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Background: Transcatheter aortic valve replacement has become an accepted alternative to surgical aortic valve replacement. We examined the trends and predictors in inflation-adjusted costs of transcatheter aortic valve replacement and surgical aortic valve replacement., Methods: National Inpatient Sample identified patients who underwent aortic valve replacement for severe aortic stenosis by International Classification of Diseases, Ninth and Tenth Revisions, codes. Hospitalization costs were inflation-adjusted using the Federal Reserve's consumer price index to reflect current valuation. Outcomes of interest were unadjusted trend in annual cost for each procedure and predictors of in-patient cost. Generalized linear models with a log link function identified predictors of adjusted costs. Interaction terms determined where cost predictors were different by operation type., Results: Between 2011 and 2019, the mean annual inflation-adjusted cost of surgical aortic valve replacement increased from $62,853 to $63,743, in contrast to decreasing cost of transcatheter aortic valve replacement from $64,913 to $56,042 ($1,854 per year; P = .004). Significant independent predictors of patient-level cost included operation type (transcatheter aortic valve replacement associated with $9,625 increase; P < .001), incidence of in-hospital mortality ($28,836 increase; P < .001), elective status ($2,410 decrease; P < .001), Elixhauser Index ($995 increase; P < .001), and postoperative length of stay ($2,014 per day increase; P < .001). Compared to discharges with Medicare, discharges with private insurance and Medicaid paid $736 less (P = .004) and $1,863 less (P = .01), respectively. Increasing hospital volume was a significant predictor of decreasing patient level cost (P < .001)., Conclusion: Annual cost of transcatheter aortic valve replacement has decreased significantly and has been a more cost-effective modality compared to surgical aortic valve replacement since 2017. Predictors of patient-level costs allow for mindful preparation of healthcare systems for aortic valve replacement., (Published by Elsevier Inc.)

Background: Institutional experience has been associated with reduced mortality after coronary artery bypass grafting and valve operations. Using a contemporary, national cohort, we examined the impact of hospital volume on hospitalization costs and postdischarge resource utilization after these operations., Methods: Adults undergoing elective coronary artery bypass grafting or valve operations were identified in the 2016 to 2017 Nationwide Readmissions Database. Institutions were grouped into volume quartiles based on annual elective cardiac surgery caseload, and comparisons were made between the lowest and highest quartiles, using generalized linear models., Results: Of an estimated 296,510 patients, 24.8% were treated at low-volume hospitals and 25.2% at high-volume hospitals. Compared with patients treated at low-volume hospitals, patients managed at high-volume hospitals were younger, had more comorbidities, and more frequently underwent combined coronary artery bypass grafting valve (13.0% vs 12.3%, P < .001) and multivalve operations (6.2% vs 3.1%, P < .001). After adjustment, operations at high-volume hospitals were associated with a $7,600 reduction (95% confidence interval $4,700-$10,500) in costs. High-volume hospitals were also associated with reduced odds of mortality, non-home discharge, and 30-day non-elective readmission compared to low-volume hospitals., Conclusion: Despite increased complexity at high-volume centers, greater operative volume was independently associated with reduced hospitalization costs and mortality after elective cardiac operations. Reduction in non-home discharge and readmissions suggests this effect to extend beyond acute hospitalization, which may guide value-based care paradigms., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Previous studies showed a large inpatient burden of psoriasis in the United States. Less is known about the hospital readmission for psoriasis., Objectives: To determine the patterns and predictors of hospital readmission rates for psoriasis., Methods: We analyzed data from the 2012-2014 Nationwide Readmissions Database, a representative sample of hospital readmissions in the United States., Results: Among 2606 admissions for psoriasis, 216 had ≥1 readmissions for psoriasis (prevalence [95% confidence interval]: 8.3% [6.6%-10.0%]) and 918 for all-causes (35.2% [32.2%-38.3%]). The mean annual cost of first readmission for any reason was $3,500,141, with $8,357,961 for subsequent readmissions. In multivariable regression models, readmission for psoriasis was associated with ≥6 day-long index hospitalization (adjusted hazard ratio [95% confidence interval]: 1.82 [1.06-3.12]), teaching hospital (1.93 [1.13-3.31]), comorbid skin infection (2.13 [1.11-4.08]), and hospitalization in the autumn (4.51 [2.54-8.00]), but inversely associated with other infections (0.49 [0.26-0.92]). Readmissions for psoriasis increased from 2012 to 2014 (1.93 [1.26-2.93])., Limitations: No data on psoriasis characteristics., Conclusion: Inpatients with psoriasis had high rates of readmission overall but low rates of readmission