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Background: We hypothesized that trauma surgeons can safely selectively manage traumatic craniomaxillofacial injuries (CMF) without specialist consult, thereby decreasing the overall cost burden to patients., Methods: A 4-year retrospective analysis of all CMF fractures diagnosed on facial CT scans. CMF consultation was compared with no-CMF consultation. Demographics, injury severity, and specialty consultation charges were recorded. Penetrating injuries, skull fractures, or patients completing inpatient craniofacial surgery were excluded., Results: 303 patients were studied (124 CMF consultation vs 179 no-CMF consultation), mean age was 47.8 years, with 70% males. Mean Glasgow Coma Scale and Injury Severity Score (ISS) was 14 ± 3.4 and 10 ± 9, respectively. Patients with CMF consults had higher ISS ( P < .001) and needed surgery on admission ( P < .001), while no-CMF consults had shorter length of stay ( P < .002). No in-hospital mortality or 30-day readmission rates were related to no-CMF consult. Total patient charges saved with no-CMF consultation was $26 539.96., Discussion: Trauma surgeons can selectively manage acute CMF injuries without inpatient specialist consultation. Additional guidelines can be established to avoid tertiary transfers for specialty consultation and decrease patient charges.

Whole grain consumption has been associated with the reduced risk of several chronic diseases with significant healthcare monetary burden, including cancer. Colorectal cancer (CRC) is one of the most common cancers globally, with the highest rates reported in Australia. Three servings of whole grains provide a 15% reduction in total cancer and 17% reduction in CRC risk; however, 70% of Australians fall short of this level of intake. The aim of this study was to assess the potential savings in healthcare costs associated with reductions in the relative risk of CRC and total cancer mortality following the whole grain Daily Target Intake (DTI) of 48 g in Australia. A three-step cost-of-illness analysis was conducted using input parameters from: (1) estimates of current and targeted whole grain intakes among proportions (5%, 15%, 50%, and 100%) of the Australian adult (≥20 years) population; (2) estimates of reductions in relative risk (with 95% confidence intervals) of CRC and total cancer mortality associated with specific whole grain intake from meta-analysis studies; and (3) estimates of annual healthcare costs of CRC and all cancers from disease expenditure national databases. A very pessimistic (5% of population) through to universal (100% of population) adoption of the recommended DTI in Australia were shown to potentially yield savings in annual healthcare costs equal to AUD 1.9 (95% CI 1.2-2.4) to AUD 37.2 (95% CI 24.1-48.1) million for CRC and AUD 20.3 (95% CI 12.2-27.0) to AUD 405.1 (95% CI 243.1-540.1) million for total cancers. As treatment costs for CRC and other cancers are increasing, and dietary measures exchanging whole grains for refined grains are not cost preclusive nor does the approach increase energy intake, there is an opportunity to facilitate cost-savings along with reductions in disease for Australia. These results suggest specific benefits of encouraging Australians to swap refined grains for whole grains, with greater overall adherence to suggestions in dietary guidelines.

Objective: Excess administrative costs in the US health care system are routinely referenced as a justification for comprehensive reform. While there is agreement that these costs are too high, there is little understanding of what generates administrative costs and what policy options might mitigate them., Data Sources: Literature review and national utilization and expenditure data., Study Design: We developed a simulation model of physician billing and insurance-related (BIR) costs to estimate how certain policy reforms would generate savings. Our model is based on structural elements of the payment process in the United States and considers each provider's number of health plan contracts, the number of features in each health plan, the clinical and nonclinical processes required to submit a bill for payment, and the compliance costs associated with medical billing., Data Extraction: For several types of visits, we estimated fixed and variable costs of the billing process. We used the model to estimate the BIR costs at a national level under a variety of policy scenarios, including variations of a single payer "Medicare-for-All" model that extends fee-for-service Medicare to the entire population and policy efforts to reduce administrative costs in a multi-payer model. We conducted sensitivity analyses of a wide variety of model parameters., Principal Findings: Our model estimates that national BIR costs are reduced between 33% and 53% in Medicare-for-All style single-payer models and between 27% and 63% in various multi-payer models. Under a wide range of assumptions and sensitivity analyses, standardizing contracts generates larger savings with less variance than savings from single-payer strategies., Conclusion: Although moving toward a single-payer system will reduce BIR costs, certain reforms to payer-provider contracts could generate at least as many administrative cost savings without radically reforming the entire health system. BIR costs can be meaningfully reduced without abandoning a multi-payer system., (© 2021 Health Research and Educational Trust.)

Background: The use of robotic total knee arthroplasty has become increasingly prevalent. Proponents of robotic total knee arthroplasty tout its potential to not only improve outcomes, but also to reduce costs compared with traditional total knee arthroplasty. Despite its potential to deliver on the value proposition, whether robotic total knee arthroplasty has led to improved outcomes and cost savings within Medicare's Bundled Payment for Care Improvement initiative remains unexplored., Methods: Medicare beneficiaries who underwent total knee arthroplasty designated under Medicare severity diagnosis related group 469 or 470 in the year 2017 were identified using the 100% Medicare Inpatient Standard Analytic Files. Hospitals participating in the Bundled Payment for Care Improvement were identified using the Bundled Payment for Care Improvement analytic file. We calculated risk-adjusted, price-standardized payments for the surgical episode from admission through 90-days postdischarge. Outcomes, utilization, and spending were assessed relative to variation between robotic and traditional total knee arthroplasty., Results: Overall, 198,371 patients underwent total knee arthroplasty (traditional total knee arthroplasty: n= 194,020, 97.8% versus robotic total knee arthroplasty: n = 4,351, 2.2%). Among the 3,272 hospitals that performed total knee arthroplasty, only 300 (9.3%) performed robotic total knee arthroplasty. Among the 183 participating in the Bundled Payment for Care Improvement, only 40 (19%) hospitals performed robotic total knee arthroplasty. Risk-adjusted 90-day episode spending was $14,263 (95% confidence interval $14,231-$14,294) among patients who underwent traditional total knee arthroplasty versus $13,676 (95% confidence interval $13,467-$13,885) among patients who had robotic total knee arthroplasty. Patients who underwent robotic total knee arthroplasty had a shorter length of stay (traditional total knee arthroplasty: 2.3 days, 95% confidence interval: 2.3-2.3 versus robotic total knee arthroplasty: 1.9 days, 95% confidence interval: 1.9-2.0), as well as a lower incidence of complications (traditional total knee arthroplasty: 3.3%, 95% confidence interval: 3.2-3.3 versus robotic total knee arthroplasty: 2.7%, 95% confidence interval: 2.3-3.1). Of note, patients who underwent robotic total knee arthroplasty were less often discharged to a postacute care facility than patients who underwent traditional total knee arthroplasty (traditional total knee arthroplasty: 32.4%, 95% confidence interval: 32.3-32.5 versus robotic total knee arthroplasty: 16.8%, 95% confidence interval 16.1-17.6). Both Bundled Payment for Care Improvement and non-Bundled Payment for Care Improvement hospitals with greater than 50% robotic total knee arthroplasty utilization had lower spending per episode of care versus spending at hospitals with less than 50% robotic total knee arthroplasty utilization., Conclusion: Overall 90-day episode spending for robotic total knee arthroplasty was lower than traditional total knee arthroplasty (Δ $-587, 95% confidence interval: $-798 to $-375). The decrease in spending was attributable to shorter length of stay, fewer complications, as well as lower utilization of postacute care facility. The cost savings associated with robotic total knee arthroplasty was only realized when robotic total knee arthroplasty volume surpassed 50% of all total knee arthroplasty volume. Hospitals participating in the Bundled Payment for Care Improvement may experience cost-saving with increased utilization of robotic total knee arthroplasty., (Published by Elsevier Inc.)

