in a Japanese population using treatment of urinary tract infection as an example. Methods We analyzed 271 patients whose most resource-consuming diagnosis at admission was urinary tract infection between April 2017 and March 2019. Propensity-matched analyses were performed to compare health care economics and the quality of care between the hospitalist system and the conventional system. Results In matched pairs, care by the hospitalist system was associated with a significantly shorter length of stay than that by the conventional system. The quality of care (oral antibiotics switch rate, rate of appropriate antibiotics change based on urine or blood culture results, detection rate of urinary tract infection etiology and the number of laboratory tests) was also considered to be favorably impacted by the hospitalist system. Although not statistically significant, hospital costs tended to be lower with the hospitalist system than with the conventional system. The mortality rate and 30-day readmission were also not significantly different between the groups. Conclusion The hospitalist system had a favorable impact on the quality of care and length of stay without increasing readmission in patients with urinary tract infection. This study is further evidence of the strong potential for the positive impact of an implemented hospitalist system in Japan.

Associations of Ambient NO2 with Daily Hospitalization, Hospitalization Expenditure and Length of Hospital Stay of Cause-Specific Respiratory Diseases - Shanxi, China, 2017-2019

WHAT IS ALREADY KNOWN ABOUT THIS TOPIC?

Numerous epidemiological studies have documented the association between ambient nitrogen dioxide (NO₂) and mortality and morbidity of respiratory diseases, however, research on the effect of NO₂ on the length of hospital stay (LOS) and hospitalization expenditure is limited.

WHAT IS ADDED BY THIS REPORT?

This study collected the respiratory hospitalization, hospital expenditure, and LOS for respiratory diseases from 2017-2019 in Shanxi, China, and comprehensively evaluated the association between ambient NO₂ exposure and respiratory hospitalization, expenditure, and LOS.

WHAT ARE THE IMPLICATIONS FOR PUBLIC HEALTH PRACTICE?

This study provides evidence on the association between ambient NO₂ and respiratory burden, suggesting that continuously reducing the NO₂ concentrations could prevent respiratory disease-associated hospital admissions and decrease the relative burden in Shanxi Province and other similar regions.

The Extent Hospital Organizational Factors Influence Inpatient Care Delivery: A Case Study Looking at Knee and Hip Replacement Surgery

There is a body of Implementation and Dissemination research describing the importance of “context”—the characteristics describing the setting where a process or innovation occurs—when evaluating delivery, outcomes and cost of health services. These contextual factors, which can occur at the system, organization, or provider level, may either facilitate or erect barriers to the utilization of evidence-based practices and the outcomes achieved. This paper examines the influence of organizational structure and operating environment characteristics of where inpatient health care is delivered, controlling for patient and provider characteristics, on health services delivery and outcomes achieved. We used inpatient cost-of-care to represent the bundle of services provided to patients receiving primary knee and hip replacement procedures. Data includes patient level data from discharge records for 62 140 knee replacements and 42 392 hip replacements from the 2015 AHRQ Healthcare Cost and Utilization Project State Inpatient Discharge database and hospital characteristics from the 2015 American Hospital Association survey. Multi-level linear estimation models controlling for patient and payer characteristics were employed to assess the impact of specific organizational and operating environment factors. We found that although patient and payer characteristics significantly impacted the inpatient cost of care, there is significant variation between hospitals and among physicians within a hospital beyond what can be explained by patient, payer and local price effect characteristics. Organizational and physician characteristics that had the most significant impact on cost of care included the volume of services provided, urban location, and for-profit ownership. These factors can inform future policy and program design and evaluation.

The association of frailty with clinical and economic outcomes among hospitalized older adults with hip fracture surgery

Frailty is a common condition among older adults with hip fracture. In our study analyzing National Inpatient Sample data, frailty was found to be associated with up to six times increase in in-patient mortality, 55% increased length of hospital stay, and 29% increase in hospital cost.

INTRODUCTION

Hip fracture is a significant public health issue posing adverse health outcomes and substantial economic burden to patients and society. Frailty is a prevalent geriatric condition associated with poor clinical outcome among older adults. The association between hip fracture and frailty on both clinical and economic outcomes at the national level has not been estimated. We aimed to determine the association between frailty and in-hospital mortality, length of hospital stay (LOS), and total hospital cost among older patients aged ≥ 65 years who underwent surgery for hip fracture.

METHODS

We did an analysis of administrative data using the National Inpatient Sample (NIS) data from 2016 and 2017. Our analysis included data on 29,735 hospitalizations. We first conducted a descriptive analysis of the patient characteristics (demographics and clinical) and hospital-related factors. Three multivariable regression analysis models were then used to determine independent associations between frailty and in-hospital mortality, LOS, and total hospital cost. All three models were adjusted for patients' demographic and clinical characteristics and hospital-related factors.

RESULTS

Moderate and high frailty risk were associated with higher odds of death (OR = 2.94 and 95% CI 1.91-4.51 and OR = 5.99 and 95% CI 3.79-9.47), increased LOS (17% and 55%, p < 0.0001), and higher total hospital cost (7% and 29%, p < 0.0001) respectively compared to low frailty risk.

CONCLUSION

Frailty was associated with mortality, LOS, and hospital cost after adjusting for patient demographic, clinical, and hospital-related factors. Further research is needed to explore what pre-surgical measures can be assessed to mitigate in-hospital mortality and hospital cost in frail older patients hospitalized for hip fracture surgery.

Trends in hospitalisation for common paediatric infections: An Australian experience

AIM

Respiratory tract infections (RTIs) and acute gastroenteritis (AGE) significantly impact health service use among children; however, recent trends in hospital admission rates are not well documented. Our objectives were to describe admission rates for RTI and AGE among children in one jurisdiction over a 10-year period and their associated length of stay (LOS), monetary costs and chronic conditions.

METHODS

This is retrospective review of hospital admissions data for Australian Capital Territory residents aged 0-16 years admitted with a primary diagnosis commensurate with RTI or AGE.

RESULTS

Between 2009 and 2018, there were 8668 admissions. Admission rates rose from 9.2/1000 age-adjusted population in 2009 to 10.5/1000 in 2018. LOS reduced by 10 h (43 to 33 h). The median cost per admission was AUD$3158 (AUD$148 to AUD$175 271) and 16.4% of children had a chronic condition, associated with longer LOS and higher episode costs. Median age at admission was 1 year 5 months. Infants were admitted three times as often as older children and admissions for lower RTI were more common than for upper RTI or AGE (P < 0.001).

CONCLUSIONS

Paediatric hospital admission rates for RTI in the Australian Capital Territory are increasing and LOS is decreasing. Admissions for AGE remain relatively low following the introduction of the rotavirus vaccine in 2007. Effective strategies are needed to reduce the burden of paediatric RTI.

Tuberculosis Screening via Chest X-Ray is Financially Burdensome in Previously Independently Living Elective Total Knee Arthroplasty Patients

BACKGROUND

In 1995, to reduce the transmission of Tuberculosis (TB) the Centers for Disease Control and Prevention recommended that all patients discharged from hospitals be required to have chest x-rays (i.e., radiography) performed before admission to long term care facilities (LTCFs). Previously independently living patients (PILPs) who undergo elective total knee replacement (TKA) surgery are a population at higher risk to end up in LTCFs for rehabilitation. By 2017, the incidence of TB was 9,105 cases compared to 22,762 in 1995. However, the recommendations that hospitals be required to perform a chest x-ray in all patients (including PILPs) being transferred to LTCF's have remained in place. The purposes of this study were to: a) determine the incidence of TB-positive chest x-rays in PILPS discharged to LTCFs after undergoing elective TKA surgery, and b) assess the cost (i.e., both financial and possible exposure to unnecessary radiation) of mandated chest x-rays before hospital discharge to LTCF for PILPs.

METHODS

Retrospective 2012-2017 patient chart data were collected from the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) to identify all elective TKAs for PILPs performed at two Ascension participating centers. Study data included sex, age, body mass index (BMI), length of stay, comorbidities, and chest x-ray results before discharge. Patients who underwent surgery for fracture, infection, trauma, or malignancy were excluded from the study. Categorical data were analyzed using Fisher's exact test and Student's t-test were used for continuous data.

RESULTS

The authors identified 4,041 total elective TKA's, from which 500 PILPs were discharged to a LTCF due to functional, medical and/or social concerns. Chest x-rays were associated with 500 (100%) negative findings for TB. Overall hospital costs for chest x-rays for patient's being discharged to an extended care facility totaled $90,848.

