Same day discharge colon surgery: is it financially worth it?

AIM: Same day discharge (SDD) for colorectal surgery shows increasing promise in the era of enhanced recovery after surgery protocols and minimally invasive surgery. It has become increasingly relevant due to the constraints posed by the COVID-19 pandemic. The aim of this study was to compare SDD and postoperative day 1 (POD1) discharge to understand the clinical outcomes and financial impact on factors such as cost, charge, revenue, contribution margin and readmission. METHOD: A retrospective review of colectomies was performed at a single institution over a 2-year period (n = 143). Two populations were identified: SDD (n = 51) and POD1 (n = 92). Patients were selected by International Statistical Classification of Diseases and Related Health Problems-10 (ICD-10) and Diagnosis Related Grouper (DRG) codes. RESULTS: There was a statistically significant difference favouring SDD in total hospital cost (p < 0.0001), average direct costs (p < 0.0001) and average charges (p < 0.0016). SDD average hospital costs were $8699 (values in USD throughout) compared with $11 652 for POD 1 (p < 0.0001), and average SDD hospital charges were $85 506 compared with $97 008 for POD1 (p < 0.0016). The net revenue for SDD was $22 319 while for POD1 it was $26 173 (p = 0.14). Upon comparison of contribution margins (SDD $13 620 vs. POD1 $14 522), the difference was not statistically significant (p = 0.73). There were no identified statistically significant differences in operating room time, robotic console time, readmission rates or surgical complications. CONCLUSIONS: Amidst the pandemic-related constraints, we found that SDD was associated with lower hospital costs and comparable contribution margins compared with POD1. Additionally, the study was unable to identify any significant difference between operating time, readmissions, and surgical complications when performing SDD.

Timing and Cost of Wound Complications After Colorectal Resection.

BACKGROUND: More than 50% of postoperative wound complications occur after discharge. They are the most common postoperative complication and the most common reason for readmission after a surgical procedure. Little is known about the long-term costs of postdischarge wound complications after surgery. OBJECTIVE: We sought to understand the differences in costs and characteristics of wound complications identified after hospital discharge for patients undergoing colorectal surgery in comparison with in-hospital complications. DESIGN: This is an observational cohort study using Veterans Health Administration Surgical Quality Improvement Program data. SETTING: This study was conducted at a Veterans Affairs medical center. SETTING: Patients undergoing colorectal resection between October 1, 2007 and September 30, 2014. MAIN OUTCOME MEASURES: The primary outcomes measured were adjusted costs of care at discharge, 30 days, and 90 days after surgery. RESULTS: Of 20,146 procedures, 11.9% had a wound complication within 30 days of surgery (49.2% index-hospital, 50.8% postdischarge). In comparison with patients with index-hospital complications, patients with postdischarge complications had fewer superficial infections (65.0% vs 72.2%, p < 0.01), more organ/space surgical site infections (14.3% vs 10.1%, p < 0.01), and higher rates of diabetes (29.1% vs 25.0%, p = 0.02), and they were to have had a laparoscopic approach for their surgery (24.7% vs 18.2%, p < 0.01). The average cost including surgery at 30 days was $37,315 (SD = $29,319). Compared with index-hospital wound complications, postdischarge wound complications were $9500 (22%, p < 0.001) less expensive at 30 days and $9736 (15%, p < 0.001) less expensive at 90 days. Patients with an index-hospital wound complication were 40% less likely to require readmission at 30 days, but their readmissions were $12,518 more expensive than readmissions among patients with a newly identified postdischarge wound complication (p < 0.001). LIMITATIONS: This study was limited to patient characteristics and costs accrued only within the Veterans Affairs system. CONCLUSIONS: Patients with postdischarge wound complications have lower 30- and 90-day postoperative costs than those with wound complications identified during their index hospitalization and almost half were managed as an outpatient. TIEMPO Y COSTO DE LAS COMPLICACIONES LA HERIDA DESPUS DE LA RESECCIN COLORRECTAL: ANTECEDENTES:Más del 50% de complicaciones postoperatorias de la herida ocurren después del alta. Es la complicación postoperatoria más común y el motivo más frecuente de reingreso después del procedimiento quirúrgico. Poco se sabe sobre los costos a largo plazo de las complicaciones de la herida después del alta quirúrgica.OBJETIVO:Intentar en comprender las diferencias en los costos y las características de las complicaciones de la herida, identificadas después del alta hospitalaria, en pacientes sometidos a cirugía colorrectal, en comparación con las complicaciones intrahospitalarias.DISEÑO:Estudio de cohorte observacional utilizando datos del Programa de Mejora de la Calidad Quirúrgica de la Administración de Salud de Veteranos.ENTORNO CLÍNICO:Administración de Veteranos.PACIENTES:Pacientes sometidos a resección colorrectal entre el 1/10/2007 y el 30/9/2014.PRINCIPALES MEDIDAS DE VALORACIÓN:Costos de atención ajustados al alta, 30 días y 90 días después de la cirugía.RESULTADOS:De 20146 procedimientos, el 11,9% tuvo una complicación de la herida dentro de los 30 días de la cirugía. (49,2% índice hospitalario, 50,8% después del alta). En comparación con los pacientes, del índice de complicaciones hospitalarias, los pacientes con complicaciones posteriores al alta, tuvieron menos infecciones superficiales (65,0% frente a 72,2%, p <0,01), más infecciones de órganos/espacios quirúrgicos (14,3% frente a 10,1%, p <0,01), tasas más altas de diabetes (29,1% versus 25,0%, p = 0,02), y deberían de haber tenido un abordaje laparoscópico para su cirugía (24,7% versus 18,2%, p <0,01). El costo promedio, incluida la cirugía a los 30 días, fue de $ 37,315 (desviación estándar = $ 29,319). En comparación con el índice de complicaciones de las herida hospitalaria, las complicaciones de la herida después del alta fueron $ 9,500 (22%, p <0,001) menor costo a los 30 días y $ 9,736 (15%, p<0,001) y menor costo a los 90 días. Los pacientes con índice de complicación de la herida hospitalaria, tenían un 40% menos de probabilidades de requerir reingreso a los 30 días, pero sus reingresos eran $ 12,518 más costosos que los reingresos entre los pacientes presentando complicación de la herida recién identificada después del alta (p <0,001).LIMITACIONES:Limitado a las características del paciente y los costos acumulados solo dentro del sistema VA.CONCLUSIONES:Pacientes con complicaciones de la herida post alta, tienen menores costos postoperatorios a los 30 y 90 días, que aquellos con complicaciones de la herida identificadas durante su índice de hospitalización y aproximadamente la mitad fueron tratados de forma ambulatoria.

