Patient Characteristics and Clinical and Economic Outcomes Associated with Unplanned Medical and Surgical Intensive Care Unit Admissions: A Retrospective Analysis.

Purpose: To characterize medical and surgical patient characteristics, as well as clinical and economic outcomes, associated with unplanned intensive care unit (ICU) admissions. Patients and Methods: This was a retrospective matched cohort analysis that utilized the PINC AITM Healthcare Database, which collects deidentified data from 25% of United States (US) hospital admissions. Discharge records were assessed for medical and surgical admissions in 2021. An unplanned ICU admission was defined as direct transfer from a medical, surgical, or telemetry unit to the ICU. Patients with and without an unplanned ICU admission were 1:1 propensity score matched. Differences between patients with and without unplanned ICU admissions were assessed using two-sample t-tests for continuous measures and Chi-square tests for categorical measures. Results: A total of 3,807,124 qualifying admissions were identified. Medical admissions with unplanned ICU transfers were more likely to be urgent/emergent (odds ratio [OR] 2.9, 95% confidence interval [CI 2.7-3.0], p<0.0001), with patient characteristics including male sex (1.4, [1.4-1.4], p<0.0001), obesity (1.7, [1.6-1.7], p<0.0001), and increased Charlson Comorbidity Index (CCI=1: 1.8, [1.8-1.9], p<0.0001; CCI≥5: 3.2, [3.1-3.3], p<0.0001). Surgical admissions with unplanned ICU transfers were more likely to be urgent/emergent (3.1, [2.9-3.2], p<0.0001) and with patients of higher CCI (2.5, [2.3-2.6], p<0.0001 to a CCI of≥5 (7.9, [7.4-8.4], p<0.0001). Between matched medical patients, mean differences in length of stay, cost, and mortality were 4.1 days (p<0.0001), $13,424 (p<0.0001), and 21% (p<0.0001), respectively. Between matched surgical patients, mean differences in these outcomes were 6.4 days (p<0.0001), $21,448 (p<0.0001), and 14% (p<0.0001), respectively. Conclusion: Emergency care in patients with a higher co-morbid burden is more likely to lead to unplanned ICU admission, putting patients at a significantly increased chance of mortality, longer length of stay, and increased costs. Improving care and monitoring of patients outside the ICU may help detect early changes in pathophysiology and enable early intervention.

Factors and Economic Outcomes Associated with Documented Difficult Intubation in the United States.

PURPOSE: Establishing good mechanical ventilation is a critical component and prerequisite to a wide range of surgical and medical interventions. Yet difficulties in intubating patients, and a variety of associated complications, are well documented. The economic burden resulting from difficult intubation (DI), however, is not well understood. The current study examines the economic burden of documented DI during inpatient surgical admissions and explores factors that are associated with DI. PATIENTS AND METHODS: Using data from the Premier Healthcare Database, adult patients with inpatient surgical admissions between January 1, 2016 and December 31, 2018 were selected. International Classification of Diseases, Tenth Edition, Clinical Modification (ICD-10-CM) diagnosis codes were used to classify the patients into matched cohorts of DI and non-DI patients. RESULTS: Patients in the DI group have mean inpatient costs and intensive care unit (ICU) costs that are substantially higher than patients without difficult intubations ($14,468 and $4,029 higher, respectively). Mean hospital length of stay and ICU length of stay were 3.8 days and 2.0 days longer, respectively (all p<0.0001, except ICU cost p=0.0001) in the DI group. Obesity, other chronic conditions, and larger hospital size were significantly associated with DI. CONCLUSION: DI is associated with higher average cost and longer average length of stay.

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.

Predictors of Robotic Versus Laparoscopic Inguinal Hernia Repair.