CONCLUSIONS

The mandated use of chest x-rays for TB screening of PILPs undergoing elective surgery TKA prior to discharge to LTCFs appear to place an unnecessary financial burden on the healthcare system. The mandatory use of x-rays for assessment of possible TB infection before transfer to LTCFs appears to also expose PILPs unnecessarily to radiation. Although further studies are needed to verify these results, the authors recommend that perhaps instead chest x-rays should be reserved for patients with specific comorbidities (e.g., patients on immunosuppressive therapy, with HIV, etc.) or for those patients residing in LTCFs prior to surgery.

The Impact of ASA Status on Cost of Care and Length of Stay Following Posterior Cervical Decompression and Fusion

BACKGROUND

Increasing numbers of posterior cervical decompression and fusion (PCDF) over the past decade have raised the prospect of bundled payment plans. The American Society of Anesthesiologists (ASA) Physical Status Classification system may enable accurate estimation of healthcare costs, length of stay, and other postoperative outcomes in PCDF patients.

OBJECTIVE

To evaluate correlations between ASA and postoperative outcomes, length of stay (LOS), and healthcare costs in patients undergoing PCDF.

METHODS

971 patients that underwent PCDF between 2008 and 2016 at a single institution were evaluated by low (I and II) versus high (III and IV) ASA. Demographics were compared using univariate analysis. Cost of care, LOS and postoperative complications were compared using multivariable logistic and linear regression, controlling for gender, age, length of surgery and number of segments fused.

RESULTS

The high ASA cohort had greater mean age (62 vs. 55, p<0.0001) and higher Elixhauser comorbidity index (ECI) scores (p<0.0001). ASA was independently associated with longer LOS (+2.1 days, CI: 1.3-2.9; p<0.0001) and higher cost (+$2,936, CI: $1,457-$4,415; p<0.0001). High ASA patients were more likely to have a non-home discharge (3.9, 95% CI 2.8-5.6, p<0.0001), delayed extubation (3.2, 95% CI 1.4-7.3, p=0.006), ICU stay (2.4, 95% CI 1.5-3.7, p=0.0001), in-hospital complications (1.5, 95% CI 1.0-2.2, p=0.03) and 30-day (3.2, 95% CI 1.5-6.8, p=0.003) and 90-day (3.2, 95% CI 1.8-5.7, p=0.0001) readmission.

CONCLUSIONS

High ASA is strongly associated with increased costs, LOS and adverse outcomes following PCDF. Therefore, ASA could be useful for preoperative prediction of these outcomes.

Variations in Cost and Readmissions of Patients in the Bundled Payment for Care Improvement Bundle for Hip and Femur Fractures

Introduction

The Bundled Payment for Care Improvement (BPCI) for hip and femur fractures is an effort to increase care quality and coordination at a lower cost. The bundle includes all patients undergoing an operative fixation of a hip or femur fracture (diagnosis-related group codes 480-482). This study aims to investigate variance in the hospital cost and readmission rates for patients within the bundle.

Materials and Methods

The study is a retrospective analysis of patients ≥65 years old billed for a diagnosis-related groups 480-482 in 2016 in the National Readmission Database. Cost of admission and length of stay were compared between patients who were or were not readmitted. Regression analysis was used to determine the effects of the primary procedure code and anatomical location of the femur fracture on costs, length of stay, and readmission rates.

Results

Patients that were readmitted within 90 days of surgery had an increased cost on initial admission ($18,427 vs $16,844, P < .0001), and an increased length of stay (6.24 vs 5.42, P < .0001). When stratified by procedure, patients varied in readmission rates (20.7% vs 19.6% vs 21.8%), initial cost, and length of stay (LOS). Stratification by anatomical location also led to variation in readmission rates (20.7% vs 18.3% vs 20.6%), initial cost, and LOS.

Conclusion

The hip and femur fractures bundle includes a great number of procedures with variance in cost, readmission, and length of stay. This amount of variation may make standardization difficult and may put the hospital at potential financial risk.

Early Psychiatric Consultation Is Associated With Decreased Cost and Length of Stay in the Patient Population at a Level I Trauma Center

Introduction

Psychiatric illness impacts nearly one-quarter of the US population. Few studies have evaluated the impact of psychiatric illness on in-hospital trauma patient care. In this study, we conducted a retrospective cohort study to evaluate hospital resource utilization for trauma patients with comorbid psychiatric illnesses.

Methodology

Trauma patients admitted to a level I center over a one-year period were included in the study. Patients were categorized into one of three groups: (1) no psychiatric history or in-hospital psychiatric service consultation; (2) psychiatric history but no psychiatric service consultation; and (3) psychiatric service consultation. Time to psychiatric service consultation was calculated and considered early if occurring on the day of or the day following admission. Patient demographics, outcomes, and resource utilization were compared between the three groups.

Results

A total of 1,807 patients were included in the study (n = 1,204, 66.6% no psychiatric condition; n = 508, 28.1% psychiatric condition without in-hospital psychiatric service consultation; and n = 95, 5.3% in-hospital psychiatric service consultation). Patients requiring psychiatric service consultation were the youngest (P < .001), with the highest injury severity (P = .024), the longest hospital length of stay (P < .001), and the highest median hospital cost (P < .001). Early psychiatric service consultation was associated with an average saving in-hospital length of stay of 2.9 days (P = .021) and an average hospital cost saving of $7,525 (P = .046).

Conclusion

One-third of our trauma population had an existing psychiatric diagnosis or required psychiatric service consultation. Resource utilization was higher for patients requiring consultation. Early consultation was associated with a savings of hospital length of stay and cost.

Economic analysis of the use of video laryngoscopy versus direct laryngoscopy in the surgical setting

Aim: Compared with direct laryngoscopy (DL), video laryngoscopy (VL) offers clinical benefits in routine and difficult airways. The health economic benefit of VL versus DL for routine tracheal intubation remains unknown. Materials & methods: This analysis compared VL and DL health economic outcomes, including total inpatient costs, length of hospital stay (LOS), postoperative intensive care unit (ICU) admission and incidence of procedurally associated complications. Results: Patients with VL had decreased inpatient cost (US$1144-5891 across eight major diagnostic categories [MDC]); >1-day LOS reduction in five MDC; reduced odds for postoperative ICU admission (0.04-0.68) and reduced odds of respiratory complications in three MDC (0.43-0.90). Conclusion: Video laryngoscopy may lower total costs, reduce LOS and decrease the likelihood of postoperative ICU admission.

Quality and Cost of Care by Hospital Teaching Status: What Are the Differences?

Policy Points In two respects, quality of care tends to be higher at major teaching hospitals: process of care and long-term survival of cancer patients following initial diagnosis. There is also evidence that short-term (30-day) mortality is lower on average at such hospitals, although the quality of evidence is somewhat lower. Quality of care is mulitdimensional. Empirical evidence by teaching status on dimensions other than survival is mixed. Higher Medicare payments for care provided by major teaching hospitals are partially offset by lower payments to nonhospital providers. Nevertheless, the payment differences between major teaching and nonteaching hospitals for hospital stays, especially for complex cases, potentially increase prices other insurers pay for hospital care.

CONTEXT

The relative performance of teaching hospitals has been discussed for decades. For private and public insurers with provider networks, an issue is whether having a major teaching hospital in the network is a "must." For traditional fee-for-service Medicare, there is an issue of adequacy of payment of hospitals with various attributes, including graduate medical education (GME) provision. Much empirical evidence on relative quality and cost has been published. This paper aims to (1) evaluate empirical evidence on relative quality and cost of teaching hospitals and (2) assess what the findings indicate for public and private insurer policy.

METHODS

Complementary approaches were used to select studies for review. (1) Relevant studies highly cited in Web of Science were selected. (2) This search led to studies cited by these studies as well as studies that cited these studies. (3) Several literature reviews were helpful in locating pertinent studies. Some policy-oriented papers were found in Google under topics to which the policy applied. (4) Several papers were added based on suggestions of reviewers.