Association Between 2010 Medicare Reform and Inpatient Rehabilitation Access in People With Intracerebral Hemorrhage.

Background Evidence suggests intracerebral hemorrhage survivors have earlier recovery compared with ischemic stroke survivors. The Centers for Medicare and Medicaid Services prospective payment system instituted documentation rules for inpatient rehabilitation facilities (IRFs) in 2010, with the goal of optimizing patient selection. We investigated whether these requirements limited IRF and increased skilled nursing facility (SNF) use compared with home discharge. Methods and Results Intracerebral hemorrhage discharges to IRF, SNF, or home were estimated using GWTG (Get With The Guidelines) Stroke registry data between January 1, 2008, and December 31, 2015 (n=265 444). Binary hierarchical models determined associations between the 2010 Rule and discharge setting; subgroup analyses evaluated age, geographic region, and hospital type. From January 1, 2008, to December 31, 2009, 45.5% of patients with intracerebral hemorrhage had home discharge, 22.2% went to SNF, and 32.3% went to IRF. After January 1, 2010, there was a 1.06% absolute increase in home discharge, a 0.46% increase in SNF, and a 1.52% decline in IRF. The adjusted odds of IRF versus home discharge decreased 3% after 2010 (adjusted odds ratio [aOR], 0.97; 95% CI, 0.95-1.00). Lower odds of IRF versus home discharge were observed in people aged <65 years (aOR, 0.92; 95% CI, 0.89-0.96), Western states (aOR, 0.89; 95% CI, 0.84-0.95), and nonteaching hospitals (aOR, 0.90; 95% CI, 0.86-0.95). Adjusted odds of SNF versus home discharge increased 14% after 2010 (aOR, 1.14; 95% CI, 1.11-1.18); there were significant associations in all age groups, the Northeast, the South, the Midwest, and teaching hospitals. Conclusions The Centers for Medicare and Medicaid Services 2010 IRF prospective payment system Rule resulted in fewer discharges to IRF and more discharges to SNF in patients with intracerebral hemorrhage. Health policy changes potentially affect access to intensive postacute rehabilitation.

The Effect of a Discharge Disposition Algorithm on Patient Outcomes and Satisfaction.

