Wide Provider Variation in Cost for Thyroidectomy: Potential Benefits of Standardizing Practice?

OBJECTIVE(S): Identifying provider variation in surgical costs could control rising healthcare expenditure and deliver cost-effective care. While these efforts have mostly focused on complex and expensive operations, provider-level variation in costs of thyroidectomy has not been well examined. METHODS: We retrospectively evaluated 921 consecutive total thyroidectomies performed by 14 surgeons at our institution between September 2011 and July 2016. Data were extracted from the Change Healthcare Performance Analytics Program. RESULTS: Mean patient age was 47.4 ± 0.5 y, 81% were females, 64.7% were Caucasians, and 18.8% were outpatients. The number of thyroidectomies performed by the 14 surgeons ranged from 4 to 597 (mean = 66). The mean costs per provider varied widely from $4,293 to $15,529 (P < 0.001). The mean length of stay was 1d ± .03 with wide variation among providers (0-6 d). Providers whose hospital cost exceeded the institutional mean demonstrated significantly higher anesthesia fees and lab costs (P < 0.001). CONCLUSIONS: We found substantial variation in hospital cost among providers for thyroidectomy despite practicing in the same academic institution, with some surgeons spending 3x more for the same operation. Implementing institutional standards of practice could reduce variation and the costs of surgical care.

A Depiction of Rehabilitation Patients 65 Years and Younger With Dysvascular Lower Extremity Amputation.

BACKGROUND: The majority of lower limb amputations (LLA) in Canada are dysvascular due to complications of diabetes and/or vascular disease. Traditionally dysvascular amputations have occurred in the elderly. With younger onset of adult diabetes, amputations are now occurring in non-geriatric populations. An understanding of younger patients with dysvascular LLA is needed to determine their risk factors, and unique health and psychosocial challenges. OBJECTIVES: To obtain a depiction of the key demographic and impairment characteristics of adults 65 years and younger with dysvascular LLA undergoing inpatient rehabilitation. METHODOLOGY: A retrospective chart review was completed on inpatient adult amputation rehabilitation patients over a five year period. Data extracted included socio-demographics, Functional Independence Measure (FIM) scores, comorbidities, and discharge outcomes. FINDINGS: One hundred and forty-three patients who were 65 years and younger were included, which represented almost a quarter of all admissions. Most patients were male (79%) with an average age of 55 years old (SD=8). The majority (72%) were unemployed. The mean number of co-morbidities was 5.2 (SD=8.2). Individuals discharged home (n=122) had higher (p<0.05) FIM scores than those readmitted to acute care or discharged to long-term care (n=20). CONCLUSIONS: Similar to the literature on older dysvascular LLA patients, our study found high rates of disability and co-morbidities in younger patients with dysvascular LLA, which might impact their ability to work. Given these challenges, better amputation prevention strategies and targeted rehabilitation programming for this population are needed.

Bone health in boys with Duchenne Muscular Dystrophy on long-term daily deflazacort therapy.

Quality of life in Duchenne Muscular Dystrophy (DMD) has improved significantly with corticosteroid treatment. However, corticosteroids decrease bone mass and increase vertebral fragility fracture risk. We report on bone health in 39 boys with DMD on long-term deflazacort (0.9 mg/kg/day) therapy. Bone health was defined by lumbar (L(1)-L(4)) bone mineral density (BMD), long-bone and/or symptomatic vertebral fractures. Lumbar BMD was reported as height-adjusted Z-scores at initiation of deflazacort (T(0)) and 1-2 year intervals thereafter. Subcapital body fat percentage and ambulatory status were recorded. At T(0), 39 boys, aged 6.6 ± 1.6 years had height-adjusted BMD Z-score -0.5 ± 0.8, and 23.5 ± 5.0% body fat. Height-adjusted Z-scores remained stable with years of deflazacort until loss of ambulation and accrual of body fat. Nine long-bone fractures occurred in eight ambulating boys, two before T(0). Seven vertebral fractures occurred in six non-ambulatory boys after ≥ 5 years of deflazacort with height-adjusted Z-score -1.8 ± 0.7, and 47.8 ± 12% body fat. Bone health in DMD is influenced by disease progression, corticosteroids, BMD Z-scores and fat mass accumulation. Adjustments for short stature must be considered during BMD interpretation. Percent body fat and ambulatory status are useful bone health indicators. Routine use of height adjusted Z-scores is advocated for use in routine clinical practice.

Does recruitment method make a difference? Effects on protocol retention and treatment outcome in elderly depressed patients.

The specific aim of this study was to contrast effects of recruitment method (solicited, referred) on demographic, psychosocial, medical, and treatment outcome measures in an ongoing clinical trial of maintenance therapies in late-life depression. Data from 125 elderly patients (56 solicited via media campaign, 69 clinically referred) with recurrent, unipolar major depression were available for analysis. Several statistical contrast procedures, including group t tests, chi 2 tests, survival analysis, and logistic regression, were used to assess differences in patient profiles related to method of recruitment. Referred patients included a higher proportion of African Americans and had a lower level of education, fewer economic resources, and higher chronic medical burden. Solicited patients had been in the index episode longer than the referred patients at the time of protocol entry and were 3.4 times more likely to have experienced a "provoking agent" (severe life event or chronic difficulty) during the 6 months that preceded the onset of depressive symptoms. In contrast to these demographic and illness history differences, there were no differences in treatment response rates or time to response related to recruitment method. Solicited patients had an overall treatment response rate of 71% versus 62% in the referred group. Median time to response was 14.3 weeks in the solicited group and 13.6 weeks in the referred group. These results suggest that the inclusion of solicited patients in geriatric depression clinical trials does not bias short-term treatment outcome.