FINDINGS

Quality of care as measured in process of care studies and in longitudinal studies of long-term survival of cancer patients tends to be higher at major teaching hospitals. Evidence on survival at 30 days post admission for common conditions and procedures also tends to favor such hospitals. Findings on other dimensions of relative quality are mixed. Hospitals with a substantial commitment to graduate medical education, major teaching hospitals, are about 10% to 20% more costly than nonteaching hospitals. Private insurers pay a differential to major teaching hospitals at this range's lower end. Inclusive of subsidies, Medicare pays major teaching hospitals substantially more than 20% extra, especially for complex surgical procedures.

CONCLUSIONS

Based on the evidence on quality, there is reason for patients to be willing to pay more for inclusion of major teaching hospitals in private insurer networks at least for some services. Medicare payment for GME has long been a controversial policy issue. The actual indirect cost of GME is likely to be far less than the amount Medicare is currently paying hospitals.

The impact of obesity on hospitalized patients with ulcerative colitis

Background

Obesity is the fifth leading risk factor for mortality in the world and it has increased among patients with ulcerative colitis in recent years. We examined the impact of obesity on the hospitalized patients admitted primarily with a diagnosis of ulcerative colitis.

Methods

We used the National Inpatient Sample data for the year 2016 to identify patients with ulcerative colitis and compared obese and non-obese patients in terms of length of hospital stay, total charges, and mortality. We used multiple imputations to estimate missing values and survey analysis to estimate the outcomes, and we adjusted for confounders by implementing the inverse probability of treatment weighting using propensity score.

Results

A total of 61,075 admissions with ulcerative colitis were identified. Among these, 6020 were diagnosed with obesity. Baseline hospital and patient characteristics between the 2 groups were notable for differences in age and sex. Patients with obesity were found to have a mean hospital stay longer by 0.57 days (95% confidence interval [CI] 0.22-0.93; P=0.002) and charges $6341.71 higher (95%CI 2499.72-10,183.71; P=0.001) compared to non-obese patients. There was no difference in hospital mortality, with an odds ratio of 0.28 (95%CI 0.04-2.05; P=0.212).

Conclusion

In a comprehensive review of inpatient admissions in 2016, primarily for ulcerative colitis, obesity was associated with a longer hospital stay and higher total charges per admission after balancing of confounders.

The impact of medical interventions on admission characteristics in children with congenital heart disease and cardiomyopathy

INTRODUCTION

Children with congenital heart disease and cardiomyopathy are a unique patient population. Different therapies continue to be introduced with large practice variability and questionable outcomes. The purpose of this study is to determine the impact of various medications on intensive care unit length of stay, total length of stay, billed charges, and mortality for admissions with congenital heart disease and cardiomyopathy.

MATERIALS AND METHODS

We identified admissions of paediatric patients with cardiomyopathy using the Pediatric Health Information System database. The admissions were then separated into two groups: those with and without inpatient mortality. Univariate analyses were conducted between the groups and the significant variables were entered as independent variables into the regression analyses.

RESULTS

A total of 10,376 admissions were included these analyses. Of these, 904 (8.7%) experienced mortality. Comparing patients who experienced mortality with those who did not, there was increased rate of acute kidney injury with an odds ratio (OR) of 5.0 [95% confidence interval (CI) 4.3 to 5.8, p < 0.01], cardiac arrest with an OR 7.5 (95% CI 6.3 to 9.0, p < 0.01), and heart transplant with an OR 0.3 (95% CI 0.2 to 0.4, p < 0.01). The medical interventions with benefit for all endpoints after multivariate regression analyses in this cohort are methylprednisolone, captopril, enalapril, furosemide, and amlodipine.

CONCLUSIONS

Diuretics, steroids, angiotensin-converting enzyme inhibitors, calcium channel blockers, and beta blockers all appear to offer beneficial effects in paediatric cardiomyopathy admission outcomes. Specific agents within each group have varying effects.

Cost-Effectiveness of a Multi-Disciplinary Emergency Consultation System for Suicide Attempts by Drug Overdose in Young People and Adult Populations

The purpose of this study was to compare the characteristics of suicide attempts by drug overdose between young people and adults, and evaluate the cost-effectiveness of a multi-disciplinary emergency consultation system (MECS) for suicide attempters with drug overdose. It was verified by comparing and analyzing data from June 1, 2017 to May 31, 2018 (before the MECS was implemented; pre-MECS), and from June 1, 2018 to May 31, 2019 (after the MECS was implemented; post-MECS). The data were retrospectively reviewed for a total of 251 such patients with suicide attempts by drug overdose who visited the emergency room of a university hospital in Seoul during the period. The young people group were shown to be more likely to use painkillers and less likely to use psychoactive drugs for a suicide attempt (p < 0.01), had more unplanned attempts than planned ones (p < 0.01), and had lower levels of intentionality for suicide (p = 0.04) and of suicide lethality (p = 0.02), compared to the adult group. We defined suicide attempts as being "serious" when there was both high intentionality and lethality. On this basis, the young people group had less serious suicide attempts, compared to the adult group (p = 0.02). Young people in the post-MECS group had lower intensive care unit (ICU) costs (p = 0.01) and lower costs in the 6-months after the suicide attempt (p = 0.02) compared to those in the pre-MECS group. Young people, both with serious (p < 0.01) and non-serious attempts (p < 0.01) in the post-MECS group had lower ICU costs compared to those in the pre-MECS group. Adults with non-serious attempts in the post-MECS group had lower ICU costs (p < 0.01) compared to those in the pre-MECS group. Therefore, it can be concluded that fast and precise cooperation from the multidisciplinary departments for patients who attempted suicide by drug overdose reduced unnecessary ICU treatment and costs, especially in young attempters and those with lower levels of intentionality and lethality.

Neonatal brachial plexus palsy: associated birth injury outcomes, hospital length of stay and costs

OBJECTIVE

To compare the birth injury outcomes and hospital length of stay and costs among newborns delivered at 34-42 weeks with neonatal brachial plexus palsy (NBPP) versus those without.

STUDY DESIGN

We conducted a retrospective, cross-sectional study using data from the National Inpatient Sample to identify all newborns hospitalizations that occurred in the U.S. between 2016 and 2017. We included non-anomalous single liveborn delivered in-hospital at 34-42 weeks. The newborns with NBPP were identified by International Classification of Diseases, 10th Revision, Clinical Modification codes. Birth injury outcomes, and hospital length of stay and hospital costs were examined. A multivariable Poisson regression model with robust error variance was used to examine the association between NBPP and birth injury outcomes. A multivariable generalized linear regression model was used to examine the association between NBPP and hospital length of stay and hospital costs.

RESULTS

Of 7,019,722 non-anomalous single liveborn delivered at 34-42 weeks in the U.S. from 2016 to 2017, the rate of NBPP (n = 6695) was 0.95 per 1000 newborn hospitalizations. After multivariable regression adjustment, compared to newborns without NBPP, the risk of the composite birth injury outcome was 2.91 (95% CI 2.61-3.25) times higher in those with NBPP. Similar results of an increased risk among newborns with NBPP were observed in all individual birth injury outcomes. Compared to newborns without NBPP, after adjustment, the hospital length of stay was 1.48 (95% IC 1.38-1.59) times higher and the hospital costs were 2.21 (95% CI 1.97-2.48) times higher in those with NBPP.

CONCLUSIONS

Among newborns delivered at 34-42 weeks, the risk of associated birth injuries, hospital length of stay and costs, were significantly higher in newborns with NBPP than those without.

Delirium Among Hospitalized Older Adults With Acute Heart Failure Exacerbation

BACKGROUND

Delirium among older adults hospitalized with acute heart failure is associated with increased mortality. However, studies concomitantly assessing the association of delirium with both clinical and economic outcomes in this population, such as mortality, hospital cost, or length of stay, are lacking.

METHODS AND RESULTS

We conducted a retrospective observational study using National Inpatient Sample data from 2011 to 2014. Using multivariable logistic regression, we assessed the association of delirium with in-hospital mortality, then estimated the incremental hospital cost and excessive length of stay adjusting for demographic and clinical factors using multivariable generalized linear regression. The association of other medical complications on clinical and economic outcomes was also assessed. A total of 568,565 (weighted N = 2,826,131) hospitalizations of patients 65 years or older with acute heart failure from 2011 to 2014 were included in the final analysis. The reported prevalence of delirium was 4.53%. After multivariable adjustment, delirium was associated with a 2.35-fold increase in the odds of in-hospital mortality (95% confidence interval [CI] 2.23-2.47), which was lower than the odds ratio for sepsis/septicemia (5.36; 95% CI, 5.02-5.72) or respiratory failure (4.53; 95% CI, 4.38-4.69), but similar to that for acute kidney injury (2.39; 95% CI, 2.31-2.48) and higher than for non-ST elevation myocardial infarct (1.57; 95% CI, 1.46-1.68). Delirium increased the total hospital cost by $4,262 (95% CI, $4,002-4,521) and the length of stay by 1.73 days (95% CI, 1.68-1.78), which was slightly lower than, but similar to, acute kidney injury ($4,771; 95% CI, $4,644-4,897) and 1.82 days (95% CI, 1.79-1.84), and higher than non-ST elevation myocardial infarct ($1,907; 95% CI, $1,629-2,185) and 0.31 days (95% CI, 0.25-0.37).