Total joint arthroplasties are one of the most common procedures performed in the United States. As changes have occurred in the surgical techniques of these procedures, postoperative recovery time has decreased and patients have been able to safely transition to home rather than a post-acute care facility. The demand for total joint arthroplasty (TJA) is expected to grow 44% as the prevalence of lower extremity osteoarthritis continues to rise (Sher et al., 2017) because of an aging baby boomer population. In the next 20 years, it is expected that the demand for total hip arthroplasty will grow by 174% and demand for total knee arthroplasty will grow by as much as 670% (Napier et al., 2013). An area with high variability in the postoperative period is in postdischarge rehabilitation. Post-acute inpatient care can account for up to 36% of the bundled costs of a TJA. There is a lack of evidence that patients recover better or have decreased complications by transitioning to an inpatient rehabilitation setting compared with transitioning to home. The aims of this literature search were to (a) identify the safest discharge disposition for patients following TJA; (b) determine the rate of complications and readmissions among those discharged to skilled nursing facility, inpatient rehabilitation unit, and home; and (c) explore how specified care pathways affect patient expectations and outcomes. The Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, ProQuest, and Cochrane were searched using the following key terms: discharge disposition, total joint arthroplasty, joint replacement, hip arthroplasty, knee arthroplasty, care pathway, discharge outcomes and readmissions, discharge protocols, and discharge algorithms. Five key themes emerged. Patients with significant comorbidities may require longer length of stay in the hospital or potentially discharge to a facility, discharge to facility associated with high rate of complications, setting patient expectations increases likelihood of discharge home, discharge to inpatient facilities does not improve outcomes, and discharge to any post-acute care facility is more expensive than discharge to home. This review identified themes in postoperative care of TJA patients that can be utilized to create a discharge disposition algorithm using best practices to stratify patients into the appropriate discharge disposition while setting appropriate expectations for patients undergoing these procedures to ensure high levels of patient satisfaction following these procedures.

High Cost and Resource Utilization of Frostbite Readmissions in the United States.

Frostbite is a high morbidity, high-cost injury that can lead to digit or limb necrosis requiring amputation. Our primary aim is to describe the rate of readmission following frostbite injury. Our secondary aims are to describe the overall burden of care, cost, and characteristics of repeat hospitalizations of frostbite-injured people. Hospitalizations following frostbite injury (index and readmissions) were identified in the 2016 and 2017 Nationwide Readmission Database. Multivariable logistic regression was clustered by hospital and additionally adjusted for severe frostbite injury, gender, year, payor group, severity, and comorbidity index. Population estimates were calculated and adjusted for by using survey weight, sampling clusters, and stratum. In the 2-year cohort, 1065 index hospitalizations resulted in 1907 total hospitalizations following frostbite injury. Most patients were male (80.3%), lived in metropolitan/urban areas (82.3%), and nearly half were insured with Medicaid (46.4%). Of the 842 readmissions, 53.7% were associated with complications typically associated with frostbite injury. Overall, 29% of frostbite injuries resulted in at least one amputation. The average total cost and total length of stay of readmissions were $236,872 and 34.7 days. Drug or alcohol abuse, homelessness, Medicaid insurance, and discharge against medical advice (AMA) were independent predictors of unplanned readmission. Factors associated with multiple readmissions include discharge AMA and Medicare insurance, but not drug or alcohol abuse or homelessness. The population-based estimated unplanned readmission rate following frostbite injury was 35.4% (95% confidence interval 32.2%-38.6%). This is the first study examining readmissions following frostbite injury on a national level. Drug or alcohol abuse, homelessness, Medicaid insurance, and discharge AMA were independent predictors of unplanned readmission, while only AMA discharge and Medicare insurance were associated with multiple readmissions. Supportive resources (community and hospital-based) may reduce unplanned readmissions of frostbite-injured patients with those additional risk factors.

Race Is an Independent Predictor for Nonroutine Discharges After Spine Surgery for Spinal Intradural/Cord Tumors.

OBJECTIVE: The aim of this study was to determine if race was an independent predictor of extended length of stay (LOS), nonroutine discharge, and increased health care costs after surgery for spinal intradural/cord tumors. METHODS: A retrospective cohort study was performed using the National Inpatient Sample database from 2016 to 2017. All adult (>18 years old) inpatients who underwent surgical intervention for a benign or malignant spinal intradural/cord tumor were identified using International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis and procedural coding systems. Patients were then categorized based on race: White, African American (AA), Hispanic, and other. Postoperative complications, LOS, discharge disposition, and total cost of hospitalization were assessed. A backward stepwise multivariable logistic regression analysis was used to identify independent predictors of extended LOS and nonroutine discharge disposition. RESULTS: Of 3595 patients identified, there were 2620 (72.9%) whites (W), 310 (8.6%) AAs/blacks, 275 (7.6%) Hispanic (H), and 390 (10.8%) other (O). Postoperative complication rates were similar among the cohorts (P = 0.887). AAs had longer mean (W, 5.4 ± 4.2 days vs. AA, 8.9 ± 9.5 days vs. H, 5.9 ± 3.9 days vs. O, 6.1 ± 3.9 days; P = 0.014) length of hospitalizations than the other cohorts. The overall incidence of nonroutine discharge was 55% (n = 1979), with AA race having the highest rate of nonroutine discharges (W, 53.8% vs. AA, 74.2% vs. H, 45.5% vs. O, 43.6%; P = 0.016). On multivariate regression analysis, AA race was the only significant racial independent predictor of nonroutine discharge disposition (odds ratio, 3.32; confidence interval, 1.67-6.60; P < 0.001), but not extended LOS (P = 0.209). CONCLUSIONS: Our study indicates that AA race is an independent predictor of nonroutine discharge disposition in patients undergoing surgical intervention for a spinal intradural/cord tumor.