Purpose: De-escalated treatment for human papillomavirus (HPV)+ oropharynx squamous cell carcinoma (OPSCC) has shown promising initial results. Health-care policy is increasingly focusing on high-value care. This analysis compares the cost of care for HPV+ OPSCC treated with definitive chemoradiation (CRT), surgery and adjuvant radiation (RT), and surgery and de-escalated CRT on MC1273., Methods and Materials: MC1273 is a prospective, phase 2 study evaluating adjuvant CRT to 30 to 36 Gy plus docetaxel for HPV+ OPSCC after surgery for high-risk patients. Matched standard-of-care control groups were retrospectively identified for patients treated with definitive CRT or adjuvant RT. Standardized costs were evaluated before radiation, during treatment (during RT), and at short-term (6 month) and long-term (7-24 month) follow-up periods., Results: A total of 56 definitive CRT, 101 adjuvant RT, and 66 MC1273 patients were included. The CRT arm had more T3-4 disease (63% vs 17-21%) and higher N2c-N3 disease (52% vs 20-24%) vs both other groups. The total treatment costs in the CRT, adjuvant RT, and MC1273 groups were $47,763 (standard deviation [SD], $19,060], $57,845 (SD, $17,480), and $46,007 (SD, $9019), respectively, and the chemotherapy and/or RT costs were $39,936 (SD, $18,480), $26,603 (SD, $12,542), and $17,864 (SD, $3288), respectively. The per-patient, per-month, average short-term follow-up costs were $3860 (SD, $10,525), $1072 (SD, $996), and $972 (SD, $833), respectively, and the long-term costs were $978 (SD, $2294), $485 (SD, $1156), and $653 (SD, $1107), respectively. After adjustment for age, T-stage, and N-stage, treatment costs remained lower for CRT and MC1273 versus adjuvant RT ($45,450 and $47,114 vs $58,590, respectively; P < .001), whereas the total per-patient, per-month follow-up costs were lower in the MC1273 study group and adjuvant RT versus CRT ($853 and $866 vs $2030, respectively; P = .03)., Conclusions: MC1273 resulted in 10% and 20% reductions in global costs compared with standard-of-care adjuvant RT and definitive CRT treatments. Substantial cost savings may be an added benefit to the already noted low toxicity and maintained quality of life of treatment per MC1273., (Copyright © 2020 Elsevier Inc. All rights reserved.)

The study objective was to evaluate a single institution experience with adult stereotactic intracranial biopsies and review any projected cost savings as a result of bypassing intensive care unit (ICU) admission and limited routine head computed tomography (CT). The authors retrospectively reviewed all stereotactic intracranial biopsies performed at a single institution between February 2012 and March 2019. Primary data collection included ICU length of stay (LOS), hospital LOS, ICU interventions, need for reoperation, and CT use. Secondarily, location of lesion, postoperative hematoma, neurological deficit, pathology, and preoperative coagulopathy data were collected. There were 97 biopsy cases (63% male). Average age, ICU LOS, and total hospital stay were 58.9 years (range; 21-92 years), 2.3 days (range; 0-40 days), and 8.8 days (range 1-115 days), respectively. Seventy-five (75 of 97) patients received a postoperative head CT. No patients required medical or surgical intervention for complications related to biopsy. Eight patients required transfer from the ward to the ICU (none directly related to biopsy). Nine patients transferred directly to the ward postoperatively (none required transfer to ICU). Of the patients who did not receive CT or went directly to the ward, none had extended LOS or required transfer to ICU for neurosurgical concerns. Eliminating routine head CT and ICU admission translates to approximately $584,971 in direct cost savings in 89 cases without a postoperative ICU requirement. These practice changes would save patients' significant hospitalization costs, decrease healthcare expenditures, and allow for more appropriate hospital resource use., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: The Safe Staffing for Quality Care Act under consideration in the New York (NY) state assembly would require hospitals to staff enough nurses to safely care for patients. The impact of regulated minimum patient-to-nurse staffing ratios in acute care hospitals in NY is unknown., Objectives: To examine variation in patient-to-nurse staffing in NY hospitals and its association with adverse outcomes (ie, mortality and avoidable costs)., Research Design: Cross-sectional data on nurse staffing in 116 acute care general hospitals in NY are linked with Medicare claims data., Subjects: A total of 417,861 Medicare medical and surgical patients., Measures: Patient-to-nurse staffing is the primary predictor variable. Outcomes include in-hospital mortality, length of stay, 30-day readmission, and estimated costs using Medicare-specific cost-to-charge ratios., Results: Hospital staffing ranged from 4.3 to 10.5 patients per nurse (P/N), and averaged 6.3 P/N. After adjusting for potential confounders each additional patient per nurse, for surgical and medical patients, respectively, was associated with higher odds of in-hospital mortality [odds ratio (OR)=1.13, P=0.0262; OR=1.13, P=0.0019], longer lengths of stay (incidence rate ratio=1.09, P=0.0008; incidence rate ratio=1.05, P=0.0023), and higher odds of 30-day readmission (OR=1.08, P=0.0002; OR=1.06, P=0.0003). Were hospitals staffed at the 4:1 P/N ratio proposed in the legislation, we conservatively estimated 4370 lives saved and $720 million saved over the 2-year study period in shorter lengths of stay and avoided readmissions., Conclusions: Patient-to-nurse staffing varies substantially across NY hospitals and higher ratios adversely affect patients. Our estimates of potential lives and costs saved substantially underestimate potential benefits of improved hospital nurse staffing., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: Review the safety, efficacy and cost of robot-assisted sialolithotomy with sialoendoscopy (RASS) for large submandibular gland hilar sialoliths., Study Design: Retrospective case series., Methods: Patients ≥18 years diagnosed with submandibular hilar sialolithiasis between 1/1/2015 and 7/31/2018 who underwent RASS were identified. Procedure success, post-operative complications, procedure duration, and costs associated with the procedure were reviewed., Results: 33 patients fit inclusion criteria. 94% of patients had successful sialolith removal. Mean sialolith size was 8.9 mm. 15.1% had transient tongue paresthesia. 0% had permanent tongue paresthesia compared to a 2% rate of lingual nerve damage cited in the literature for combined approach sialolithotomy (CAS). The average total cost was $16,921. Insurance paid 100%, 90-99%, 70-89.9%, and 40-69.9% of the expected reimbursement in 43.8%, 18.7%, 18.7% and 12.5% of patients respectively. 6% of patients self-paid. Compared to CAS, the cost of reusable robotic arms and drapes totaled $475, though these costs were included in the standardized operative cost per minute and were not forwarded to the patient. The mean procedure time was 62 minutes. Compared to published mean procedure times for CAS, the reduced operative time may account for a savings of $3332-$6069., Conclusion: RASS is a safe modality for submandibular hilar sialolith removal with a high success rate, low risk for temporary tongue paresthesia, and lower rate of permeant lingual nerve damage compared to CAS. Compared with CAS, RASS may result in a net reduction of operative room costs given its shorter procedure time.

Objective: This study aimed to determine the medical cost impact and return on investment (ROI) of a large, commercial, digital, weight-management intensive lifestyle intervention (ILI) program (Real Appeal)., Methods: Participants in this program were compared with a control group matched by age, sex, geographic region, health risk, baseline medical costs, and chronic conditions. Medical costs were defined as the total amount paid for all medical expenses, inclusive of both the insurers' and the study participants' responsibility., Results: In the 3 years following program registration, the intent-to-treat (ITT) cohort had significantly lower medical expenditures than the matched controls, with an average of -$771 or 12% lower costs (P = 0.002). Among 4,790 ITT participants, a total savings of $3,693,090 compared with total program costs of $1,639,961 translated into a 2.3:1 ROI. Program completers (n = 3,990), who attended more sessions than the overall ITT group, had greater mean weight loss (-4.4%), greater cost savings (-$956 or 14%), and an ROI of 2.0:1 over the 3-year time frame compared with matched controls., Conclusions: The findings demonstrated that the digital weight-management ILI was associated with a significantly positive ROI. Employers and payers willing to cover the cost of an ILI that produces both weight loss and demonstrated cost benefits can improve health and save money for their population with overweight or obesity., (© 2021 Rally Health, Inc. Obesity published by Wiley Periodicals LLC on behalf of The Obesity Society (TOS).)

Robotic-assisted surgery is criticized for its high cost. As surgeons get more experienced in robotic surgery, modifications to existing techniques are tried to reduce surgical costs. Vaginal cuff closure using prograsp forceps in lieu of needle holder can be safe and cost-effective in patients undergoing robotic-assisted hysterectomy. The objective of this study is to compare the safety, efficacy, and cost effectiveness of using prograsp forceps in lieu of needle holder for suturing the vaginal cuff after robotic-assisted hysterectomy. This was a single-institution retrospective review of patients who underwent robotic-assisted hysterectomy for benign and malignant conditions from October 2015 to August 2018. Patients were stratified based on whether prograsp forceps or needle holder was used for suturing vaginal cuff. Data obtained included demographic, surgical data, and postoperative outcomes. Mann-Whitney U test and Chi-square test were used to compare qualitative and quantitative data, respectively. 367 patients underwent robotic-assisted hysterectomies during this period. 75 patients belonged to the needle holder cohort; 292 patients had vaginal cuff closure using prograsp forceps. Vault closure time was comparable between the groups (6.4 vs. 6.6 p = 0.33). There were no significant differences in the postoperative vault-related complications between groups. There was no instrument damage in either group. Using prograsp saved 220 USD in instrument-related charges. This study shows that using prograsp in lieu of needle holder for suturing is safe, there is no increase in operative time or complications, and there is a cost advantage.