CONCLUSIONS

Delirium was associated with increased in-hospital mortality, total hospital cost, and length of stay, and the magnitude of the effect was similar to that for acute kidney injury. Enhanced efforts to prevent delirium are needed to decrease its adverse impact on clinical and economic outcomes for hospitalized older adults with acute heart failure.

Association between Extracorporeal Membrane Oxygenation (ECMO) and Mortality in the Patients with Cardiac Arrest: A Nation-Wide Population-Based Study with Propensity Score Matched Analysis

We attempted to determine the impact of extracorporeal membrane oxygenation (ECMO) on short-term and long-term outcomes and find potential resource utilization differences between the ECMO and non-ECMO groups, using the National Health Insurance Service database. We selected adult patients (≥20 years old) with non-traumatic cardiac arrest from 2007 to 2015. Data on age, sex, insurance status, hospital volume, residential area urbanization, and pre-existing diseases were extracted from the database. A total of 1.5% (n = 3859) of 253,806 patients were categorized into the ECMO group. The ECMO-supported patients were more likely to be younger, men, more covered by national health insurance, and showed, higher usage of tertiary level and large volume hospitals, and a lower rate of pre-existing comorbidities, compared to the non-ECMO group. After propensity score-matching demographic data, hospital factors, and pre-existing diseases, the odds ratio (ORs) of the ECMO group were 0.76 (confidence interval, (CI) 0.68–0.85) for 30-day mortality and 0.66 (CI 0.58–0.79) for 1-year mortality using logistic regression. The index hospitalization was longer, and the 30-day and 1-year hospital costs were greater in the matched ECMO group. Although ECMO support needed longer hospitalization days and higher hospital costs, the ECMO support reduced the risk of 30-day and 1-year mortality compared to the non-ECMO patients.

The financial burden associated with multiple shoulder dislocations and the potential cost savings of surgical stabilization

Introduction

Shoulder dislocation is a costly problem and can have a high risk for recurrent instability after initial dislocation based on well-defined patient characteristics. Patients with recurrent instability can be treated with shoulder stabilizing procedures. Although more costly, surgery may decrease the overall health care burden of managing a patient with multiple shoulder dislocations nonoperatively.

Methods

We performed a retrospective chart review of all patients who presented to the emergency department (ED) with a diagnosis of a shoulder dislocation at a level 1 academic trauma center during the year 2016. Patient information regarding the current dislocation episode, previous dislocations, shoulder surgeries, and postreduction follow-up was gathered. These data were then used to determine the average cost of an ED presentation for a shoulder dislocation episode as obtained from the hospital finance department. The average cost of shoulder stabilization surgery was used to conduct a cost-benefit analysis of operative vs. nonoperative management.

Results

Data were collected on 104 individuals who presented to the ED with shoulder dislocations. Of these, 65 were primary dislocations and 39 were recurrent dislocations. Twelve patients underwent shoulder stabilization surgery after their ED presentation. The average cost to the institution for an ED visit requiring the closed reduction of a shoulder dislocation was $2207 ($973.21 without sedation and $3744 with conscious sedation). The average cost of a shoulder stabilization procedure performed at this same institution was $7807.

Discussion and conclusion

Although shoulder stabilization has a higher cost on the front end, this intervention results in cost savings if it prevents 2-3 future shoulder dislocations resulting in ED visits. These findings suggest that, for patients with a high risk for recurrent instability, not only would stabilization surgery help prevent subsequent dislocation events but would also minimize health care costs.

Sentinel lymph node biopsy is associated with increased cost in higher risk thin melanoma

INTRODUCTION

National Comprehensive Cancer Network guidelines recommend that sentinel lymph node biopsy (SLNB) be discussed with patients with thin melanoma at higher risk for lymph node metastasis (T1b or T1a with positive deep margins, lymphovascular invasion, or high mitotic index). We examined the association between SLNB and resource utilization in this cohort.

METHODS

We conducted a retrospective cohort study of patients that underwent wide local excision for higher risk thin melanomas from 2009 to 2018 at a tertiary care center. Patients who underwent SLNB were compared to those who did not undergo SLNB with regard to resource utilization, including total hospital cost.

RESULTS

A total of 70 patients were included in the analysis and 50 patients (71.4%) underwent SLNB. SLNB was associated with increased hospital costs ($6700 vs. $3767; p < .01) and increased operative time (68.5 vs. 36.0 min; p < .01). This cost difference persisted in multivariable regression (p < .01). Of patients who underwent successful SLN mapping, 3 out of 49 patients had a positive SLN (6.1%). The cost to identify a single positive sentinel lymph node (SLN) was $47,906.

CONCLUSION

In patients with a higher risk of thin melanoma, SLNB is associated with increased cost despite a low likelihood of SLN positivity. These data better inform patient-provider discussions as the role of SLNB in thin melanoma evolves.

Extubation in the Operating Room After Transapical Transcatheter Aortic Valve Implantation Safely Improves Time-Related Outcomes and Lowers Costs: A Propensity Score-Matched Analysis

OBJECTIVE

The experience of safe extubation in the operating room (OR) after transcatheter aortic valve implantation (TAVI) procedure remains not well established. The authors conducted this study to assess the effect of OR extubation in comparison with extubation in the intensive care unit (ICU) on the outcomes and cost in patients undergoing transapical-TAVI.

DESIGN

A propensity score-matched analysis.

SETTING

A single major urban teaching and university hospital.

PARTICIPANTS

A total of 266 patients undergoing transapical TAVI under general anesthesia between June 2015 and March 2020.

INTERVENTIONS

Propensity matching on pre- and intraoperative variables was used to identify 99 patients undergoing extubation in the OR versus 72 undergoing extubation in the ICU for outcome analysis.

MEASUREMENTS AND MAIN RESULTS

After matching, extubation in the OR showed significant reductions of length of stay (LOS) in ICU (38.8 ± 17.4 v 58.0 ± 70.0 h, difference -19.2, 95% confidence interval [CI] -35.7 to -2.7, p = 0.009) and postoperative LOS in hospital (7.1 ± 3.9 v 10.1 ± 4.6 d, difference -3.0, 95% CI -4.3 to -1.7, p < 0.0001) compared with ICU extubation, but did not significantly affect the composite incidence of any postoperative complications (46.5% [46 of 99] v 52.8% [38 of 72], difference -6.3%, 95% CI -21.5 to 8.9, p = 0.415). Also, extubation in the OR led to significant reduction of total hospital cost compared with extubation in the ICU (¥303.5 ± 17.3 v ¥329.9 ± 52.3 thousand, difference -26.2, 95% CI -38.8 to -13.7, p < 0.0001).

CONCLUSIONS

The current study provided evidence that extubation in the OR could be performed safely without increases in morbidity, mortality, or reintubation rate and could provide cost-effective outcome benefits in patients undergoing transapical-TAVI.

Antibiotic use in children hospitalised with pneumonia in Central Vietnam

BACKGROUND AND OBJECTIVES

Excessive use of antibiotics has been noted in children with respiratory tract infections in Vietnam, but antibiotic use in hospitalised children is poorly documented. Antibiotic use and direct healthcare costs in children hospitalised with pneumonia in central Vietnam were assessed.

METHODS

A prospective descriptive study of children under 5 years old admitted with a primary admission diagnosis of 'pneumonia' to the Da Nang Hospital for Women and Children over 1 year.