Understanding value and patient complexity among common inpatient vascular surgery procedures.

OBJECTIVE: Vascular surgery patients are highly complex, second only to patients undergoing cardiac procedures. However, unlike cardiac surgery, work relative value units (wRVU) for vascular surgery were undervalued based on an overall patient complexity score. This study assesses the correlation of patient complexity with wRVUs for the most commonly performed inpatient vascular surgery procedures. METHODS: The 2014 to 2017 National Surgical Quality Improvement Program Participant Use Data Files were queried for inpatient cases performed by vascular surgeons. A previously developed patient complexity score using perioperative domains was calculated based on patient age, American Society of Anesthesiologists class of ≥4, major comorbidities, emergent status, concurrent procedures, additional procedures, hospital length of stay, nonhome discharge, and 30-day major complications, readmissions, and mortality. Procedures were assigned points based on their relative rank and then an overall score was created by summing the total points. An observed to expected ratio (O/E) was calculated using open ruptured abdominal aortic aneurysm repair (rOAAA) as the referent and then applied to an adjusted median wRVU per operative minute. RESULTS: Among 164,370 cases, patient complexity was greatest for rOAAA (complexity score = 128) and the least for carotid endarterectomy (CEA) (complexity score = 29). Patients undergoing rOAAA repair had the greatest proportion of American Society of Anesthesiologists class of ≥IV (84.8%; 95% confidence interval [CI], 82.6%-86.8%), highest mortality (35.5%; 95% CI, 32.8%-38.3%), and major complication rate (87.1%; 95% CI, 85.1%-89.0%). Patients undergoing CEA had the lowest mortality (0.7%; 95% CI, 0.7%-0.8%), major complication rate (8.2%; 95% 95% CI, 8.0%-8.5%), and shortest length of stay (2.7 days; 95% CI, 2.7-2.7). The median wRVU ranged from 10.0 to 42.1 and only weakly correlated with overall complexity (Spearman's ρ = 0.11; P < .01). The median wRVU per operative minute was greatest for thoracic endovascular aortic repair (0.25) and lowest for both axillary-femoral artery bypass (0.12) and open femoral endarterectomy, thromboembolectomy, or reconstruction (0.12). After adjusting for patient complexity, CEA (O/E = 3.8) and transcarotid artery revascularization (O/E = 2.8) had greater than expected O/E. In contrast, lower extremity bypass (O/E = 0.77), lower extremity embolectomy (O/E = 0.79), and open abdominal aortic repair (O/E = 0.80) had a lower than expected O/E. CONCLUSIONS: Patient complexity varies substantially across vascular procedures and is not captured effectively by wRVUs. Increased operative time for open procedures is not adequately accounted for by wRVUs, which may unfairly penalize surgeons who perform complex open operations.

Hospital to Home Transition for Patients With Stroke Under Bundled Payments.

Bundled payments are a promising alternative payment model for reducing costs and improving the coordination of postacute stroke care, yet there is limited evidence supporting the effectiveness of bundled payments for stroke. This may be due to the lack of effective strategies to address the complex needs of stroke survivors. In this article, we describe COMprehensive Post-Acute Stroke Services (COMPASS), a comprehensive transitional care intervention focused on discharge from the acute care setting to home. COMPASS may serve as a potential care redesign strategy under bundled payments for stroke, such as the Centers for Medicare & Medicaid Innovation Bundled Payment for Care Improvement Initiative. The COMPASS care model is aligned with the incentive structures and essential components of bundled payments in terms of care coordination, patient assessment, patient and family involvement, and continuity of care. Ongoing evaluation will inform the design of incorporating COMPASS-like transitional care interventions into a stroke bundle.

A policy of day-case sinonasal surgery is safe, well tolerated and cost-effective.

OBJECTIVE: Practices vary regarding the timing of discharge after sinonasal surgery. This study aimed to examine the cost-effectiveness of same-day discharge compared to next-day discharge after sinonasal surgery. METHODS: A retrospective single-surgeon audit of sinonasal surgery over a 12-month period was performed. Demographic and clinical details, including distance travelled home, timing of discharge, hospital re-presentation, and complications, were collected and compared between the same-day discharge and next-day discharge groups. A cost-effectiveness analysis was performed. RESULTS: A total of 181 patients were identified; 117 underwent day-case surgery, of which 6 re-presented to the emergency department. Sixty-four patients stayed overnight after surgery, and six of those patients re-presented to the emergency department. The per patient cost was $3262 for day-case sinonasal surgery and $5050 for those admitted overnight after surgery (p < 0.001). CONCLUSION: Routine same-day discharge after sinonasal surgery is achievable, safe and cost-effective.

Barriers and financial impact of same-day discharge after atrial fibrillation ablation.