for psoriasis per se. A subset of psoriasis patients was hospitalized repeatedly and responsible for most inpatients costs. Future interventions are needed to lower readmission rates among psoriasis patients., (Copyright © 2019 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Readmissions for skin disease, particularly for the same diagnosis and over time, have not been well studied., Objective: To characterize hospital readmissions for skin disease., Methods: A cross-sectional observational study examined the Nationwide Readmissions Database from 2010 to 2014, a national sample of hospital discharges in the United States., Results: Of the patients in 3,602,599 dermatologic hospitalizations from 2010 to 2014, 9.8% were readmitted for any cause, 3.3% were admitted for the same diagnosis within 30 days, and 7.8% were readmitted for the same diagnosis within the calendar year (CY). The cost of all CY same-cause readmissions was $508 million per year. Mycosis fungoides had the highest 30-day all-cause readmission rate (32%), vascular hamartomas and dermatomyositis had the highest 30-day same-cause readmission rates (21% and 18%, respectively), and dermatomyositis and systemic lupus erythematosus had the highest CY same-cause readmission rates (31% and 24%, respectively). Readmission rates stayed stable from 2010 to 2014. Readmission for the same diagnosis was strongly associated with Medicaid and morbid obesity., Limitations: This study is a broad description of hospitalizations for skin disease. Conclusions for individual diseases are not intended., Conclusion: The rates and costs of readmissions for skin diseases remained high from 2010 to 2014. This study identifies diseases associated with high risk of hospital readmission, but disease-specific studies are needed. The diseases and risk factors presented should guide additional studies focused on strategies to reduce readmissions in specific skin diseases., (Copyright © 2019 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Objectives: Readmission rates after cardiac surgery are being used as a quality indicator; they are also being collected by Medicare and are tied to reimbursement. Accurate knowledge of readmission rates may be difficult to achieve because patients may be readmitted to different hospitals. In our area, 81 hospitals share administrative claims data; 28 of these hospitals (from 5 different hospital systems) do cardiac surgery and share Society of Thoracic Surgeons (STS) clinical data. We used these 2 sources to compare the readmissions data for accuracy., Methods: A total of 45,539 STS records from January 2008 to December 2016 were matched with the hospital billing data records. Using the index visit as the start date, the billing records were queried for any subsequent in-patient visits for that patient. The billing records included date of readmission and hospital of readmission data and were compared with the data captured in the STS record., Results: We found 1153 (2.5%) patients who had STS records that were marked "No" or "missing," but there were billing records that showed a readmission. The reported STS readmission rate of 4796 (10.5%) underreported the readmission rate by 2.5 actual percentage points. The true rate should have been 13.0%. Actual readmission rate was 23.8% higher than reported by the clinical database. Approximately 36% of readmissions were to a hospital that was a part of a different hospital system., Conclusions: It is important to know accurate readmission rates for quality improvement processes and institutional financial planning. Matching patient records to an administrative database showed that the clinical database may fail to capture many readmissions. Combining data with an administrative database can enhance accuracy of reporting., (Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Percutaneous coronary intervention (PCI) is widely used; however, factors of high-cost care after PCI have not been thoroughly investigated. We sought to evaluate the in-hospital costs related to PCI and identify predictors of high costs., Methods: We extracted 2,354 consecutive PCI cases (1,243 acute cases, 52.8%) from 3 Japanese cardiovascular centers from 2011 to 2015. In-hospital complications were predefined under consensus definitions (eg, acute kidney injury [AKI]). We extracted the facility cost data for each patient's resource under the universal Japanese insurance system. We classified the patients into total cost quartiles and identified predictors for the highest quartile ("high-cost" group). In addition, incremental costs for procedure-related complications were calculated., Results: During the study period, a total of 401 cases (17.0%) experienced procedure-related complications. The in-hospital acute and elective PCI costs per case were US $14,840 (interquartile range [IQR] 11,370-20,070) and US $11,030 (IQR 8929-14,670), respectively. After adjusting for baseline differences, any of the procedure-related complications remained an independent predictor of high costs (acute: odds ratio 1.66, 95% CIs 1.13-2.43; elective: odds ratio 3.73, 95% CIs 1.96-7.11). Notably, incremental costs were mainly attributed to AKI, which accounted for 37.5% of all incremental costs; it increased by US $9,840 for each AKI event, and the