Objective: To examine how plan premiums are associated with physician network breadth, hospital network breadth, and hospital network quality on the Affordable Care Act's Health Insurance Marketplaces in all 50 states and the DC in 2016., Data Sources: Data on plan premiums and characteristics came from 2016 Robert Wood Johnson Foundation Health Insurance Exchange (HIX) Compare. Provider network information was obtained from Vericred. Hospital characteristics were obtained from CMS Hospital Compare and the American Hospital Association (AHA) survey., Study Design: We analyzed how plan premiums were associated with variations in physician network breadth, hospital network breadth, and hospital network quality using ordinary least square regressions with state-rating area fixed effects and carrier fixed effects., Principal Findings: Plan premiums were positively associated with physician network breadth and hospital network breadth. We find the following statistically significant results: a one standard deviation increase in physician network breadth was linked to a premium increase of 2.8 percent or $101 per year; a one standard deviation increase in hospital network breadth was linked to a premium increase of 2.4 percent or $86 per year. There was no significant association between premiums and hospital network quality, as measured by hospital star ratings and the inclusion of teaching hospitals or the top-20 hospitals nationwide., Conclusions: Physician network breadth and hospital network breadth contributed positively to plan premiums. The roles of the two types of provider network breadth are quantitatively similar. Premiums appear to be insensitive to hospital network quality., (© 2020 Health Research and Educational Trust.)

Pressure on health care providers is growing due to capping of remuneration for medical services in most Western European countries. We wanted to investigate, if robotic-assisted ventral hernia repair is reasonable from an economic point of view in our setting. Patients undergoing open or robotic-assisted repair for complex abdominal wall hernia using a Transversus Abdominis Release (TAR) between September 2017 and January 2019 were included. Procedure-related costs were calculated exact to the minute and cost unit accounting for the postoperative in-patient stay was done. Abdominal wall reconstruction using the TAR-technique was done in a total of 26 (10 female) patients via an open (n = 10) or robotic-assisted (n = 16) approach. No significant difference was seen in regard to age, BMI and ASA scores between subgroups. Time for operation was longer (253.5 vs 211.5 min; p = 0.0322), while postoperative hospital stay was shorter for patients operated with a robotic-assisted approach (4.5 vs 12.5 days; p < 0.005). Procedure-related costs were 2.7-fold higher when a robotic-assisted reconstruction was done (EUR 5397 vs. 1989), while total costs for in-patient stay were about 60% lower (EUR 2715 vs 6663). Currently, revenues by national insurance account for a total of EUR 9577 leading to a profit of EUR 1465 and 925 for the robotic-assisted and open myofascial release, respectively. In addition, 30-day re-admission rate was in favor of the robotic-assisted approach as well (6.3% vs 20%). From an economic point of view, robotic-assisted TAR for complex ventral hernia repair is a viable option in our setting. Higher procedure-related costs are offset by a significant shorter hospital stay. The economic advantage goes along with improvement in outcome of patients.

Objectives: Recognize the avoidable costs incurred due to overpacking of rhinoplasty instrument trays. Reduce rhinoplasty instrument trays by including only instruments used frequently. Establish methods to reduce trays prepared for other otolaryngologic procedures., Methods: This is a prospective study. The study evaluates the specific use of instruments opened for rhinoplasty procedures at the New York Eye & Ear Infirmary of Mount Sinai. Instruments were counted in 10 rhinoplasty cases. Usage rate was calculated for each instrument. Additionally, all instruments used in at least 20% of cases were noted. This "20%" threshold was used to create new rhinoplasty tray inventories more reflective of actual instrument usage. Some instruments above the 20% threshold were included in multiples (i.e. two Adson Brown forceps vs. one curved iris scissor)., Results: 189 instruments were opened, and 32 instruments were used on average in each rhinoplasty. 55 instruments were used in at least 20% of cases. The 55 "high usage" instruments were used to create new, reduced rhinoplasty tray inventory lists. Based on our analysis, a new rhinoplasty tray inventory was created comprised of 68 instruments, a 64% reduction from 189., Conclusion: Instruments are sterilized and packed in gross excess for rhinoplasty procedures. Previously published figures estimate re-sterilization costs of $0.51 to $0.77 per instrument. Reduction in instruments opened from 189 to 68 is expected to lead to cost savings ranging from $62 to $93 per case, yielding a savings between $6200 and $9300 per 100 cases performed., Level of Evidence: II-3., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objectives: Testing and treatment for hepatitis B virus (HBV) and hepatitis C virus (HCV) infection are highly effective, high-impact interventions. This article aims to estimate the cost-effectiveness of scaling up these interventions by scenarios, regions, and income groups., Methods: We modeled costs and impacts of hepatitis elimination in 67 low- and middle-income countries from 2016 to 2030. Costs included testing and treatment commodities, healthcare consultations, and future savings from cirrhosis and hepatocellular carcinomas averted. We modeled disease progression to estimate disability-adjusted life-years (DALYs) averted. We estimated incremental cost-effectiveness ratios (ICERs) by regions and World Bank income groups, according to 3 scenarios: flatline (status quo), progress (testing/treatment according to World Health Organization guidelines), and ambitious (elimination)., Results: Compared with no action, current levels of testing and treatment had an ICER of $807/DALY for HBV and -$62/DALY (cost-saving) for HCV. Scaling up to progress scenario, both interventions had ICERs less than the average gross domestic product/capita of countries (HBV: $532/DALY; HCV: $613/DALY). Scaling up from flatline to elimination led to higher ICERs across countries (HBV: $927/DALY; HCV: $2528/DALY, respectively) that remained lower than the average gross domestic product/capita. Sensitivity analysis indicated discount rates and commodity costs were main factors driving results., Conclusions: Scaling up testing and treatment for HBV and HCV infection as per World Health Organization guidelines is a cost-effective intervention. Elimination leads to a much larger impact though ICERs are higher. Price reduction strategies are needed to achieve elimination given the substantial budget impact at current commodity prices., (Copyright © 2020 World Health Organization. Published by Elsevier Inc. All rights reserved.)

A non-randomized single center prospective, descriptive, correlational design was used to determine what end-tidal carbon dioxide (EtCO 2 ) level provided the best sensitivity, specificity, and negative predictive value to exclude pulmonary embolism (PE) diagnosis in hemodynamically stable hospitalized adults ( n = 111). The financial impact and harm avoidance of adding EtCO 2 to the PE diagnostic process also were examined. PE diagnosis was determined by computed tomography pulmonary angiography (CTPA). PE prevalence was 18.9%. Mean±SD EtCO 2 was lower for PE positive than negative participants (28 ± 7.8 to 33 ± 8.1 mmHg respectively 95% CI: 1.22-8.96; P = .01). For PE exclusion, an EtCO 2 cutoff ≥42 mmHg yielded 100% sensitivity, 12.2% specificity, and 100% negative predictive value. For every six inpatients assessed with EtCO 2 , one could be saved from unnecessary CTPA. Eliminating unnecessary CTPA removes the potential harm associated with radiation and intravenous contrast exposure. Additionally, an EtCO 2 cutoff ≥42 mmHg could eliminate ~$88,000/year in healthcare waste at this institution.

Objectives: Traditional risk scores improved the definition of the initial therapeutic strategy in acute coronary syndrome (ACS), but they were not designed for predicting long-term individual risks and costs. In parallel, attempts to directly predict costs from clinical variables in ACS had limited success. Thus, novel approaches to predict cardiovascular risk and health expenditure are urgently needed. Our objectives were to predict the risk of major/minor adverse cardiovascular events (MACE) and estimate assistance-related costs., Methods: We used a 2-step approach that: (1) predicted outcomes with a common pathophysiological substrate (MACE) by using machine learning (ML) or logistic regression (LR) and compared with existing risk scores; (2) derived costs associated with noncardiovascular deaths, dialysis, ambulatory-care-sensitive-hospitalizations (ACSH), strokes, and MACE. With consecutive ACS individuals (n = 1089) from 2 cohorts, we trained in 80% of the population and tested in 20% using a 4-fold cross-validation framework. The 29-variable model included socioeconomic, clinical/lab, and coronarography variables. Individual costs were estimated based on cause-specific hospitalization from the Brazilian Health Ministry perspective., Results: After up to 12 years follow-up (mean = 3.3 ± 3.1; MACE = 169), the gradient-boosting machine model was superior to LR and reached an area under the curve (AUROC) of 0.891 [95% CI 0.846-0.921] (test set), outperforming the Syntax Score II (AUROC = 0.635 [95% CI 0.569-0.699]). Individuals classified as high risk (>90th percentile) presented increased HbA1c and LDL-C both at <24 hours post-ACS and 1-year follow-up. High-risk individuals required 33.5% of total costs and showed 4.96-fold (95% CI 3.71-5.48, P < .00001) greater per capita costs compared with low-risk individuals, mostly owing to avoidable costs (ACSH). This 2-step approach was more successful for finding individuals incurring high costs than predicting costs directly from clinical variables., Conclusion: ML methods predicted long-term risks and avoidable costs after ACS., (Copyright © 2020 ISPOR–The Professional Society for Health Economics and Outcomes Research. Published by Elsevier Inc. All rights reserved.)