BACKGROUND: Same-day discharge (SDD) after atrial fibrillation (AF) ablation is increasingly being considered. This study examined the barriers and financial impact associated with SDD in a contemporary cohort of patients undergoing elective AF ablation. METHODS: A single center retrospective review was conducted of the 249 first case-of-the-day outpatient AF ablations performed in 2019 to evaluate the proportion of patients that could have undergone SDD. Barriers to SDD were defined as any intervention that prevented SDD by 8 p.m. The financial impact of SDD was based on savings from avoidance of the overnight hospital stay and revenue related to management of chest pain facilitated by a vacant hospital bed. RESULTS: SDD could have occurred in 157 patients (63%) without change in management and in up to 200 patients (80%) if avoidable barriers were addressed. Barriers to SDD included non-clinical logistical issues (43%), prolonged post-procedure recovery (42%) and minor procedural complications (15%). On multivariate analysis, factors associated with barriers to SDD included increasing age (P = .01), left ventricular ejection fraction ≤ 35% (P = .04), and severely dilated left atrium (P = .04). The financial gain from SDD would have ranged from $1,110,096 (assuming discharge of 63% of eligible patients) to $1,480,128 (assuming 80% discharge) over the course of a year. CONCLUSIONS: Up to 80% of patients undergoing outpatient AF ablation were amenable to SDD if avoidable delays in care had been anticipated. Based on reduced hospital operating expenses and increased revenue from management of individuals with chest pain, this would translate to a financial savings of ∼$1.5 million.

The Effect of Patient and Hospital Characteristics on Total Costs of Peripheral Bypass in New York State.

INTRODUCTION: With the aging U.S. population, peripheral vascular procedures will become increasingly common. The objective of this study is to characterize the factors associated with increased total costs after peripheral bypass surgery. METHODS: Data for 34,819 patients undergoing peripheral bypass surgery in NY State were extracted using the Statewide Planning and Research Cooperative System (SPARCS) database for years 2009-2017. Patient demographics, All Patient Refined Diagnostic Related Groups (APR) severity score, mortality risk, hospital volume, and length of stay data were collected. Primary outcomes were total costs and length of stay. Data were analyzed using univariate and multivariate analysis. RESULTS: 28.1% of peripheral bypass surgeries were performed in New York City. 7.9% of patients had extreme APR severity of illness whereas 32.0% had major APR severity of illness. 6.3% of patients had extreme risk of mortality and 1 in every 5 patients (20%) had major risk of mortality. 24.9% of patients were discharged to a facility. The mean length of stay (LOS) was 9.9 days. Patient LOS of 6-11 days was associated with +$2,791.76 total costs. Mean LOS of ≥ 12 days was associated with + $27,194.88 total costs. Multivariate analysis revealed risk factors associated with an admission listed in the fourth quartile of total costs (≥$36,694.44) for peripheral bypass surgery included NYC location (2.82, CI 2.62-3.04), emergency surgery (1.12, CI 1.03-1.22), extreme APR 2.08, 1.78-2.43, extreme risk of mortality (2.73, 2.34-3.19), emergency room visit (1.68, 1.57-1.81), discharge to a facility (1.27, CI 1.15-1.41), and LOS in the third or fourth quartile (11.09, 9.87-12.46). CONCLUSION: The cost of peripheral bypass surgery in New York State is influenced by a variety of factors including LOS, patient comorbidity and disease severity, an ER admission, and discharge to a facility.

Sepsis-Associated Mortality, Resource Use, and Healthcare Costs: A Propensity-Matched Cohort Study.

OBJECTIVES: To examine long-term mortality, resource utilization, and healthcare costs in sepsis patients compared to hospitalized nonsepsis controls. DESIGN: Propensity-matched population-based cohort study using administrative data. SETTING: Ontario, Canada. PATIENTS: We identified a cohort of adults (≥ 18) admitted to hospitals in Ontario between April 1, 2012, and March 31, 2016, with follow-up to March 31, 2017. Sepsis patients were flagged using a validated International Classification of Diseases, 10th Revision-coded algorithm (Sepsis-2 definition), including cases with organ dysfunction (severe sepsis) and without (nonsevere). Remaining hospitalized patients were potential controls. Cases and controls were matched 1:1 on propensity score, age, sex, admission type, and admission date. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Differences in mortality, rehospitalization, hospital length of stay, and healthcare costs were estimated, adjusting for remaining confounders using Cox regression and generalized estimating equations. Of 270,669 sepsis cases, 196,922 (73%) were successfully matched: 64,204 had severe and 132,718 nonsevere sepsis (infection without organ dysfunction). Over follow-up (median 2.0 yr), severe sepsis patients had higher mortality rates than controls (hazard ratio, 1.66; 95% CI, 1.63-1.68). Both severe and nonsevere sepsis patients had higher rehospitalization rates than controls (hazard ratio, 1.53; 95% CI, 1.50-1.55 and hazard ratio, 1.41; 95% CI, 1.40-1.43, respectively). Incremental costs (Canadian dollar 2018) in sepsis cases versus controls at 1-year were: $29,238 (95% CI, $28,568-$29,913) for severe and $9,475 (95% CI, $9,150-$9,727) for nonsevere sepsis. CONCLUSIONS: Severe sepsis was associated with substantially higher long-term risk of death, rehospitalization, and healthcare costs, highlighting the need for effective postdischarge care for sepsis survivors.