RESULTS

Of 2911 children hospitalised with pneumonia, 2735 (94.0%) were classified as 'non-severe' pneumonia by the admitting physician. In total, 2853 (98.0%) children received antibiotics. Intravenous antibiotics were given to 336 (12.3%) children with 'non-severe' and 157/176 (89.2%) children with 'severe' pneumonia; those with 'non-severe' pneumonia accounted for 68.2% (336/493) of intravenous antibiotics given. Only 19.3% (95/493) of children on intravenous antibiotics were stepped down to an oral antibiotic. Cefuroxime was the preferred oral agent, and ceftriaxone was the preferred injectable agent. Hospital admission for oral antibiotics in 'non-severe' pneumonia was a major cost driver, with an average direct cost of US$78.9 per patient, accounting for 54.0% of the total hospitalisation cost in the study cohort. In addition, 336 (12.3%) children with non-severe pneumonia received intravenous antibiotics without indication, accounting for a further 23.2% of hospitalisation costs.

CONCLUSION

Limiting unnecessary hospitalisation and considering early intravenous to oral step down antibiotic will reduce direct health system costs and morbidity in children with respiratory tract infections in Vietnam.

Trends in safety and cost of deep brain stimulation for treatment of movement disorders in the United States: 2002-2014

PURPOSE

Deep brain stimulation (DBS) is being increasingly utilized to treat movement disorders including Parkinson's disease (PD), essential tremor (ET), and dystonia. An improved understanding of national trends in safety and cost is necessary. Herein, our objectives are to (1) characterize complication, mortality, and cost profiles of patients undergoing DBS for movement disorders in the United States, (2) identify predictors of morbidity and mortality, and (3) evaluate impact of complications on cost.

METHODS

DBS surgeries were extracted from the National Inpatient Sample (NIS) 2002-2014 for the clinical indications of PD, ET, and dystonia. Patient characteristics and eight complication categories (hardware malfunction, infection, neurological, other haemorrhagic, thromboembolic, cardiac, pulmonary, and renal/urinary) were reviewed. Outcomes included complications, mortality, hospitalization length, and inflation-adjusted cost.

RESULTS

There were 44,866 weighted admissions (PD-73.5%, ET-22.7%, dystonia-3.8%). The number of procedures increased 2.22-fold from 2002 to 2014 (N = 2372 in 2002; N = 5260 in 2014). Inpatient cost was $22,802 ± 13,164, remaining stable from 2002 to 2014 ($24,188 ± 15,910, $20,630 ± 11,031, respectively). Four percent experienced complications (dystonia-6.0%, PD-4.4%, ET-3.1%, p < .001). In-hospital mortality was 0.2%. Cost was greater in patients with complications ($36,306 ± 29,263 vs. $22,196 ± 11,560, p < .001). Most common complications were renal/urinary (1.5%), neurological (1.1%), and pulmonary (0.7%). Thromboembolic, pulmonary, and haemorrhagic complications were associated with greatest cost.

CONCLUSION

Increased DBS utilization for adult movement disorders in the United States from 2002 to 2014 was attributed to rapid adoption by teaching hospitals for PD. DBS remains a safe procedure with low overall complications and stable inpatient costs from 2002 to 2014. Complication risks vary by type of movement disorder, and although rare, multiple complications increase morbidity and cost of care.

A Comparison of Length of Hospitalization and Costs in Obese and Non-Obese Pediatric Patients at a Single Hospital in Honolulu

The association of obesity with increased hospital costs and length of stay among hospitalized pediatric patients identified by ICD-9 coding may be underestimated due to underreporting of appropriate ICD-9 coding for obesity status. The objective of this study was to compare these lengths of stay and hospital costs. A retrospective chart review was conducted of pediatric patients admitted from May 2009 to January 2012 at Kapi'olani Medical Center, Honolulu, Hawai'i, with the 20 most common primary admission diagnosis ICD-9 codes. Length of hospital stay and total hospital costs were compared for obese, overweight, and normal-weight patients based on body mass index (BMI), controlling for age, sex, ethnicity, insurance type, diagnosis, and calendar year using logistic regression. Analysis of 730 patients showed 1% of overweight patients and 35% of obese patients were correctly coded with the corresponding ICD-9 code for weight status. Obese patients had 15% longer hospital stays and 19% higher hospital costs than normal weight patients, when controlled for age, sex, ethnicity, insurance type, calendar year, and primary diagnosis. Subgroup analyses of the top 3 most common primary admission diagnoses showed obese patients with asthma had significantly higher hospital costs than normal weight patients. Obesity is an independent risk factor for increasing hospital resource utilization in hospitalized pediatric patients. Documentation of ICD-9 codes for overweight and obesity in this cohort drastically underrepresented the true prevalence of obesity and overweight status in this sample of hospitalized children. Further research is needed to better understand the complex role of obesity in pediatric inpatients, particularly among those with asthma.

Outcomes in Elderly Japanese Patients Treated for Aneurysmal Subarachnoid Hemorrhage: A Retrospective Nationwide Study

OBJECTIVE

Japan has the largest elderly population in the world. As data on the clinical outcomes in elderly patients with aneurysmal subarachnoid hemorrhage (aSAH), including those older than 80 years, are lacking, we analyzed the characteristics of 54,805 aSAH patients and recorded their treatments and clinical outcomes using a Japanese nationwide inpatient database.

METHODS

Using the Japanese Diagnostic Procedure Combination database, we identified aSAH patients aged 18 years or older who were hospitalized between July 1, 2010 and March 31, 2016. They were categorized as less than or equal to 60-, 61-70-, 71-80-, 81-90-, and greater than or equal to 91 years of age. The primary outcome was the modified Rankin Scale (mRS) score at discharge. Multivariable logistic regression analysis was performed to examine factors affecting the mRS score at discharge.

RESULTS

Of 54,805 patients, 37.5% were aged less than or equal to 60 years; 24.8% were 61-70-, 21.8% were 71-80-, 13.9% were 81-90-, and 2.0% were greater than or equal to 91 years old at the time of the insult. Among 46,107 patients younger than 81 years, 58.9% underwent surgical clipping (SC), 22.9% endovascular coiling (EC), and 18.2% were treated conservatively. There were 8,698 patients aged 81 years or older, 32.4% underwent SC, 23.2% EC, and 44.4% were treated conservatively. A poor mRS score (3-6) at discharge was recorded in 87.2% of patients older than 80 years. Multivariable logistic regression was used to compare their estimated odds ratio (OR) for a poor mRS score at discharge with that of patients aged less than or equal to 60 years. The OR increased by 87% in patients between 61 and 70 years of age (P < .001; OR, 1.87; 95% confidence interval (CI), 1.77-1.98), by 358% in patients aged from 71 to 80 years (P < .001; OR, 4.58; 95%CI, 4.29-4.89), by 1,035% in patients between 81 and 90 years (P < .001; OR, 11.35; 95%CI, 10.32-12.49), and by 1,710% in patients aged more than or equal to 91 years (P < .001; OR, 18.10; 95%CI, 13.96-23.46).

CONCLUSIONS

As the treatment outcomes in elderly aSAH patients, especially those 80 years old or older, were poor, the appropriate therapy decisions must be made on a case-by-case basis.

A 5-Year Review of Hospital Costs and Reimbursement in the Surgical Management of Degenerative Spondylolisthesis

Background

To evaluate charges, expenses, reimbursement, and hospital margins with noninstrumented posterolateral fusion in situ (PLF), posterolateral fusion with pedicle screws (PPS), and PPS with interbody device (PLIF) in degenerative spondylolisthesis with spinal stenosis.

Methods

A retrospective chart review was performed from 2010 to 2014 based on ICD-9 diagnoses of degenerative spondylolisthesis with spinal stenosis in patients undergoing single-level fusions. All charges, expenses, reimbursement, and margins were obtained through financial auditing. A multivariate linear regression model was used to compare demographics, charges, etc. A 1-way analysis of variance with Tukey post hoc analysis was used to analyze reimbursements and margins based upon insurances.

Results

Two hundred thirty-three patients met inclusion criteria. The overall charges and expenses for PLF were significantly less compared to both types of instrumented fusions (P < .0001). Medicare and private insurance were the most common insurance types; Medicare and private insurance mean reimbursements for PLF were $36,903 and $47,086, respectively; for PPS, $37,450 and $53,851, and for PLIF $40,171 and $51,640. Hospital margins for PPS and PLIF in Medicaid patients were negative (-$3,702 and -$6,456). Hospital margins were largest for both worker's compensation and private insurance patients in all fusion groups. Hospital margins with Medicare for PLF, PPS, and PLIF were $24,347, $19,205, and $23,046, respectively. Hospital margins for private insurance for PLF, PPS, and PLIF were $37,569, $36,834, and $33,134, respectively.