Acute appendicitis is one of the main indications for urgent surgery representing a high-volume procedure worldwide. The current spending review in Italy (and not only in this country) affects the health service and warrants care regarding the use of different surgical devices. The aim of our study is to perform a cost evaluation, comparing the use of endoloops and staplers in complicated acute appendicitis (phlegmonous and gangrenous), taking into consideration the cost of the device in relation to the management of any associated postoperative complications. We retrospectively evaluated 996 laparoscopic appendectomies of adult patients performed in the Emergency General Surgery-St. Orsola University Hospital in Bologna (Italy). Surgical procedures together with the related choice of using endoloops or staplers were performed by attending surgeons or resident surgeons supervised by a tutor. A systematic review was performed to compare our outcomes with those reported in the literature. In our experience, the routine use of endoloop leads to a real estimated saving of 375€ for each performed laparoscopic appendectomy, even considering post-operative complications. Comparing endoloop and stapler groups, the total number of complications is significantly lower in the endoloop group. Our systematic review confirmed these findings even if the superiority of one technique has not been proved yet. Our analysis shows that the routine use of endoloop is safe in most patients affected by acute appendicitis, even when complicated, and it is a cost-effective device even when taking into consideration extra costs for potential post-operative complications.

Purpose: To model Medicare Part B and patient savings associated with increased bevacizumab payment and use for intravitreal anti-vascular endothelial growth factor (VEGF) therapy., Design: Cost analysis., Participants: Intelligent Research in Sight (IRIS®) Registry data., Methods: Medicare claims and IRIS® Registry data were used to calculate Medicare Part B expenditures and patient copayments for anti-VEGF agents with increasing reimbursement and use of bevacizumab relative to ranibizumab and aflibercept., Main Outcome Measures: Medicare Part B costs and patient copayments for anti-VEGF agents in the Medicare fee-for-service population., Results: Increasing bevacizumab reimbursement to $125.78, equalizing the dollar margin with aflibercept, would result in Medicare Part B savings of $468 million and patient savings of $119 million with a 10% increase in bevacizumab market share., Conclusions: Increased use of bevacizumab achievable with increased reimbursement to eliminate the financial disincentive to its use would result in substantial savings for the Medicare Part B program and for patients receiving anti-VEGF intravitreal injections., (Copyright © 2020 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Background: With health care practice consolidation, the increasing geographic scope of health care systems, and the advancement of mobile telecommunications, there is increasing interest in telemedicine-based health care consultations. Anesthesiology has had experience with telemedicine consultation for preoperative evaluation since 2004, but the majority of studies have been conducted in rural settings. There is a paucity of literature of use in metropolitan areas. In this article, we describe the implementation of a telemedicine-based anesthesia preoperative evaluation and report the program's patient satisfaction, clinical case cancellation rate outcomes, and cost savings in a large metropolitan area (Los Angeles, CA)., Methods: This is a descriptive study of a telemedicine-based preoperative anesthesia evaluation process in an academic medical center within a large metropolitan area. In a 2-year period, we evaluated 419 patients scheduled for surgery by telemedicine and 1785 patients who were evaluated in-person., Results: Day-of-surgery case cancellations were 2.95% and 3.23% in the telemedicine and the in-person cohort, respectively. Telemedicine patients avoided a median round trip driving distance of 63 miles (Q1 24; Q3 119) and a median time saved of 137 (Q1 95; Q3 195) and 130 (Q1 91; Q3 237) minutes during morning and afternoon traffic conditions, respectively. Patients experienced time-based savings, particularly from traveling across a metropolitan area, which amounted to $67 of direct and opportunity cost savings. From patient satisfaction surveys, 98% (129 patients out of 131 completed surveys) of patients who were consulted via telemedicine were satisfied with their experience., Conclusions: This study demonstrates the implementation of a telemedicine-based preoperative anesthesia evaluation from an academic medical center in a metropolitan area with high patient satisfaction, cost savings, and without increase in day-of-procedure case cancellations.

Background: Enhanced Recovery After Surgery (ERAS) is a global surgical qualityimprovement initiative. Little is known about the economic effects of implementing multiple ERAS guidelines in both the short and long term., Methods: We performed a return on investment (ROI) analysis of the implementation of multiple ERAS guidelines (for colorectal, pancreas, cystectomy, liver and gynecologic oncology procedures) across multiple sites (9 hospitals) in Alberta using 30-, 180- and 365-day time horizons. The effects of ERAS on health services utilization (length of stay of the primary admission, number of readmissions, length of stay of the readmissions, number of emergency department visits, number of outpatient clinic visits, number of specialist visits and number of general practitioner visits) were assessed by mixed-effect multilevel multivariate negative binomial regressions. Net benefits and ROI were estimated by a decision analytic modelling analysis. All costs were reported in 2019 Canadian dollars., Results: The net health system savings per patient ranged from $26.35 to $3606.44 and ROI ranged from 1.05 to 7.31, meaning that every dollar invested in ERAS brought $1.05 to $7.31 in return. Probabilities for ERAS to be cost-saving were from 86.5% to 99.9%. The effects of ERAS were found to be larger in the longer time horizons, indicating that if only the 30-day time horizon had been used, the benefits of ERAS would have been underestimated., Conclusion: These results demonstrated that ERAS multiguideline implementation was cost-saving in Alberta. To produce a better ROI, it is important to consider a broad range of health service utilizations, long-term impact, economies of scale, productive efficiency and allocative efficiency for sustainability, scale and spread of ERAS implementations., Competing Interests: G. Nelson is secretary of the ERAS Society. No other competing interests were declared., (© 2020 Joule Inc. or its licensors.)

Purpose: Stereotactic radiosurgery (SRS) historically has been used to treat multiple brain lesions using a multiple-isocenter technique-frequently associated with significant complexity in treatment planning and long treatment times. Recently, given innovations in planning algorithms, patients with multiple brain lesions may now be treated with a single-isocenter technique using fewer total arcs and less time spent during image guidance (though with stricter image guided radiation therapy tolerances). This study used time-driven activity-based costing to determine the difference in cost to a provider for delivering SRS to multiple brain lesions using single-isocenter versus multiple-isocenter techniques., Methods and Materials: Process maps, consisting of discrete steps, were created for each phase of the SRS care cycle and were based on interviews with department personnel. Actual treatment times (including image guidance) were extracted from treatment record and verify software. Additional sources of data to determine costs included salary/benefit data of personnel and average list price/maintenance costs for equipment., Results: Data were collected for 22 patients who underwent single-isocenter SRS (mean lesions treated, 5.2; mean treatment time, 30.2 minutes) and 51 patients who underwent multiple-isocenter SRS (mean lesions treated, 4.4; mean treatment time, 75.2 minutes). Treatment time for multiple-isocenter SRS varied substantially with increasing number of lesions (11.8 minutes/lesion; P < .001), but to a much lesser degree in single-isocenter SRS (1.8 minutes/lesion; P = .029). The resulting cost savings from single-isocenter SRS based on number of lesions treated ranged from $296 to $3878 for 2 to 10 lesions treated. The 2-mm planning treatment volume margin used with single-isocenter SRS resulted in a mean 43% increase of total volume treated compared with a 1-mm planning treatment volume expansion., Conclusions: In a comparison of time-driven activity-based costing assessment of single-isocenter versus multiple-isocenter SRS for multiple brain lesions, single-isocenter SRS appears to save time and resources for as few as 2 lesions, with incremental benefits for additional lesions treated., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Introduction: To evaluate perioperative costs of canal wall-down (CWD) mastoidectomy as an initial surgery compared to revision surgery following initial canal wall-up (CWU) mastoidectomy., Methods: This study is a retrospective chart review of adult patients who underwent CWD mastoidectomy for chronic otitis media with or without cholesteatoma at a tertiary referral center. Patients were divided into groups that had previous CWU surgery and were undergoing revision CWD and those that were having an initial CWD mastoidectomy. Cost variables including previous surgeries, imaging costs, audiometric testing, and post-operative visits were compared between the two groups using t-test analysis., Results: There was no significant difference with regards to the cost of post-operative visits, peri-operative imaging, or revision surgeries between the two groups. Hearing outcomes based on mean speech reception threshold (SRT) were not statistically different between the two groups (p = 0.087). There was a significant difference in total cost with the revision group having a higher mean cost by $6967.84, most of which was accounted for by the difference in the cost of the previous surgeries of $6488.53., Conclusions: The revision CWD surgery group had increased total cost that could be attributed to the cost of previous surgery. Increased peri-operative cost was not noted with the initial CWD surgery group for any individual variables examined. Initial CWD mastoidectomy should be considered in the proper patient population to help decrease healthcare costs., (Copyright © 2020. Published by Elsevier Inc.)