Adverse Events and Bundled Costs after Cranial Neurosurgical Procedures: Validation of the LACE Index Across 40,431 Admissions and Development of the LACE-Cranial Index.

OBJECTIVE: Anticipating postdischarge complications after neurosurgery remains difficult. The LACE index, based on 4 hospitalization descriptors, stratifies patients by risk of 30-day postdischarge adverse events but has not been validated in a procedure-specific manner in neurosurgery. Our study sought to explore the usefulness of the LACE index in a population undergoing cranial neurosurgery and to develop an enhanced model, LACE-Cranial. METHODS: The OptumClinformatics Database was used to identify cranial neurosurgery admissions (2004-2017). Procedures were grouped as trauma/hematoma/intracranial pressure, open vascular, functional/pain, skull base, tumor, or endovascular. Adverse events were defined as postdischarge death/readmission. LACE-Cranial was developed using a logistic regression framework incorporating an expanded feature set in addition to the original LACE components. RESULTS: A total of 40,431 admissions were included. Predictions of 30-day readmissions was best for skull base (area under the curve [AUC], 0.636) and tumor (AUC, 0.63) admissions but was generally poor. Predictive ability of 30-day mortality was best for functional/pain admissions (AUC, 0.957) and poorest for trauma/hematoma/intracranial pressure admissions (AUC, 0.613). Across procedure types except for functional/pain, a high-risk LACE score was associated with higher postdischarge bundled payment costs. Incorporating features identified to contribute independent predictive value, the LACE-Cranial model achieved procedure-specific 30-day mortality AUCs ranging from 0.904 to 0.98. Prediction of 30-day and 90-day readmissions was also improved, with tumor and skull base cases achieving 90-day readmission AUCs of 0.718 and 0.717, respectively. CONCLUSIONS: Although the unmodified LACE index shows inconsistent classification performance, the enhanced LACE-Cranial model offers excellent prediction of short-term postdischarge mortality across procedure groups and significantly improved anticipation of short-term postdischarge readmissions.

Factors Complicating Discharge to Home following Total Knee Arthroplasty-A Single Institution Initiative.

Recently, with the Medicare bundled payments initiative for total knee arthroplasty (TKA), there has been a move by many institutions to further streamline costs associated with the entire operative and perioperative process. One of these cost-saving strategies has been to favor discharging patients to home with outpatient services as opposed to discharging to the relatively more expensive rehabilitation facilities. Our aim was to determine the success of a teaching institute's initiative in discharging patients to home instead of a rehabilitation facility. Specifically, we evaluated if there were differences in discharge disposition based off of (1) surgeon/patient preference, (2) length of stay, (3) demographics, and (4) postoperative complications. A retrospective review of all patients who had a TKA from 2015 to 2017 at a single teaching institution was performed and assessed discharge to home or to a rehabilitation facility. If they were not discharged to home, we evaluated why that did not happen, stratified the reason they were discharged to a rehabilitation facility into four groups based on (1) physician and occupational health team assessment, (2) patient preference, (3) physician preference, and (4) family or caretaker preference. A total of 229 patients were enrolled in this initiative, with 107 patients (47%) discharged to home with outpatient physical therapy services and 122 (53%) discharged to a rehabilitation facility. Of these, 35 patients (29%) went to these facilities because of physician and occupational health team assessment. However, 31 (25%) patients were due to patient preference, 32 (26%) were because of surgeon's preference, and 24 (20%) were not discharged to home because of family or caretaker preference. There were no differences in length of stay, gender, or complication rates between cohorts. Many patients can be safely discharged to home following TKA at a community teaching institution; however, there continues to be a strong prejudice by patients, physicians, and caretakers to be discharged to a rehabilitation facility despite the home discharge initiative.

What Are the Cost Drivers for the Major Bowel Bundled Payment Care Improvement Initiative?

