Exploring Trajectories of Health Care Utilization Before and After Surgery.

BACKGROUND: Long-term trajectories of health care utilization in the context of surgery have not been well characterized. The objective of this study was to examine health care utilization trajectories among surgical patients and identify factors associated with high utilization that could possibly be mitigated after surgical admissions. STUDY DESIGN: Hospital medical and surgical admissions within 2 years of an index inpatient surgery in the Veterans Health Administration (October 1, 2007 to September 30, 2014) were identified. Group-based trajectory analysis identified 5 distinct trajectories of inpatient admissions around surgery. Characteristics of trajectories of utilization were compared across groups using bivariate statistics and multivariate logistic regression. RESULTS: Of 280,681 surgery inpatients, most underwent orthopaedic (29.2%), general (28.4%), or peripheral vascular procedures (12.2%). Five trajectories of health care utilization were identified, with 5.2% of patients among consistently high inpatient users accounting for 34.0% of inpatient days. Male (95.4% vs 93.5%, p < 0.01), African-American (21.6% vs 17.3%, p < 0.01), or unmarried patients (61.6% vs 52.5%, p < 0.01) were more likely to be high health care users as compared with other trajectories. High users also had a higher comorbidity burden and a strikingly higher burden of mental health diagnoses (depression: 30.3% vs 16.3%; bipolar disorder: 5.3% vs 2.1%, p < 0.01), social/behavioral risk factors (smoker: 41.1% vs 33.6%, p < 0.01; alcohol use disorder: 28.9% vs 12.9%, p < 0.01), and chronic pain (6.4% vs 2.8%, p < 0.01). CONCLUSIONS: Mental health, social/behavioral, and pain-related factors are independently associated with high pre- and postoperative health care utilization in surgical patients. Connecting patients to social workers and mental health care coordinators around the time of surgery may mitigate the risk of postoperative readmissions related to these factors.

Impact of linezolid on economic outcomes and determinants of cost in a clinical trial evaluating patients with MRSA complicated skin and soft-tissue infections.

BACKGROUND: In clinical trials, linezolid has demonstrated higher clinical cure rates and shorter hospital duration for patients than has vancomycin for the treatment of complicated skin and soft-tissue infections (cSSTIs). OBJECTIVE: To assess economic outcomes of linezolid versus vancomycin and evaluate determinants of treatment costs for cSSTIs. METHODS: Economic data were obtained from US subjects enrolled in a multinational, open-label, clinical trial of cSSTIs caused by suspected or proven methicillin-resistant Staphylococcus aureus (MRSA). Subjects were randomized to receive intravenous or oral linezolid or intravenous vancomycin for 7-21 days. Costs for each patient were evaluated by applying nationally representative per diem hospital costs by hospital ward. Intravenous administration costs were applied to the duration of intravenous treatment. Factors contributing to the cost of therapy were evaluated using multivariate regression analysis. RESULTS: Seven hundred seventeen US patients were included in the study. Demographics were similar between treatment groups. Length of stay and duration of intravenous therapy were shorter for linezolid-treated patients. Mean +/- SD cost for intent-to-treat population patients treated with linezolid versus vancomycin was 4865 US dollars +/- 4367 versus 5738 US dollars +/- 5190, respectively (p = 0.017), and in the MRSA population was 4881 US dollars +/- 3987 versus 6006 US dollars +/- 5039, respectively (p = 0.041). Factors significantly associated with increased cost included vancomycin therapy, age, and comorbidities, including diabetes. After adjusting for all other factors, treatment with linezolid was associated with significantly lower treatment costs compared with vancomycin. CONCLUSIONS: Linezolid therapy was associated with improved clinical outcomes and significantly lower treatment costs than was vancomycin. The largest cost advantage was demonstrated in patients with documented MRSA cSSTIs.