Purpose: The clinic efficiency and cost savings achieved by eliminating formal visual acuity (VA) and dilated fundus examinations (DFEs) were assessed for established patients receiving optical coherence tomography (OCT)-guided intravitreal injections., Design: Comparative cost analysis., Methods: Two different treatment models were evaluated. The first model included patients undergoing routine VA assessment, DFEs, OCT imaging, and intravitreal injections. The second model eliminated the routine VA assessment and DFE while using OCT imaging through an undilated pupil followed by the intravitreal injection. The 2 models incorporated both bevacizumab and aflibercept. The number of patients per clinic day, the cost per visit, and the daily revenues were compared between the 2 models., Results: Optimized schedules with and without VA assessments and DFEs allowed for 48 and 96 patients to be injected per day, respectively. Excluding drug costs, the cost per encounter for the visits with and without a DFE were $39.33 and $22.63, respectively. Including the drug costs, the costs per encounter for the visits with and without a DFE were $85.55 and $68.85 for bevacizumab and $1787.58 and $17770.88 for aflibercept, respectively. Once the reimbursements for each visit type were included, the clinics that eliminated the VA and DFEs were more cost efficient., Conclusion: Eliminating both VA assessments and DFEs for patients undergoing OCT-guided retreatment with intravitreal injections resulted in decreased exposure times between patients and clinic staff, decreased cost per encounter, and increased patient volumes per clinic day, resulting in improved clinic efficiency and safety while seeing more patients in a clinic day., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: We assessed the hypothesis that nonoperative management would be a viable treatment option for patients with underlying degenerative disease who have traumatic cervical spinal cord injury (TCSI) without neurological deterioration and/or spinal instability during hospitalization., Methods: Data were collected prospectively from 2011 to 2016. All the patients had been treated nonoperatively with hard cervical collar immobilization. The clinical parameters assessed included the Frankel grade at presentation and discharge, the occurrence of deep vein thrombosis, urinary tract infection, sphincter dysfunction, and pressure sores. The radiographic data collected included magnetic resonance imaging signal cord changes. P ≤ 0.05 represented a significant association between the Frankel grade at presentation and the outcome parameters., Results: A total of 28 patients were included in the present study. Of the patients who had presented with Frankel grade B, 85.71% had improved to a higher grade, 90.91% of the patients with Frankel grade C had improved to a higher grade, and 14.29% of the patients with Frankel grade D had improved to Frankel grade E. All the patients had satisfactory spinal stability, as evidenced by dynamic radiographs, after treatment., Conclusion: The findings from the present study have shown that nonoperative management can result in improved neurological outcomes for patients with underlying degenerative disease who have experienced TCSI without evidence of neurological deterioration and spinal instability. The Frankel grade at presentation was significantly associated with outcome parameters such as the neurological outcome on discharge and the occurrence of urinary tract infection. The results from the present study could be helpful to neurological surgeons in rural and other low-resource settings because the cost savings realized by nonoperative treatment will not sacrifice the provision of adequate care to their patients., (Copyright © 2020 Elsevier Inc. All rights reserved.)

WHO has set global targets for the elimination of hepatitis B and hepatitis C as a public health threat by 2030. However, investment in elimination programmes remains low. To help drive political commitment and catalyse domestic and international financing, we have developed a global investment framework for the elimination of hepatitis B and hepatitis C. The global investment framework presented in this Health Policy paper outlines national and international activities that will enable reductions in hepatitis C incidence and mortality, and identifies potential sources of funding and tools to help countries build the economic case for investing in national elimination activities. The goal of this framework is to provide a way for countries, particularly those with minimal resources, to gain the substantial economic benefit and cost savings that come from investing in hepatitis C elimination., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Policy Points Concerns have been raised about risk selection in the Medicare Shared Savings Program (MSSP). Specifically, turnover in accountable care organization (ACO) physicians and patient panels has led to concerns that ACOs may be earning shared-savings bonuses by selecting lower-risk patients or providers with lower-risk panels. We find no evidence that changes in ACO patient populations explain savings estimates from previous evaluations through 2015. We also find no evidence that ACOs systematically manipulated provider composition or billing to earn bonuses. The modest savings and lack of risk selection in the original MSSP design suggest opportunities to build on early progress. Recent program changes provide ACOs with more opportunity to select providers with lower-risk patients. Understanding the effect of these changes will be important for guiding future payment policy., Context: The Medicare Shared Savings Program (MSSP) establishes incentives for participating accountable care organizations (ACOs) to lower spending for their attributed fee-for-service Medicare patients. Turnover in ACO physicians and patient panels has raised concerns that ACOs may be earning shared-savings bonuses by selecting lower-risk patients or providers with lower-risk panels., Methods: We conducted three sets of analyses of Medicare claims data. First, we estimated overall MSSP savings through 2015 using a difference-in-differences approach and methods that eliminated selection bias from ACO program exit or changes in the practices or physicians included in ACO contracts. We then checked for residual risk selection at the patient level. Second, we reestimated savings with methods that address undetected risk selection but could introduce bias from other sources. These included patient fixed effects, baseline or prospective assignment, and area-level MSSP exposure to hold patient populations constant. Third, we tested for changes in provider composition or provider billing that may have contributed to bonuses, even if they were eliminated as sources of bias in the evaluation analyses., Findings: MSSP participation was associated with modest and increasing annual gross savings in the 2012-2013 entry cohorts of ACOs that reached $139 to $302 per patient by 2015. Savings in the 2014 entry cohort were small and not statistically significant. Robustness checks revealed no evidence of residual risk selection. Alternative methods to address risk selection produced results that were substantively consistent with our primary analysis but varied somewhat and were more sensitive to adjustment for patient characteristics, suggesting the introduction of bias from within-patient changes in time-varying characteristics. We found no evidence of ACO manipulation of provider composition or billing to inflate savings. Finally, larger savings for physician group ACOs were robust to consideration of differential changes in organizational structure among non-ACO providers (eg, from consolidation)., Conclusions: Participation in the original MSSP program was associated with modest savings and not with favorable risk selection. These findings suggest an opportunity to build on early progress. Understanding the effect of new opportunities and incentives for risk selection in the revamped MSSP will be important for guiding future program reforms., (© 2020 Milbank Memorial Fund.)

Background: Internationally, most studies have focused on quality and safety in long-term care. However, studies focusing on the economic evaluation of quality and security in long-term care are sparse. Moreover, the economic evaluation of nurse practitioner care in long-term care is lacking, particularly in Québec Canada where roles are new., Purpose: To evaluate the effectiveness of introducing nurse practitioners in six long-term care facilities in Québec using a cost-savings analysis in terms of reduction of nurse practitioner sensitive events (NPSEs)., Methods: A cost savings analysis was completed using a prospective observational study. All residents (n = 538) under the care of teams that included nurse practitioners who experienced at least one of the following NPSEs: falls, pressure ulcers, short-term transfers, and a change in the time needed to administer the medications consumed were included. Data were collected from September 1st 2015 to August 31st 2016. Descriptive statistics identified numbers of cases for falls, pressure ulcers, short-term transfers, and the number of medications consumed. A literature analysis was used to estimate excess median long-term care facility related costs of these NPSEs. Costs were calculated in 2016 Canadian dollars. The cost savings with the reductions that occurred for falls, pressure ulcers, short term transfers, and the time needed to administer medications after the implementation of a primary healthcare nurse practitioner role in the six long term care facilities were also estimated., Findings: The median cost of 341 cases of falls, 32 cases of pressure ulcers and 53 cases of short-term transfers in the six long-term facilities would range between CAD 4,516,337.8 and CAD 5,281,824.4. Moreover, the total costs savings from the reduction of adverse events including the reduction of nursing administration time for medications would be between CAD 1,942,533.6 and CAD 3,254,403.4., Discussion: This is the first study to present the financial consequence of adverse events sensitive to nurse practitioner care in long-term care. Important cost savings were generated from the reduction of adverse events after the implementation of nurse practitioner roles in long-term care. Government should consider these results for prevention and improvements in quality and safety in long-term care., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