BACKGROUND: The Bundled Payments for Care Improvement initiative links payments for service beneficiaries during an episode of care (limited to 90 days from index surgery discharge). OBJECTIVE: The purpose of this study was to identify drivers of costs/payments for the major bowel Bundled Payments for Care Improvement initiative. DESIGN: Discharges from the Medicare Standard Analytic Files of hospitals participating in the major bowel bundle of the Bundled Payments for Care Improvement initiative were analyzed. SETTINGS: The study was conducted at 4 tertiary care centers. PATIENTS: All patients in diagnostic related groups of 329, 330, or 331 treated at eligible facilities between September 1, 2012, and September 30, 2014, were included. MAIN OUTCOME MEASURES: We calculated all costs/payments for the bundled period, that is, 3 days before surgery, the index hospitalization including surgery, and the 90-day postoperative period. We then determined costs for laparoscopic versus open procedures using International Classification of Diseases, Ninth Revision, procedure codes for each of the diagnostic related groups, as well as in aggregate. Last, we calculated differential impact of cost drivers on overall total episode costs. RESULTS: In the cohort of hospitals participating in the major bowel Bundled Payments for Care Improvement initiative, open procedures ($45,073) cost 1.6 times more than laparoscopic. For the lowest complexity diagnostic related group (331), performance of the procedure with open techniques was the largest total episode cost driver, because use of postdischarge services remained low. In the highest complexity diagnostic related group (329), readmission costs, skilled nursing facilities costs, and home health services costs were the greatest cost drivers after hospital services. LIMITATIONS: The analyses are limited by the retrospective nature of the study. CONCLUSIONS: These results indicate that efforts to safely perform open procedures with laparoscopic techniques would be most effective in reducing costs for lower complexity diagnostic related groups, whereas efforts to impact readmission and postdischarge service use would be most impactful for the higher complexity diagnostic related groups. See Video Abstract at http://links.lww.com/DCR/B420. ¿CUÁLES SON LOS FACTORES DETERMINANTES DE LOS COSTOS DE LA INICIATIVA DE MEJORA DE LA ATENCIÓN DE PAGOS COMBINADOS PARA EL INTESTINO MAYOR?: La iniciativa de pagos combinados para la mejora de la atención (BPCI) vincula los pagos para los beneficiarios del servicio durante un episodio de atención (limitado a 90 días desde el alta hospitalaria de la cirugía índice).Identificar los factores determinantes de los costos / pagos de la iniciativa BPCI intestinal mayor.Análisis de altas de los Archivos Analíticos Estándar de Medicare de los hospitales que participan en el paquete intestinal principal de la iniciativa BPCI.Todos los pacientes en Grupos Relacionados con el Diagnóstico (GRD) de 329, 330 o 331 tratados en instalaciones elegibles desde el 1 de Septiembre de 2012 hasta el 30 de Septiembre de 2014.Calculamos todos los costos / pagos para el período combinado, es decir, tres días antes de la cirugía, el índice de hospitalización incluida la cirugía y el período posoperatorio de 90 días. Luego, determinamos los costos de los procedimientos laparoscópicos versus abiertos utilizando códigos de procedimiento ICD-9 para cada uno de los GRD, así como en conjunto. Por último, calculamos el impacto diferencial de los generadores de costos sobre los costos totales del episodio.En la cohorte de hospitales que participan en la iniciativa BPCI del intestino principal, los procedimientos abiertos ($ 45.073) cuestan 1,6 veces más que los laparoscópicos. Para el GRD de menor complejidad (331), la realización del procedimiento con técnicas abiertas fue el mayor factor de costo total del episodio, ya que la utilización de los servicios posteriores al alta se mantuvo baja. En el GRD de mayor complejidad (329), los costos de readmisión, los costos de las instalaciones de enfermería especializada y los costos de los servicios de salud en el hogar fueron los mayores factores de costo después de los servicios hospitalarios.Los análisis están limitados por la naturaleza retrospectiva del estudio.Estos resultados indican que los esfuerzos para realizar procedimientos abiertos de manera segura con técnicas laparoscópicas serían más efectivos para reducir los costos de los GRD de menor complejidad, mientras que los esfuerzos para impactar la readmisión y la utilización del servicio posterior al alta serían más impactantes para los GRD de mayor complejidad. See Video Abstract at http://links.lww.com/DCR/B420.

Drivers of variation in 90-day episode payments after mechanical thrombectomy for acute ischemic stroke.

BACKGROUND: Although mechanical thrombectomy for acute ischemic stroke from a large vessel occlusion is now the standard of care, little is known about cost variations in stroke patients following thrombectomy and factors that influence these variations. METHODS: We evaluated claims data for 2016 to 2018 for thrombectomy-performing hospitals within Michigan through a registry that includes detailed episode payment information for both Medicare and privately insured patients. We aimed to analyze price-standardized and risk-adjusted 90-day episode payments in patients who underwent thrombectomy. Hospitals were grouped into three payment terciles for comparison. Statistical analysis was carried out using unpaired t-test, Chi-square, and ANOVA tests. RESULTS: 1076 thrombectomy cases treated at 16 centers were analyzed. The average 90-day episode payment by hospital ranged from $53 046 to $81,767, with a mean of $65 357. A $20 467 difference (35.1%) existed between the high and low payment hospital terciles (P<0.0001), highlighting a significant payment variation across hospital terciles. The primary drivers of payment variation were related to post-discharge care which accounted for 38% of the payment variation (P=0.0058, inter-tercile range $11,977-$19,703) and readmissions accounting for 26% (P=0.016, inter-tercile range $3,315-$7,992). This was followed by professional payments representing 20% of the variation (P<0.0001, inter-tercile range $7525-$9,922), while index hospitalization payment was responsible for only 16% of the 90-day episode payment variation (P=0.10, inter-tercile range $35,432-$41,099). CONCLUSIONS: There is a wide variation in 90-day episode payments for patients undergoing mechanical thrombectomy across centers. The main drivers of payment variation are related to differences in post-discharge care and readmissions.