Conclusions

As more instrumentation is used, the more it costs both the hospital and the insurance companies; hospital margins did not increase correspondingly.

Clinical Relevance

Improved understanding of related costs and margins associated with lumbar fusions to help transition to more cost effective spine centers.

The Clinical and Economic Impact of Antibiotic Resistance in China: A Systematic Review and Meta-Analysis

Antibiotic resistance (ABR) is one of the biggest threats to global health, especially in China. This study aims to analyze the published literature on the clinical and economic impact of ABR or multi-drug resistant (MDR) bacteria compared to susceptible bacteria or non-infection, in mainland China. English and Chinese databases were searched to identify relevant studies evaluating mortality, hospital stay, and hospital costs of ABR. A meta-analysis of mortality was performed using a random effects model. The costs were converted into 2015 United States (US) dollars. Of 13,693 studies identified, 44 eligible studies were included. Twenty-nine investigated the impact of ABR on hospital mortality, 37 were focused on hospital stay, and 21 on hospital costs. Patients with ABR were associated with a greater risk of overall mortality compared to those with susceptibility or those without infection (odds ratio: 2.67 and 3.29, 95% confidence interval: 2.18–3.26 and 1.71–6.33, p < 0.001 and p < 0.001, respectively). The extra mean total hospital stay and total hospital cost were reported, ranging from 3 to 46 days, and from US$238 to US$16,496, respectively. Our study indicates that ABR is associated with significantly higher mortality. Moreover, ABR is not always, but usually, associated with significantly longer hospital stay and higher hospital costs.

Institution-Wide Blood Management Protocol Reduces Transfusion Rates Following Spine Surgery

Background

Spine surgery is associated with significant intraoperative blood loss, often leading to transfusion. Patients who receive transfusions have an increased length of stay and risk of perioperative complications. To decrease the transfusion rate, we implemented an evidence-based institution-wide restrictive transfusion blood management guideline. The goal of this study is to describe the impact of this guideline on our spine surgery patients.

Methods

We analyzed the incidence of transfusion following 3709 single-institution, inpatient spine procedures before and after implementation of a revised blood transfusion protocol. The baseline period (1742 patients) from January 2014 to March 2015 was compared to the study period (1967 patients) of April 2015 to July 2016. One patient was excluded because of incomplete medical records. The revised protocol included establishing a postoperative blood transfusion trigger at hemoglobin < 7g/dL, instituting a computerized provider order entry, and appointing a physician champion to monitor and report progress.

Results

Transfusion rate decreased from 16.2% to 9.7% from baseline to study period, respectively (P < .001). The number of transfusions in patients with hemoglobin > 7g/dL decreased to 4.9% from 6.1% (P = .09). The rate of transfusions with a prior hemoglobin test increased from 42.0% to 59.1% (P < .001). Length of stay was reduced from 3.67 to 3.46 days (P = .04), and postsurgical infection rate was reduced from 1.5% to 0.6% (P = .01). There was no significant difference in total hospital costs following protocol implementation.

Conclusions

Implementation of a restrictive transfusion protocol through use of a computerized provider order entry and a physician champion to oversee clinician compliance led to a 40.1% reduction in blood transfusion following spine surgery. Behavior changes were visible with a 40.7% increase in hemoglobin documentation before transfusion, and patients benefited from a reduction in length of stay and postsurgical infection rate. Future study is encouraged to understand the long-term impact of this intervention and its role in hospital expenditure.

Health economic implications of postoperative complications following liver resection surgery: a systematic review

BACKGROUND

Limited data exists concerning the health economics of liver resection, with even less information on the costs emerging from complications, despite this remaining an important target from a health economic perspective. Our objective was to describe the financial burden of complications following liver resection.

METHODS

We conducted a systematic search and included studies reporting resource use of in-hospital complications during the index liver resection admission. All indications for liver resection were considered. All techniques were considered. Data was collected using a data extraction table and a narrative synthesis was performed.

RESULTS

We identified 12 eligible articles. There was considerable heterogeneity in study designs, patient populations and outcome definitions. We found weak evidence of increased costs associated with major liver resection compared to minor resections. We found robust evidence supporting the increasing economic burden arising from complications after liver resection. Acceptable evidence for increased cost due to the presence and grade of complication was found. Strong evidence concerning the association of length of stay with costs was demonstrated.

CONCLUSIONS

The presence and grade of complications increase hospital cost across diverse settings. The costing methodology should be transparent and complication grading systems should be consistent in future studies.

Correlation of perioperative risk scores with hospital costs in neurosurgical patients

OBJECTIVE

The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) online surgical risk calculator uses inherent patient characteristics to provide predictive risk scores for adverse postoperative events. The purpose of this study was to determine if predicted perioperative risk scores correlate with actual hospital costs.

METHODS

A single-center retrospective review of 1005 neurosurgical patients treated between September 1, 2011, and December 31, 2014, was performed. Individual patient characteristics were entered into the NSQIP calculator. Predicted risk scores were compared with actual in-hospital costs obtained from a billing database. Correlational statistics were used to determine if patients with higher risk scores were associated with increased in-hospital costs.

RESULTS

The Pearson correlation coefficient (R) was used to assess the correlation between 11 types of predicted complication risk scores and 5 types of encounter costs from 1005 health encounters involving neurosurgical procedures. Risk scores in categories such as any complication, serious complication, pneumonia, cardiac complication, surgical site infection, urinary tract infection, venous thromboembolism, renal failure, return to operating room, death, and discharge to nursing home or rehabilitation facility were obtained. Patients with higher predicted risk scores in all measures except surgical site infection were found to have a statistically significant association with increased actual in-hospital costs (p < 0.0005).

CONCLUSIONS

Previous work has demonstrated that the ACS NSQIP surgical risk calculator can accurately predict mortality after neurosurgery but is poorly predictive of other potential adverse events and clinical outcomes. However, this study demonstrates that predicted high-risk patients identified by the ACS NSQIP surgical risk calculator have a statistically significant moderate correlation to increased actual in-hospital costs. The NSQIP calculator may not accurately predict the occurrence of surgical complications (as demonstrated previously), but future iterations of the ACS universal risk calculator may be effective in predicting actual in-hospital costs, which could be advantageous in the current value-based healthcare environment.

Short-term outcomes associated with drain use in shoulder arthroplasties: a prospective, randomized controlled trial

BACKGROUND

This study examined the immediate outcomes during the perioperative period associated with drains in the setting of total shoulder arthroplasty or reverse shoulder arthroplasty. We hypothesized that drain use would result in lower postoperative hemoglobin and hematocrit levels that would increase transfusion rates and longer hospital stays that would increase hospital costs.

METHODS

The study prospectively randomized 100 patients (55% women; average age, 69.3 years) who underwent total shoulder arthroplasty or reverse shoulder arthroplasty to receive a closed-suction drainage device (drain group, n = 50) or not (control group, n = 50) at the time of wound closure. Basic demographic information and intraoperative and postoperative data were collected.

RESULTS

The groups were similar with respect to basic patient demographics. Postoperatively, drains had no effect on transfusion rates or any perioperative complication (P > .715). There were also no significant differences in hemoglobin or hematocrit levels immediately after surgery or on postoperative day 1. On average, patients were discharged from the hospital 1.6 days and 2.1 days postoperatively in the control and drain groups, respectively (P = .124). The average cost associated for the control cohort's hospital stay was $35,796 ± $13,078 compared with $43,219 ± $24,679 for the drain cohort (P = .063).

DISCUSSION

Drain use after shoulder arthroplasty had no appreciable difference on short-term perioperative outcomes, postoperative anemia, length of hospital stay, or cost. It is possible that the potential negative effects of postoperative drainage are blunted by the routine use of tranexamic acid.

Extended care unit: a feasible economic solution for longer-term palliative inpatients

Palliative patients who cannot go home are placed into nursing homes. This involves moving between up to five locations in the final weeks of life. We censored all inpatients on a single day from a large tertiary centre to investigate the feasibility of a proposed extended care unit to accommodate patients with a prognosis of less than 90 days, unable to return home, and with nursing home referral process commenced. This study identifies a present demand for an extended care unit (15 patients identified), outlines admission criteria, and proposes a funding model that is predicted to save hospital costs (savings of $207.70 per patient per bed day). This patient-focused approach is a feasible economic solution to the current unmet needs of this patient demographic.