Policy Points Evidence suggests that bundled payment contracting can slow the growth of payer costs relative to fee-for-service contracting, although bundled payment models may not reduce absolute costs. Bundled payments may be more effective than fee-for-service payments in containing costs for certain medical conditions. For the most part, Medicare's bundled payment initiatives have not been associated with a worsening of quality in terms of readmissions, emergency department use, and mortality. Some evidence suggests a worsening of other quality measures for certain medical conditions. Bundled payment contracting involves trade-offs: Expanding a bundle's scope and duration may better contain costs, but a more comprehensive bundle may be less attractive to providers, reducing their willingness to accept it as an alternative to fee-for-service payment., Context: Bundled payments have been promoted as an alternative to fee-for-service payments that can mitigate the incentives for service volume under the fee-for-service model. As Medicare has gained experience with bundled payments, it has widened their scope and increased their duration. However, there have been few reviews of the empirical literature on the impact of Medicare's bundled payment programs on cost, resource use, utilization, and quality., Methods: We examined the history and features of 16 of Medicare's bundled payment programs involving hospital-initiated episodes of care and conducted a literature review of articles about those programs. Database and additional searches yielded 1,479 articles. We evaluate the studies' methodological quality and summarize the quantitative findings about Medicare expenditures and quality of care from 37 studies that used higher-quality research designs., Findings: Medicare's bundled payment initiatives have varied in their design features, such as episode scope and duration. Many initiatives were associated with little to no reduction in Medicare expenditures, unless large pricing discounts for providers were negotiated in advance. Initiatives that included post-acute care services were associated with lower expenditures for certain conditions. Hospitals may have been able to reduce internal production costs with help from physicians via gainsharing. Most initiatives were not associated with significant changes in quality of care, as measured by readmission and mortality rates. Of the significant changes in readmission rates, the results were mixed, showing increases and decreases associated with bundled payments. Some evidence suggested that worse patient outcomes were associated bundled payments, although most results were not statistically significant. Results on case-mix selection were mixed: Several initiatives were associated with reductions in episode severity, whereas others were associated with little change., Conclusions: Bundled payments for hospital-initiated episodes may be a good alternative to fee-for-service payments. Bundled payments can help slow the growth of payer spending, although they do not necessarily reduce absolute spending. They are associated with lower provider production costs, and there is no overwhelming evidence of compromised quality. However, designing a bundled payment contract that is attractive to both providers and payers proves to be a challenge., (© 2020 Milbank Memorial Fund.)

Background: Lantus, the reference insulin glargine used for the treatment of diabetes, lost its patent protection in 2014, opening the market to biosimilar competitors., Objective: First, to analyze the adoption rates of insulin glargine biosimilars in primary care in England and estimate the savings realized and missed, since an insulin glargine biosimilar was first used, and second, to assess potential variations in adoption rates across Clinical Commissioning Groups (CCGs)., Research Design and Methods: Data sets capturing information on all insulin glargine items prescribed by all general practitioners up to December 2018 were used. Total costs of insulin glargine and uptake rates of biosimilars were calculated. The real-world budget impact was estimated assuming the cost of reference insulin glargine for all items and comparing the total costs in this scenario with the total costs in the real world. The missed savings were estimated assuming the cost of biosimilars for all insulin glargine items. Choropleth maps were generated to assess potential variations in uptake across CCGs., Results: Insulin glargine biosimilars generated savings of £900,000 between October 2015 (time of first prescription) and December 2018. The missed savings amounted to £25.6 million in this period, indicating that only 3.42% of the potential savings were achieved. The analyses demonstrated a large level of variation in the uptake of insulin glargine biosimilars across CCGs, with market shares ranging from 0 to 53.3% (December 2018)., Conclusions: These results may encourage decision makers in England to promote the use of best-value treatments in primary care and to reevaluate variation across CCGs., (© 2020 by the American Diabetes Association.)

This study aimed (1) to estimate the impact of an incremental reduction in excess readmissions on a hospital's Medicare reimbursement revenue, for hospitals subject to penalties under the Medicare's Hospital Readmissions Reduction Program and (2) to evaluate the economic case for an investment in a readmission reduction program. For 2,465 hospitals with excess readmissions in the Fiscal Year 2016 Hospital Compare data set, we (1) used the Hospital Readmissions Reduction Program statute to estimate hospital-specific Medicare reimbursement gains per an avoided readmission and (2) carried out a pro forma analysis of investment in a broad-scale readmission reduction program under conservative assumptions regarding program effectiveness and using program costs from earlier studies. For an average hospital, avoiding one excess readmission would result in reimbursement gains of $10,000 to $58,000 for Medicare discharges. The economic case for investments in a readmission reduction effort was strong overall, with the possible exception of hospitals with low excess readmissions.

Background: External fixation improves open fracture management in emerging countries. However, sophisticated models are often expensive and unavailable. We assessed the biomechanical properties of a low-cost external fixation system in comparison with the Hoffmann® 3 system, as a reference., Methods: Transversal, oblique, and comminuted fractures were created in the diaphysis of tibia sawbones. Six external fixators were tested in three modes of loading-axial compression, medio-lateral (ML) bending, and torsion-in order to determine construction stiffness. The fixator construct implies two uniplanar (UUEF1, UUEF2) depending the pin-rods fixation system and two biplanar (UBEF1, UBEF2) designs based on different bar to bar connections. The designed low-cost fixators were compared to a Hoffmann® 3 fixator single rod (H3-SR) and double rod (H3-DR). Twenty-seven constructs were stabilized with UUEF1, UUEF2, and H3-SR (nine constructs each). Nine constructs were stabilized with UBEF1, UBEF2, and H3-DR (three constructs each)., Results: UUEF2 was significantly stiffer than H3-SR (p < 0.001) in axial compression for oblique fractures and UUEF1 was significantly stiffer than H3-SR (p = 0.009) in ML bending for transversal fractures. Both UUEFs were significantly stiffer than H3-SR in axial compression and torsion (p < 0.05), and inferior to H3-SR in ML bending, for comminuted fractures. In the same fracture pattern, UBEFs were significantly stiffer than H3-DR (p = 0.001) in axial compression and torsion, while only UBEF1 was significantly stiffer than H3-DR in ML bending (p = 0.013)., Conclusions: The results demonstrated that the stiffness of the UUEF and UBEF device compares to the reference fixator and may be helpful in maintaining fracture reduction. Fatigue testing and clinical assessment must be conducted to ensure that the objective of bone healing is achievable with such low-cost devices.

Background: Health insurance reimbursement structure has evolved, with patients becoming increasingly responsible for their health care costs through rising out-of-pocket expenses. High levels of cost sharing can lead to delays in access to care, influence treatment decisions, and cause financial distress for patients., Methods: Patients undergoing the most common outpatient reconstructive plastic surgery operations were identified using Truven MarketScan databases from 2009 to 2017. Total cost of the surgery paid to the insurer and out-of-pocket expenses, including deductible, copayment, and coinsurance, were calculated. Multivariable generalized linear modeling with log link and gamma distribution was used to predict adjusted total and out-of-pocket expenses. All costs were inflation-adjusted to 2017 dollars., Results: The authors evaluated 3,165,913 outpatient plastic and reconstructive surgical procedures between 2009 and 2017. From 2009 to 2017, total costs had a significant increase of 25 percent, and out-of-pocket expenses had a significant increase of 54 percent. Using generalized linear modeling, procedures performed in outpatient hospitals conferred an additional $1999 in total costs (95 percent CI, $1978 to $2020) and $259 in out-of-pocket expenses (95 percent CI, $254 to $264) compared with office procedures. Ambulatory surgical center procedures conferred an additional $1698 in total costs (95 percent CI, $1677 to $1718) and $279 in out-of-pocket expenses (95 percent CI, $273 to $285) compared with office procedures., Conclusions: For outpatient plastic surgery procedures, out-of-pocket expenses are increasing at a faster rate than total costs, which may have implications for access to care and timing of surgery. Providers should realize the increasing burden of out-of-pocket expenses and the effect of surgical location on patients' costs when possible.

