Implementation of Outpatient Minimally Invasive Lumbar Decompression at an Academic Medical Center without Ambulatory Surgery Centers: A Cost Analysis and Systematic Review.

BACKGROUND: Lumbar decompressions are increasingly performed at ambulatory surgery centers (ASCs). We sought to compare costs of open and minimally invasive (MIS) lumbar decompressions performed at a university without dedicated ASCs. METHODS: Lumbar decompressions performed at a tertiary academic hospital or satellite university hospital dedicated to outpatient surgery were retrospectively reviewed. Care pathways were same-day, overnight observation, or inpatient admission. Patient demographics, American Society of Anesthesiologists classification, Charlson Comorbidity Index, surgical characteristics, 30-day readmission, and costs were collected. A systematic review of lumbar decompression cost literature was performed. RESULTS: A total of 354 patients, mean age 55 years with 128 women (36.2%), were reviewed. There was no significant difference in age, gender, body mass index, American Society of Anesthesiologists classification, or Charlson Comorbidity Index between patients treated with open and minimally invasive surgery. Open decompression was associated with higher total cost ($21,280 vs. $14,407; P < 0.001); however, this was driven by care pathway and length of stay. When stratifying by care pathway, there was no difference in total cost between open versus minimally invasive surgery among same-day ($10,609 vs. $11,074; P = 0.556), overnight observation ($14,097 vs. $13,992; P = 0.918), or inpatient admissions ($24,507 vs. $27,929; P = 0.311). CONCLUSIONS: When accounting for care pathway, the cost of open and MIS decompression were no different. Transition from a tertiary academic hospital to a university hospital specializing in outpatient surgery was not associated with lower costs. Academic departments may consider transitioning lumbar decompressions to a dedicated ASC to maximize cost savings; however, additional studies are needed.

Cost Analysis of Outpatient Anterior Cervical Discectomy and Fusion at an Academic Medical Center without Dedicated Ambulatory Surgery Centers.

BACKGROUND: Anterior cervical discectomy and fusion (ACDF) are increasingly performed at ambulatory surgical centers (ASCs). Academic centers lacking dedicated ASCs must perform these at large university hospitals, which pose unique challenges to cost savings and efficiency. OBJECTIVE: To describe the safety and cost of outpatient ACDF at a major academic medical center without a dedicated ASC. METHODS: ACDFs performed from 2015 to 2018 were retrospectively reviewed. Cases were performed at the major tertiary university hospital or a satellite university hospital dedicated to outpatient surgery. Patient demographics, surgical characteristics, perioperative complications, fusion at 12 months, and cost were collected. RESULTS: A total of 470 patients were included. The mean age was 56 years, with 255 women (54.3%). When comparing same-day discharge, overnight observation, or inpatient admission, there were no differences in age, gender, or number of levels fused. Same-day and overnight observation cases were associated with shorter procedure duration and less estimated blood loss. There were no differences in perioperative complications, 30-day readmissions, or fusion at 12 months. Direct and total costs were lowest for same-day cases, followed by overnight observation and inpatient admissions (P < 0.001). CONCLUSION: Academic centers without dedicated ASCs can safely perform ACDF as a same-day or overnight observation procedure with significant reductions in cost. The lack of a dedicated ASC should not preclude academic centers from allocating appropriately selected patients into same-day or overnight observation care pathways. This strategy can improve resource utilization and preserve precious hospital resources for the most critically ill patients while also allowing these centers to build viable outpatient spine practices.

Contextualizing Oncologic Imaging Utilization Through End-of-Life Spending Patterns.