Enhanced recovery after surgery protocol for prostate cancer patients undergoing laparoscopic radical prostatectomy

Objective

To determine the value of an enhanced recovery after surgery (ERAS) protocol for prostate cancer patients undergoing laparoscopic radical prostatectomy (LRP).

Methods

We conducted a retrospective cohort study using clinical data for 288 patients who underwent LRP in our hospital from June 2010 to December 2016. A total of 124 patients underwent ERAS (ERAS group) and the remaining 164 patients were allocated to the control group. ERAS comprised prehabilitation exercise, carbohydrate fluid loading, targeted intraoperative fluid resuscitation and keeping the body warm, avoiding drain use, early mobilization, and early postoperative drinking and eating.

Results

The times from LRP to first water intake, first ambulation, first anal exhaust, first defecation, pelvic drainage-tube removal, and length of hospital stay (LOS) were all significantly shorter, and hospitalization costs and the incidence of postoperative complications were significantly lower in the ERAS group compared with the control group. No deaths or reoperations occurred in either group, and there were no readmissions in the ERAS group, within 90 days after surgery.

Conclusion

ERAS protocols may effectively accelerate patient rehabilitation and reduce LOS and hospitalization costs in patients undergoing LRP.

The burden of cardiac arrhythmias in sarcoidosis: a population-based inpatient analysis

Background

Cardiac involvement in the sarcoidosis is known to ensue with diverse clinical forms and its investigation is challenging at times. This article features the under-perceived burden, patterns, and outcomes of different arrhythmias, which may have a prognostic significance in patients with sarcoidosis.

Methods

We queried the National Inpatient Sample (NIS) for 2010-2014 to recognize sarcoidosis, arrhythmia, and comorbidities affecting hospitalizations. The nationwide estimates were attained using discharge records. We assessed incidence and trends in sarcoidosis-related arrhythmia and consequential inpatient mortality, hospital length of stay (LOS), hospitalization charges and predictors of mortality with multivariate analysis.

Results

We identified 369,285 sarcoidosis-related hospitalizations. Of these, nearly one-fifth suffered from arrhythmias (n=73,424). The sarcoidosis patients developing arrhythmias were older (61.9 vs. 56.0 years) compared to those without. Males had the higher incidence of arrhythmias compared to females. Atrial fibrillation (Afib) (10.97%) was the most common subtype, followed by ventricular tachycardia (1.97%). There was a rising trend in arrhythmia-related hospital admissions and mortality among sarcoidosis, with Afib incidence displaying the highest increase. Traditional cardiac comorbidities were higher in the sarcoid-arrhythmia group. The arrhythmia group had significantly higher mortality (3.7% vs. 1.5%), mean hospital LOS (6.4 vs. 5.2 days) and hospital charges ($64,118 vs. $41,565) compared to non-arrhythmia group (P<0.001). Incident arrhythmia significantly increased the mortality odds in sarcoidosis (adjusted odds ratio, 2.06).

Conclusions

The growing trend, deteriorating outcomes and higher mortality associated with sarcoid-related arrhythmias highlight the importance of timely diagnosis and aggressive management in this population.

Economic impact of tolvaptan treatment vs. fluid restriction based on real-world data among hospitalized patients with heart failure and hyponatremia

OBJECTIVES

To estimate the cost difference associated with tolvaptan treatment vs. fluid restriction (FR) among hospitalized patients with heart failure (HF) and hyponatremia (HN) based on a real-world registry of HN patients.

METHODS

An Excel-based economic model was developed to evaluate the cost impact of tolvaptan treatment vs. FR. Model input for hospital length of stay (LOS) was based on published data from the Hyponatremia Registry (HNR). Based on HNR data, tolvaptan-treated patients had a 2-day (median) shorter LOS compared to FR. Real-world effectiveness of tolvaptan treatment from the HNR was applied to a national sample of inpatients visits from the Premier Hospital database to estimate the potential LOS-related cost difference between tolvaptan treatment and FR. A one-way sensitivity and multivariable Monte Carlo sensitivity analysis were conducted.

RESULTS

Economic modeling results of the base-case analysis indicated that among hospitalized patients with HF, the hospital cost per admission, not including HN drug cost, was $3453 lower among patients treated with tolvaptan vs. FR, due to the shorter LOS associated with tolvaptan treatment. At wholesale acquisition cost of $362 per day and an average treatment duration of 3.2 days, the pharmacy cost of tolvaptan treatment per admission was estimated at $1157. Thus, after factoring the decrease in hospital medical costs and increase in pharmacy costs associated with tolvaptan treatment, results indicated a cost-offset opportunity of -$2296 per admission for patients treated with tolvaptan versus FR. Results of the sensitivity analyses were consistent with the base-case analysis.

LIMITATIONS

The model derives inputs from real-world observational data. No causal relationship can be inferred from this analysis.

CONCLUSIONS

Based on this economic analysis, tolvaptan treatment vs. FR among hospitalized patients with HF and HN may be associated with lower hospital-related costs, which offset the increase in pharmacy costs associated with tolvaptan treatment.

Depression Effects on Hospital Cost of Heart Failure Patients in California: An Analysis by Ethnicity and Gender

Background

Depression often interferes with self-management and treatment of medical conditions. This may result in serious medical complications and escalated health-care cost.

Objectives

Study distribution of heart failure (HF) cases estimates the prevalence of depression and its effects on HF-related hospital costs by ethnicity and gender.

Methods

Secondary data files of California Hospital Discharge System for he year 2010 were examined. For patients with a HF diagnosis, details regarding depression, demographics, comorbid conditions, and hospital costs were studied. Age-adjusted HF rates and depression were examined for whites, blacks, Hispanics, and Asians/Pacific Islanders (AP) by comparing HF patients with depression (HF^+D) versus HF without depression (HF^ND).

Results

HF cases (n = 62,685; average age: 73) included nearly an equal number of males and females. HF rates were higher (P < 0.001) among blacks compared to Hispanics, AP, and whites and higher among males than females. One-fifth of HF patients had depression, higher among females and whites compared to males and other ethnic groups. Further, HF hospital costs for blacks and AP were higher (P < 0.001) compared to other groups. The cost for HF^+D was 22% higher compared to HF^ND, across all gender and ethnic groups, largely due to higher comorbidities, more admissions, and longer hospitalization.

Conclusion

Depression, ethnicity, and gender are all associated with increased hospital costs of HF patients. The higher HF and HF^+D costs among blacks, AP, and males reflect additional burden of comorbidities (hypertension and diabetes). Prospective studies to assess if selective screening and treating depression among HF patients can reduce hospital costs are warranted.

The HEART Pathway and Hospital Cost Savings

Chest pain is a common complaint in emergency departments. Several guidelines and tools exist to help the clinician determine need for hospitalization. For low-risk patients, clinical judgment can underestimate a patient's risk of major adverse cardiac event. Implementation of an advanced diagnostic protocol with the HEART Pathway can reduce hospital cost. For our academic institution, we saw an approximate $1 million in total savings during the initial implementation year along with increased outpatient visits. In addition, an increase in outpatient visits confirmed previous estimates that implementation of the HEART Pathway results in >20% reduction of hospital costs. We also identify challenges and considerations for facilities looking to repeat our successes.

Association between costs and quality of acute myocardial infarction care hospitals under the Korea National Health Insurance program

If cost reductions produce a cost-quality trade-off, healthcare policy makers need to be more circumspect about the use of cost-effective initiatives. Additional empirical evidence about the relationship between cost and quality is needed to design a value-based payment system. We examined the association between cost and quality performances for acute myocardial infarction (AMI) care at the hospital level.In 2008, this cross-sectional study examined 69 hospitals with 6599 patients hospitalized under the Korea National Health Insurance (KNHI) program. We separately estimated hospital-specific effects on cost and quality using the fixed effect models adjusting for average patient risk. The analysis examined the association between the estimated hospital effects against the treatment cost and quality. All hospitals were distributed over the 4 cost × quality quadrants rather than concentrated in only the trade-off quadrants (i.e., above-average cost and above-average quality, below-average cost and below-average quality). We found no significant trade-off between cost and quality among hospitals providing AMI care in Korea.Our results further contribute to formulating a rationale for value-based hospital-level incentive programs by supporting the necessity of different approaches depending on the quality location of a hospital in these 4 quadrants.