Background Awareness of energy efficiency has been rising in the industrial and residential sectors but only recently in the health care sector. Purpose To measure the energy consumption of modern CT and MRI scanners in a university hospital radiology department and to estimate energy- and cost-saving potential during clinical operation. Materials and Methods Three CT scanners, four MRI scanners, and cooling systems were equipped with kilowatt-hour energy measurement sensors (2-Hz sampling rate). Energy measurements, the scanners' log files, and the radiology information system from the entire year 2015 were analyzed and segmented into scan modes, as follows: net scan (actual imaging), active (room time), idle, and system-on and system-off states (no standby mode was available). Per-examination and peak energy consumption were calculated. Results The aggregated energy consumption imaging 40 276 patients amounted to 614 825 kWh, dedicated cooling systems to 492 624 kWh, representing 44.5% of the combined consumption of 1 107 450 kWh (at a cost of U.S. $199 341). This is equivalent to the usage in a town of 852 people and constituted 4.0% of the total yearly energy consumption at the authors' hospital. Mean consumption per CT examination over 1 year was 1.2 kWh, with a mean energy cost (±standard deviation) of $0.22 ± 0.13. The total energy consumption of one CT scanner for 1 year was 26 226 kWh ($4721 in energy cost). The net consumption per CT examination over 1 year was 3580 kWh, which is comparable to the usage of a two-person household in Switzerland; however, idle state consumption was fourfold that of net consumption (14 289 kWh). Mean MRI consumption over 1 year was 19.9 kWh per examination, with a mean energy cost of $3.57 ± 0.96. The mean consumption for a year in the system-on state was 82 174 kWh per MRI examination and 134 037 kWh for total consumption, for an energy cost of $24 127. Conclusion CT and MRI energy consumption is substantial. Considerable energy- and cost-saving potential is present during nonproductive idle and system-off modes, and this realization could decrease total cost of ownership while increasing energy efficiency. © RSNA, 2020.

Background: Improvement initiatives promote safe and efficient care for hospitalized children. However, these may be associated with limited cost savings. In this article, we sought to understand the potential financial benefit yielded by improvement initiatives by describing the inpatient allocation of costs for common pediatric diagnoses., Methods: This study is a retrospective cross-sectional analysis of pediatric patients aged 0 to 21 years from 48 children's hospitals included in the Pediatric Health Information System database from January 1, 2017, to December 31, 2017. We included hospitalizations for 8 common inpatient pediatric diagnoses (seizure, bronchiolitis, asthma, pneumonia, acute gastroenteritis, upper respiratory tract infection, other gastrointestinal diagnoses, and skin and soft tissue infection) and categorized the distribution of hospitalization costs (room, clinical, laboratory, imaging, pharmacy, supplies, and other). We summarized our findings with mean percentages and percent of total costs and used mixed-effects models to account for disease severity and to describe hospital-level variation., Results: For 195 436 hospitalizations, room costs accounted for 52.5% to 70.3% of total hospitalization costs. We observed wide hospital-level variation in nonroom costs for the same diagnoses (25%-81% for seizure, 12%-51% for bronchiolitis, 19%-63% for asthma, 19%-62% for pneumonia, 21%-78% for acute gastroenteritis, 21%-63% for upper respiratory tract infection, 28%-69% for other gastrointestinal diagnoses, and 21%-71% for skin and soft tissue infection). However, to achieve a cost reduction equal to 10% of room costs, large, often unattainable reductions (>100%) in nonroom cost categories are needed., Conclusions: Inconsistencies in nonroom costs for similar diagnoses suggest hospital-level treatment variation and improvement opportunities. However, individual improvement initiatives may not result in significant cost savings without specifically addressing room costs., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2020 by the American Academy of Pediatrics.)

Chagas disease, caused by Trypanosoma cruzi , is transmitted by insect vectors, and through transfusions, transplants, insect feces in food, and mother to child during gestation. An estimated 30% of infected persons will develop lifelong, potentially fatal cardiac or digestive complications. Treatment of infants with benznidazole is highly efficacious in eliminating infection. This work evaluates the costs of maternal screening and infant testing and treatment for Chagas disease in the United States, including the cost of commercially available benznidazole. We compare costs of testing and treatment for mothers and infants with the lifetime societal costs without testing and consequent morbidity and mortality due to lack of treatment or late treatment. We constructed a decision-analytic model, using one tree that shows the combined costs for every possible mother-child pairing. Savings per birth in a targeted screening program are $1,314, and with universal screening, $105 per birth. At current screening costs, universal screening results in $420 million in lifetime savings per birth-year cohort. We found that a congenital Chagas screening program in the United States is cost saving for all rates of congenital transmission greater than 0.001% and all levels of maternal prevalence greater than 0.06% compared with no screening program.

In the United States (US), the lifetime incidence of incarceration is 6.6%, exceeding that of any other nation. Compared to the general US population, incarcerated individuals are disproportionally affected by chronic health conditions, mental illness, and substance use disorders. Barriers to accessing medical care are common in correctional facilities. We sought to characterize the local incarcerated patient population and explore barriers to medical care in these patients. We conducted a retrospective, observational cohort study by reviewing the medical records of incarcerated patients presenting to the adult emergency department (ED) of a single academic, tertiary care facility with medical or psychiatric (med/psych) and trauma-related emergencies between January 2012 and December 2014. Data on demographics, medical complexity, trauma intentionality, and barriers to medical care were analyzed using descriptive statistics, unpaired student's t-test or one-way analysis of variance for continuous variables, and chi-square analysis or Fisher's exact test as appropriate. Trauma patients were younger with fewer medical comorbidities and were less likely to be admitted to the hospital than med/psych patients. 47.8% of injuries resulted from violence or were self-inflicted. Most trauma-related complaints were managed by the emergency medicine physician in the ED. While barriers to medical care were not correlated with hospital admission, 5.4% of med/psych and 2.9% of trauma patients reported barriers as a contributing factor to the ED encounter. Med/psych patients commonly reported a lack of access to medications, while trauma patients reported a delay in medical care. Trauma-related presentations were less medically complex than med/psych-related complaints. Medical management of most injuries required no hospital resources outside of the ED, indicating a potential role for outpatient management of trauma-related complaints. Additional opportunities for health care improvement and cost savings include the implementation of programs that target violence, prevent injuries, and promote the continuity of medical care while incarcerated., Competing Interests: While author NT is currently employed with Medical Associates LLC, she had no affiliation with this commercial entity at the time of her contribution to this manuscript. University of Tennessee College of Medicine at Chattanooga provided support in the form of salaries for NT, JW, and RM, but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. ApolloMD provided salaries for JW and RM, but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. RM owns a small number of shares in Merck (42.618 shares) and Proctor and Gamble (51.27 shares), which were purchased for her when she was a minor and are not relevant to this research study. Our commercial entity affiliations do not alter our adherence to PLOS ONE policies on sharing data and materials. We feel authors’ contributions are accurately reflected as documented in our manuscript submission.

Background Renal dosage adjustment for patients with reduced kidney function is a common function of clinical pharmacy service. Assessment of pharmacist's intervention in the aspect of quality and economic impact should be conducted to evaluate the benefit of this service. Objective This study aimed to assess the quality and cost saving of clinical pharmacists' recommendation on renal dosage adjustment among patients with reduced kidney function. Setting Eight medical wards of the Siriraj Hospital, a tertiary-care hospital in Bangkok, Thailand. Method A retrospective study was conducted using medical records and clinical pharmacist's intervention database. All patients admitted to the study wards whose estimated creatinine clearance were less than 60 mL/min or presented with acute kidney injury on admission during October 2016-December 2017 were included. The targeted medications were antimicrobial agents. Main outcome measure Percentage of the concordance between pharmacists' recommendation compared to standard dosing references and related cost saving. Results Among 158 patients, pharmacists provided 190 recommendations, including 151 (79.1%) dose reduction, 17 (8.9%) dose increase and 22 (11.5%) recommendations to provide supplemental dose after dialysis. These recommendations were 90.5% consistent with standard references. Physician accepted and complied with 89.5% of pharmacists' recommendations. Average direct cost saving was €5,114.11 while cost avoidance was €863.47. Conclusion Trained clinical pharmacists were able to provide high-quality recommendation on dosage adjustment in these patients in accordance to standard dosing guidelines. In addition, dosage adjustment also led to a significant direct cost saving and cost avoidance from prevention of adverse drug reactions.

Objectives: Understanding variation in spending across organizations, rather than across geographic areas, is important because care is delivered by organizations and interventions increasingly focus on organizations. Accountable care organizations (ACOs) are particularly important to study given their incentives to reduce spending. Analyzing spending differences across ACOs may help identify cost savings opportunities., Study Design: Cross-sectional analysis of Medicare claims., Methods: We stratified ACOs into quartiles based on the deviation between each ACO's risk-adjusted spending and average risk-adjusted fee-for-service spending in the same market (hospital referral region). We compared spending between top- and bottom-quartile ACOs on each of 7 major service categories and 10 clinical condition groups to identify areas of potential savings. We simulated spending reductions if ACOs with high adjusted spending reduced spending to the levels of lower-spending ACOs., Results: In 2016, geographically adjusted and risk-adjusted total per-beneficiary spending for the highest-spending quartile of ACOs was 14% higher than for ACOs in the lowest quartile. Variation between high- and low-spending ACOs was greatest, at 27%, in the use of skilled nursing facilities-a service category in which ACOs have reduced spending by the greatest percentage. Inpatient care was the largest driver of absolute dollar differences in spending, however, accounting for 37% of the total spread. If spending in ACOs above median adjusted spending were brought down to the median, savings would be 3% to 4%., Conclusions: By extending the variations literature to focus on ACOs, we illustrated that meaningful further savings opportunities exist both within and across markets.