Reallocating Cancer Surgery Payments for Alternate Level of Care in Ontario: What Are the Options?

This article examines how alternate-level-of-care (ALC) days are funded through the cancer surgery funding model in Ontario and evaluates policy options to better address ALC days. The contribution of ALC days to hospital funding and the impact of removing or reallocating this funding from cancer surgery is measured. Though costs associated with ALC days in cancer surgery are low, this article highlights the need for policy options that would realign funding across the healthcare system in Ontario to better meet the needs of patients waiting for ALC, reduce pressure on inpatient bed capacity and improve value for money.

A new model of multidimensional discharge planning: continuity of care for frail and complex inpatients.

OBJECTIVE: Delays in patient discharge can adversely affect hospital and emergency room productivity and increase healthcare costs. The discharge should be structured from the hospital admission towards the most appropriate environment. This study aims to investigate the efficacy of the Unit, named "Continuity of Care Center" (CCC), to guarantee a safest and fastest hospital discharge in frail patients and to test the effect of our team-approach on hospital outcomes (length of stay and hospital mortality). MATERIALS AND METHODS: This is a prospective cohort study carried out in an acute care hospital with 1,558 beds and is equipped with 41 operating theaters. We collected data from October 2016 to June 2019. RESULTS: The time of patient discharge had an important reduction: 15.5±30.8 in the first 3 months vs. 11.0±20.1 in the last 3 months considered. The median of the time of discharge in all 12 months considered was 12 day. The length of stay presented an important reduction from 33.3±47.5 during the first 3 months vs. 28.8±39.5 in the last 3 months of activity of CCC; and a significant reduction of hospital deaths was recorded from 20% during the first 3 months to 14% in the last 3 months of activity of CCC. CONCLUSIONS: Results indicate a constant decrease in patient discharge time and length of hospital stay, with a consequent significant reduction of healthcare costs. According to the estimates of Italian Health Ministry concerning Latium region, every hospitalization day has a mean cost of € 674.00. Thus, the CCC activity has contributed to a reduction of approximately 12,832 days of hospitalization, in the considered period, with an estimated hospital saving of € 8,648,761.

Characteristics and related factors of emergency department visits, readmission, and hospital transfers of inpatients under a DRG-based payment system: A nationwide cohort study.

OBJECTIVES: Taiwan has implemented the Diagnosis Related Groups (DRGs) since 2010, and the quality of care under the DRG-Based Payment System is concerned. This study aimed to examine the characteristics, related factors, and time distribution of emergency department (ED) visits, readmission, and hospital transfers of inpatients under the DRG-Based Payment System for each Major Diagnostic Category (MDC). METHODS: We conducted a retrospective cohort study using data from the National Health Insurance Research Database (NHIRD) from 2012 to 2013 in Taiwan. Multilevel logistic regression analysis was used to examine the factors related to ED visits, readmissions, and hospital transfers of patients under the DRG-Based Payment System. RESULTS: In this study, 103,779 inpatients were under the DRG-Based Payment System. Among these inpatients, 4.66% visited the ED within 14 days after their discharge. The factors associated with the increased risk of ED visits within 14 days included age, lower monthly salary, urbanization of residence area, comorbidity index, MDCs, and hospital ownership (p < 0.05). In terms of MDCs, Diseases and Disorders of the Kidney and Urinary Tract (MDC11) conferred the highest risk of ED visits within 14 days (OR = 4.95, 95% CI: 2.69-9.10). Of the inpatients, 6.97% were readmitted within 30 days. The factors associated with the increased risk of readmission included gender, age, lower monthly salary, comorbidity index, MDCs, and hospital ownership (p < 0.05). In terms of MDCs, the inpatients with Pregnancy, Childbirth and the Puerperium (MDC14) had the highest risk of readmission within 30 days (OR = 20.43, 95% CI: 13.32-31.34). Among the inpatients readmitted within 30 days, 75.05% of them were readmitted within 14 days. Only 0.16% of the inpatients were transferred to other hospitals. CONCLUSION: The study shows a significant correlation between Major Diagnostic Categories in surgery and ED visits, readmission, and hospital transfers. The results suggested that the main reasons for the high risk may need further investigation for MDCs in ED visits, readmissions, and hospital transfers.