Predicting the Incremental Hospital Cost of Adverse Events Among Medicare Beneficiaries in the Comprehensive Joint Replacement Program During Fiscal Year 2014

BACKGROUND

The Medicare program's Comprehensive Care for Joint Replacement (CJR) payment model places hospitals at financial risk for the treatment cost of Medicare beneficiaries (MBs) undergoing lower extremity joint replacement (LEJR).

METHODS

This study uses Medicare Provider Analysis and Review File and identified 674,777 MBs with LEJR procedure during fiscal year 2014. Adverse events (death, acute myocardial infarction, pneumonia, sepsis or shock, surgical site bleeding, pulmonary embolism, mechanical complications, and periprosthetic joint infection) were studied. Multivariable regressions were modeled to estimate the incremental hospital cost of treating each adverse event.

RESULTS

The risk-adjusted estimated hospital cost of treating adverse events varied from a high of $29,061 (MBs experiencing hip fracture and joint infection) to a low of $6308 (MBs without hip fracture that experienced pulmonary embolism).

CONCLUSION

Avoidance of adverse events in the LEJR hospitalization will play an important role in managing episode hospital costs in the Comprehensive Care for Joint Replacement program.

Preoperative biliary drainage versus direct surgery for perihilar cholangiocarcinoma: A retrospective study at a single center

Perihilar cholangiocarcinoma (pCC, also known as a Klatskin tumor) is the most common type of cholangiocarcinoma (CC). Preoperative biliary drainage (PBD) is indicated for pCC patients with acute cholangitis or patients who need portal vein embolization (PVE). However, the routine performance of PBD in other patients with pCC is still controversial. The current study retrospectively examined patients with pCC who did not undergo PVE and who did not have cholangitis who were seen at this Hospital to assess the advantages and disadvantages of PBD. This study also sought to find an optimal value of total bilirubin (TB) to indicate performing PBD. Between 2009 and 2014, after excluding patients with acute cholangitis and PVE, patients who had undergone hepatectomy for pCC were enrolled in this study. First, the surgical outcomes and postoperative outcomes were compared between PBD group and direct surgery group. Second, ROC curve analysis of a subgroup of patients was performed to find the best cut off value of TB for indicating the PBD. Third, the costs for patients, including the total charges and the charges per day were compared between the two groups. Subjects were 218 patients in total. Fifty-five patients underwent PBD. This group had a longer operative time [390 (210-700) vs. 360 (105-730) min, p = 0.013], and a longer hospital stay [20 (9-48) vs. 17 (6-93) days, p = 0.007], but underwent vascular resection and reconstruction less often [8 (14.5%) vs. 50 (30.7%), p = 0.019]. Mortality and morbidity were comparable between the two groups. ROC curve analysis of a subgroup of patients indicated that the cut-off value for total bilirubin was 218.75 μmol/L (12.4 mg/dL). The total hospital charges and the charges per day did not differ significantly for the two groups. Disadvantages of PBD were a longer operating time and a longer duration of hospitalization, but the short-term surgical outcomes and hospital charges of PBD group were comparable to the direct surgery group. PBD should be considered for patients when the diagnosis is still suspicious of pCC. Based on the current data, the optimal cut-off value for preoperative TB was 218.75 μmol/L (12.4 mg/dL) to indicate PBD for patients with pCC.

The cost-quality relationship in European hospitals: a systematic review

Objective To determine the relationship between cost and quality in European hospitals. Methods Juran's cost-quality curve served as a theoretical framework, linked to basic efficiency concepts. Based on systematic database searches, citation searches and cross-referencing, we identify 1093 empirical studies. After exclusion of studies from outside Europe (699), non-hospital settings (10 studies), lack of a cost parameter (194) or a quality parameter (27 studies), 22 studies (28 analyses) were assessed for direction of association and methodological heterogeneity. Results There was evidence of positive, negative, two-directional and no association between cost and quality. We examined whether diagnosis, procedure, type of quality measure and specification of the econometric model could explain the inconsistent evidence, but no clear explanation is identified. Despite the significant policy relevance, evidence on the relationship between costs and quality is limited. The literature is characterized by substantial methodological heterogeneity and lack of explicit definitions of the chosen cost and quality parameters, the econometric model and the underlying hypothesis for the cost-quality relationship. Conclusion It has been more than 60 years since Juran introduced the idea of failure costs, which implied that the marginal costs of quality could be non-constant. It seems imperative to acknowledge this idea in future studies.

A cost analysis of road traffic injuries in a tertiary hospital in south-west Nigeria

This study examines the burden of road traffic injuries (RTIs) among road crash victims in a tertiary hospital in Ibadan, Nigeria. The study adopted a purposive sampling method to obtain primary data. Interview was done with 266 RTI victims who were admitted to the University College Hospital, Ibadan and discharged between March and May, 2015, using a structured questionnaire. From the data obtained, the study carried out descriptive statistical analyses. The results showed that the average cost per patient for RTI treatment was ₦ 42,946 ($215.9); on average, the amount expended on surgery was the highest followed by wound dressing and drugs; and the prevalence of catastrophic out-of-pocket (OOP) expenditure was over 86%. It is recommended that given the high burden of OOP hospital expenditure associated with RTI, there is need to implement more effective financial protection mechanisms against the high OOP expenditure faced by crash victims.

Clinical and economic impact of meropenem resistance in Pseudomonas aeruginosa-infected patients

BACKGROUND

The emergence of carbapenem resistance has had a significant impact on both clinical and economic outcomes.

METHODS

A retrospective, observational cohort study was performed in a 433-bed tertiary care medical center. The cohort was established from all inpatients with Pseudomonas aeruginosa-positive cultures over a 3-year period. Two multivariate models were developed: a logistic regression model to evaluate the primary outcome of in-hospital mortality and a linear regression model to evaluate the secondary outcome of total hospital cost.

RESULTS

The adjusted odds ratio for in-hospital mortality among patients with meropenem-resistant isolates was 2.89 (95% confidence interval [CI], 1.15-7.28). There were significantly more deaths in the meropenem-resistant group (28.1% vs 8.9%, P = .003). Patients with meropenem-resistant P aeruginosa experienced a 4-day increase in median length of stay versus those in the meropenem-susceptible group (14 vs 9 days, P = .004). Likewise, the percentage of patients who required intensive care unit (ICU) admission increased from 42% to 81.3% (P <.001). Meropenem resistance was also associated with a significant increase in total hospital cost by a factor of 1.42 among patients who were not admitted to the ICU (95% CI, 1.03-1.95).

CONCLUSIONS

Our results demonstrate that meropenem resistance was a significant predictor of in-hospital mortality. Carbapenem resistance also resulted in a significant increase in hospital cost, but only among patients who were not admitted to the ICU.

Incidence, Morbidity, and Costs of Human Metapneumovirus Infection in Hospitalized Children

BACKGROUND

Human metapneumovirus (HMPV) causes acute respiratory tract infections in infants and children. We sought to measure the clinical and economic burden of HMPV infection in hospitalized children.

METHODS

We conducted a retrospective cohort study from 2007 to 2013 at Primary Children's Hospital in Salt Lake City, Utah. Children <18 years of age with laboratory-confirmed HMPV infection were included. Demographic, clinical, and financial data were abstracted from the electronic medical record.

RESULTS

During the study period, 815 children were hospitalized with laboratory-confirmed HMPV infection: 16% <6 months, 50% 6-23 months, 23% 2-4 years, and 11% 5-17 years of age. A complex chronic condition was identified in 453 (56%) children hospitalized with HMPV infection; this proportion increased with increasing age (P < .001). There was marked variation in annual HMPV hospitalization rates, ranging from 9 of 100 000 person-years in 2012-2013 to 79 of 100 000 in 2009-2010. Hospitalization rates were highest among children <2 years (200 of 100 000 person-years) and lowest among children 5-17 years of age (5 of 100 000). Of hospitalized children, 18% were treated in the intensive care unit and 6% required mechanical ventilation. The median length of stay was 2.8 days (interquartile range [IQR], 1.8-4.6) and did not vary by age. The median total hospital cost per patient was $5513 (IQR, $3850-$9946) with significantly higher costs for patients with chronic medical conditions (P < .001).

CONCLUSIONS

Human metapneumovirus infection results in a large number of hospitalizations with substantial morbidity, resource utilization, and costs. The development of a safe and effective vaccine could reduce the clinical and economic burden of HMPV.