BACKGROUND: The advent of robotic-assisted surgery has added an additional decision point in the treatment of inguinal hernias. The goal of this study was to identify the patient, surgeon, and hospital demographic predictors of robotic inguinal hernia repair (IHR). METHODS: We conducted a retrospective analysis of 102,241 IHRs (1096 robotic and 101,145 laparoscopic) from 2010 through 2015 with data collected in the Premier Hospital Database. The adjusted odds ratio (OR) of receiving a robotic IHR was calculated for each of several demographic factors using multivariable logistic regression. RESULTS: The rate of robotic IHR increased from 2010 through 2015. Age <65 y and Charlson comorbidity index were not predictors of a robotic IHR. Females were more likely to receive a robotic IHR (OR 1.69, confidence interval [CI] 1.40-2.05, P < 0.0001). Compared with white patients, black patients were more likely (OR 1.33, CI 1.06-1.68, P = 0.0138), and other race patients were less likely (OR 0.47, CI 0.38-0.58, P < 0.0001) to receive a robotic IHR. Compared with Medicare insurance, patients with all other types of insurance were more likely to receive a robotic IHR (OR > 1.00, lower limit of CI > 1.00, P < 0.05). Higher volume surgeons were less likely to perform robotic IHR (OR < 1.00, upper limit of CI < 1.00, P < 0.05). Nonteaching (OR 1.81, CI 1.53-2.13, P < 0.0001), larger (OR > 1.00, lower limit of CI > 1.00, P < 0.05), and rural (OR 1.27, CI 1.03-1.57, P = 0.025) hospitals were more likely to perform robotic IHR. Significant regional variation in the rate of robotic IHR was identified (OR > 1.00, lower limit of CI > 1.00, P < 0.05). CONCLUSIONS: The rate of robotic IHR is increasing exponentially. This study found that female gender, black race, insurance other than Medicare, lower surgeon annual volume, larger hospital size, nonteaching hospital status, rural hospital location, and hospital region were predictors of robotic IHR.

Predictors of laparoscopic versus open inguinal hernia repair.

BACKGROUND: Inguinal hernia repair (IHR) is among the most common general surgery procedures. Multiple studies have examined costs and benefits of laparoscopic approach versus open repair. This study aimed to identify patient, surgeon, and hospital demographic predictors of laparoscopic versus open IHR. METHODS: We conducted a retrospective analysis of 342,814 IHRs (241,669 open; 101,145 laparoscopic) performed in adults (age ≥ 18) from 2010 to 2015 using the Premier Hospital Database. Multivariate logistic regression was used to estimate the adjusted odds ratio of an IHR being laparoscopic versus open with respect to several demographic variables. RESULTS: The odds of an IHR being laparoscopic increased from 2010 to 2015. A laparoscopic procedure was more likely in patients who were < age 65 (OR 1.29, CI 1.24-1.31, p < 0.0001), male (OR 1.31, CI 1.27-1.34, p < 0.0001), privately insured (OR 1.36, CI 1.33-1.40, p < 0.0001), and neither white, black, nor Hispanic (OR 1.11, CI 1.09-1.14, p < 0.0001). The likelihood of a procedure being laparoscopic decreased 13% with each one-unit increase in Charlson comorbidity index value (OR 0.88, CI 0.87-0.89, p < 0.0001). Surgeons were more likely to perform a laparoscopic procedure if they had larger annual IHR caseloads (≥ 45/year; OR 1.57, CI 1.53-1.60, p < 0.0001), and operated at large hospitals (> 500 beds; OR 1.36, CI 1.33-1.39, p < 0.0001) in New England (OR 2.38, CI 2.29-2.47, p < 0.0001). Non-predictors of a laparoscopic procedure included urban/rural hospital location (OR 1.02, CI 0.10-1.05, p = 0.06) and hospital teaching status (OR 1.01, CI 0.99-1.03, p = 0.2084). CONCLUSIONS: Use of laparoscopic IHR is increasing. Patient age, gender, race, and insurance type, as well as surgeon annual volume, hospital size, and hospital region were predictors of a laparoscopic procedure. Further studies are needed to explain and remedy underlying differences impacting these predictors.