PURPOSE: The aim of this study was to assess the effect of spending patterns during the final year of life on high-cost imaging utilization in the final 3 months of life. METHODS: An academic comprehensive cancer center's radiology, cancer registry, and claims records were matched to identify decedents with dates of death from April 2013 through June 2014. Spending patterns in the final year of life were identified using group-based trajectory modeling. Descriptive analysis of CT, MRI, and PET utilization across trajectories was conducted. Multivariate logistic regressions modeled the likelihood of imaging utilization in the final 3 months of life, and a sensitivity analysis assessed the impact of spending trajectories on model fit. RESULTS: Six spending trajectories were identified. Membership in the late rising trajectory was the strongest predictor of high-cost imaging in the final 3 months of life (odds ratio, 11.61; P = .000), followed by diagnosis 12 to 6 months premortem (odds ratio, 7.49; P = .000). The likelihood of imaging the final 3 months of life was no different between high persistent and low persistent trajectory patients, despite the heterogeneity between the two patient groups. Sensitivity analysis indicated that spending trajectory improved the prediction of imaging in the final 3 months of life to a greater extent than temporal proximity to death at the time of diagnosis, which may serve as a proxy for severity and/or complexity. CONCLUSIONS: Clinical measures of severity and patients' utilization histories should be considered by hospital administrators in estimations of aggregate and individual oncologic imaging utilization. This analytic approach may aid in evaluating participation in advanced payment models.

What's cost got to do with it? Association between hospital costs and frequency of admissions among "high users" of hospital care.

BACKGROUND: Efforts to curb healthcare spending have included interventions that target frequently hospitalized individuals. It is unclear the extent to which the most frequently hospitalized individuals also represent the costliest individuals. OBJECTIVE: To examine the relationship between 2 types of "high users" commonly targeted in cost-containment interventions-those incurring the highest hospital costs ("high cost") and those incurring the highest number of hospitalizations ("high admit"). DESIGN, SETTING, AND PATIENTS: Cross-sectional study of 2566 individuals with a primary care physician and at least 1 hospitalization within an academic health system from 2010 to 2011. MEASUREMENTS: Overlap between the population constituting the top decile of hospital costs and the population constituting the top decile of hospitalizations; characteristics of the 3 resulting high user subgroups. RESULTS: Only 48% of individuals who were high cost (>$65,000) were also high admit (≥ 3 hospitalizations). Compared to hospitalizations incurred by high cost-high admit individuals (n = 605), hospitalizations incurred by high cost-low admit individuals (n = 206) were more likely to be for surgical procedures (58 vs 22%, P < 0.001), had a higher cost ($68,000 vs $28,000, P < 0.001), longer length of stay (10 vs 5 days, P < 0.001), and were less likely to be a 30-day readmission (17 vs 47%, P < 0.001). CONCLUSIONS: Stratifying high admit individuals by costs and high cost individuals by hospitalizations yields 3 distinct high user subgroups with important differences in clinical characteristics and utilization patterns. Consideration of these distinct subgroups may lead to better-tailored interventions and achieve greater cost savings.

Hospital implementation of computerized provider order entry systems: results from the 2003 leapfrog group quality and safety survey.

A critical element of The Leapfrog Group's strategy for advancing improvements in healthcare is its ongoing survey of hospital patient safety and quality improvement activities, including computerized provider order entry (CPOE) systems. This survey is distinct from other surveys of CPOE adoption because individual hospital responses are publicly disseminated. Furthermore, this survey offers an opportunity to explore the drivers of hospital CPOE adoption before financial incentives for patient safety proliferate, as well as an opportunity to compare the characteristics of participating and non-participating hospitals. Results from the 2003 survey show that only 3.7 percent of the 842 participating hospitals located in The Leapfrog Group's targeted regions had fully implemented a CPOE system consistent with the Leapfrog standard, although 92 percent reported at least planned or partial implementation of a CPOE system. While prior research suggests that a hospital's financial condition should be positively correlated with decisions to invest in CPOE, the analysis generally failed to detect such a relationship.

Physician use of IT: results from the Deloitte Research Survey.

The authors analyzed 1,200 physician responses to a Deloitte Research/Fulcrum Analytics survey of office-based physician use of the Internet and other information technology (IT). Overall, the results suggest that 40 to 50 percent of all respondents are using, or are ready to use, IT for substantial clinical care. However, time and liability concerns about patient e-mail were pervasive across all IT user categories. The results also indicate that some public/private policies aimed at increasing physician IT use for clinical management should be tailored to specific segments of the physician IT user spectrum, rather than using a "one-size-fits-all" policy approach.