Background: Outpatient management has proven to be the most useful method of treatment for various minimally complex surgical specialties compared to day-hospital management or ordinary inpatient processes, a fact confirmed by numerous technical documents and works in the literature., Methods: We analyzed 27,713 surgical interventions carried out in our hospital between 2005 and 2017. This analysis included all interventions for which the indication of the level of care has moved, over the years, to an outpatient setting. We evaluated the direct costs of these services, comparing them by year and by treatment setting., Results: From the analysis of costs in general, for the same number of services, a reduction of 56.6% can be seen in the comparison between 2005 and 2017. In addition, the analysis of the length of stay shows an average reduction in the number of days of hospitalization from 2.9 to 1.2 between 2005 and 2017. On the basis of a large quantity of data, our study confirms that outpatient surgery can have a significant impact in reducing costs and days of hospitalization, even in a pediatric setting, demonstrating that it is the best choice in terms of saving resources and, above all, clinical and organizational appropriateness., Conclusions: Outpatient surgery is in fact a valuable solution that provides an advantage for both the patient and his/her family, especially in the pediatric field, for the hospital and more generally for the health system as a whole.

Objective: Pulmonary arterial hypertension is a rare and progressive respiratory disease characterised by high blood pressure and vascular resistance producing right ventricular fatigue. In Italy, pulmonary hypertension can be treated with different drugs available on the market at different costs, and in the Marche region distributed exclusively by hospital pharmacies. The present study examined in an area of the Marche region the use of drugs specifically indicated for pulmonary hypertension, and evaluated how the introduction of the generic bosentan might lower pharmaceutical costs for the healthcare budget., Methods: The study examined oral administration prescriptions and costs using data from the Apotheke Gold (Record Data) database from 1 January 2012 to 31 August 2017., Results: Annually (from 1 January 2012 to 31 August 2017), an average of 4.83 patients were treated (prevalence of 102.35 cases per 1 million residents) with ambrisentan (Volibris), bosentan (Tracleer), macitentan (Opsumit), tadalafil (Adcirca) or sildenafil (Revatio). The total expenditure during the 5-year 8-month period was €472 405. Ambrisentan was by far the most expensive product overall, with a total expenditure of €222 380 for the period studied (a daily cost of €67.39), even though Tracleer had the highest cost for a day of treatment (a daily cost of €94.48, but a total expenditure of €163 976 for the period, due to its more recent marketing). Providing patients with the generic form bosentan in place of Tracleer would lower the costs dramatically. A very significant annual savings per patient of approximately €31 879 would be achieved, a striking 92.4% reduction in costs., Conclusion: The prevalence of pulmonary arterial hypertension reported for Camerino and its surrounding area in the Marches region is quite high compared with that reported by other authors for France and Scotland. The introduction of the generic bosentan would cut costs drastically. It is to be hoped that centralised procurement at the regional level would bring further savings., Competing Interests: Competing interests: None declared., (© European Association of Hospital Pharmacists 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: National changes in health care disparities within the setting of trauma care have not been examined within Accountable Care Organizations (ACOs) or non-ACOs. We sought to examine the impact of ACOs on post-treatment outcomes (in-hospital mortality, 90-day complications, and readmissions), as well as surgical intervention among whites and nonwhites treated for spinal fractures., Materials and Methods: We identified all beneficiaries treated for spinal fractures between 2009 and 2014 using national Medicare fee for service claims data. Claims were used to identify sociodemographic and clinical criteria, receipt of surgery and in-hospital mortality, 90-day complications, and readmissions. Multivariable logistic regression analysis accounting for all confounders was used to determine the effect of race/ethnicity on outcomes. Nonwhites were compared with whites treated in non-ACOs between 2009 and 2011 as the referent., Results: We identified 245,704 patients who were treated for spinal fractures. Two percent of the cohort received care in an ACO, whereas 7% were nonwhite. We found that disparities in the use of surgical fixation for spinal fractures were present in non-ACOs over the period 2009-2014 but did not exist in the context of care provided through ACOs (odds ratio [OR] 0.75; 95% confidence interval [CI] 0.44, 1.28). A disparity in the development of complications existed for nonwhites in non-ACOs (OR 1.09; 95% CI 1.01, 1.17) that was not encountered among nonwhites receiving care in ACOs (OR 1.32; 95% CI 0.90, 1.95). An existing disparity in readmission rates for nonwhites in ACOs over 2009-2011 (OR 1.34; 95% CI 1.01, 1.80) was eliminated in the period 2012-2014 (OR 0.85; 95% CI 0.65, 1.09)., Conclusions: Our work reinforces the idea that ACOs could improve health care disparities among nonwhites. There is also the potential that as ACOs become more familiar with care integration and streamlined delivery of services, further improvements in disparities could be realized., (Copyright © 2019 Elsevier Inc. All rights reserved.)

The reimbursement system at 16 Federally Qualified Health Centers in Washington State transformed to a per-member-per-month model with a prospective adjustment for quality performance. The results of this qualitative study suggest that 3 to 5 years would be required to achieve significant progress in the Triple Aim goals of the initiative and also demonstrate that Federally Qualified Health Centers are potentially more advanced in their readiness to offer value-based care. By providing positive financial incentives without downside risk, the state is stimulating replicable models of care, and in longer term such reforms may lead to a greater care coordination and a whole person-centered care.

Objectives　To examine the effects of a multifactorial intervention for improving frailty-comprising resistance exercise and nutritional and psychosocial programs-on the risk of long-term care insurance (LTCI) certification, death, and long-term care (LTC) cost among community-dwelling older adults.Methods　Seventy-seven individuals (47 in 2011 and 30 in 2013) from the Hatoyama Cohort Study (742 individuals) participated in a multifactorial intervention. Non-participants were from the same cohort (including people who were invited to participate in the multifactorial intervention but declined). We performed propensity score matching with a ratio of 1 : 2 (intervention group vs. non-participant group). Afterward, 70 individuals undergoing the multifactorial intervention and 140 non-participants were selected. The risk of LTCI certification and/or death and the mean LTC cost during the follow-up period (32 months) were compared using the Cox proportional hazards model and generalized linear model (gamma regression model).Results　The incidence of new LTCI certification (per 1,000 person-years) tended to be lower in the intervention group than in the non-participant group (1.8 vs. 3.6), but this was not statistically significant as per the Cox proportional hazards model (hazard ratio=0.51, 95% confidence interval [CI]=0.17-1.54). Although the incidence of LTC cost was not significant, the mean cumulative LTC cost during the 32 months and the mean LTC cost per unit during the follow-up period (1 month) were 375,308 JPY and 11,906 JPY/month, respectively, in the intervention group and 1,040,727 JPY and 33,460 JPY/month, respectively, in the non-participant group. Cost tended to be lower in the intervention group than in the non-participant group as per the gamma regression model (cumulative LTC cost: cost ratio=0.36, 95%CI=0.11-1.21, P=0.099; LTC cost per unit follow-up period: cost ratio=0.36, 95%CI=0.11-1.12, P=0.076).Conclusions　These results suggest that a multifactorial intervention comprising resistance exercise, nutritional, and psychosocial programs is effective in lowering the incidence of LTCI certification, consequently saving LTC cost, although the results were not statistically significant. Further research with a stricter study design is needed.

The high cost of drugs for hepatitis C limits access and adherence to treatment. In 2017, the Colombian health care system decided to design a strategy. It consisted of centralized purchasing, regulations, clinical practice guidelines, and direct observation of the treatment and follow-up of patients. The main objective of this study was to assess the centralized purchasing strategy in Colombia. The study design was a policy implementation assessment. We analyzed the change in prices, the clinical outcomes, and the opinions of stakeholders using data from the Ministry of Health. Additional information about effectiveness came from the Colombian Fund for High-Cost Diseases and semi-structured interviews of the stakeholders. The follow-up was from October, 2017 to October, 2018. The total number of patients reported in the cohort period was 1069. The number that finished 12 weeks of treatment, completed the follow-up for the case closure, and were considered cured through the end of October, 2018 was 563 (53%). The remainder, 506 patients (47%), are currently in treatment. A total of 543 of these treated patients (96%) were cured. After implementing this strategy, the drug prices decreased by more than 90% overall. Before implementation, the total direct cost was $100 102 171.75 dollars. Afterward, the cost was $8 378 747 dollars., Competing Interests: None of the authors have a conflict of interest., (© 2019 The Authors. Pharmacology Research & Perspectives published by John Wiley & Sons Ltd, British Pharmacological Society and American Society for Pharmacology and Experimental Therapeutics.)