total cost increase reached US $2,588,035., Conclusions: Procedure-related complications, particularly postprocedural AKI, were associated with higher costs in PCI. Further studies are required to evaluate prospectively whether the preventive strategy with a personalized risk stratification for AKI could save costs., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Although sarcopenia has been identified as a predictor of poor, postoperative, clinical outcomes, the financial impact of sarcopenia remains undetermined. We sought to evaluate the relationship between sarcopenia and hospital finances among a cohort of patients undergoing a hepato-pancreatico-biliary or colorectal resection., Methods: Clinical, financial, and morphometric data were collected for 1,169 patients undergoing operative resection between January 2011 and December 2013 at the Johns Hopkins Hospital. Multivariable regression analysis was performed to assess the relationship between sarcopenia and total hospital costs., Results: Using sex-specific cutoffs for total psoas volume, 293 patients were categorized as sarcopenic. The presence of sarcopenia was associated with a $14,322 increase in the total hospital cost (median covariate-adjusted cost, sarcopenia versus no sarcopenia: $38,804 vs $24,482, P < .001). Patients who presented with sarcopenia demonstrated a higher total hospital cost within the subgroup of patients who developed a postoperative complication (sarcopenia versus no sarcopenia: $65,856 vs $59,609) and among those patients who did not develop a postoperative complication (sarcopenia versus no sarcopenia: $26,282 vs $23,763, both P < .001). Similarly, total hospital costs were higher among patients presenting with sarcopenia regardless of the length of stay for index admission (observed:expected, length of stay < 1: sarcopenia versus no sarcopenia: $25,038 vs $22,827; observed:expected, length of stay > 1: sarcopenia versus no sarcopenia: $43,283 vs $38,679, both P < .001)., Conclusion: As measured by sarcopenia, patient frailty is inversely related to total hospital costs. Sarcopenia represents a novel tool for forecasting patient outcomes and operative costs and can be used to inform quality improvement and cost containment strategies., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Most peripheral artery disease (PAD) clinical device trials are supported by commercial manufacturers and designed for regulatory device approval, with extensive inclusion/exclusion criteria to support homogeneous patient populations. High-risk patients with advanced disease, including critical limb ischemia (CLI), are often excluded leading to difficulty in translating trial results into real-world clinical practice. As a result, physicians have no direct guidance regarding the use of endovascular devices. There is a need for objectively assessed studies to evaluate clinical, functional, and economic outcomes in PAD patient populations., Study Design: LIBERTY is a prospective, observational, multicenter study sponsored by Cardiovascular Systems Inc (St Paul, MN) to evaluate procedural and long-term clinical and economic outcomes of endovascular device interventions in patients with symptomatic lower extremity PAD. Approximately 1,200 patients will be enrolled and followed up to 5 years: 500 patients in the "Claudicant Rutherford 2-3" arm, 600 in the "CLI Rutherford 4-5" arm, and 100 in the "CLI Rutherford 6" arm. The study will use 4 core laboratories for independent analysis and will evaluate the following: procedural and lesion success, rates of major adverse events, duplex ultrasound interpretations, wound status, quality of life, 6-minute walk test, and economic analysis. The LIBERTY Patient Risk Score(s) will be developed as a clinical predictor of outcomes to provide guidance for interventions in this patient population., Conclusion: LIBERTY will investigate real-world PAD patients treated with endovascular revascularization with rigorous study guidelines and independent oversight of outcomes. This study will provide observational, all-comer patient clinical data to guide future endovascular therapy., (Copyright © 2016 The Authors. Published by Elsevier Inc. All rights reserved.)

Objectives: The scientific understanding of aortic dilation associated with bicuspid aortic valve (BAV) has evolved during the past 2 decades, along with improvements in diagnostic technology and surgical management. We aimed to evaluate secular trends and predictors of thoracic aortic surgery among patients with BAV in the United States., Methods: We used the 1998-2009 Nationwide Inpatient Sample, an administrative dataset representative of US hospital admissions, to identify hospitalizations for adults aged 18 years or more with BAV and aortic valve or thoracic aortic surgery. Covariates included age, gender, year, aortic dissection, endocarditis, thoracic aortic aneurysm, number of comorbidities, hospital teaching status and region, primary insurance, and concomitant coronary artery bypass surgery., Results: Between 1998 and 2009, 48,736 ± 3555 patients with BAV underwent aortic valve repair or replacement and 1679 ± 120 patients with BAV underwent isolated thoracic aortic surgery. The overall number of surgeries increased more than 3-fold, from 4556 ± 571 in 1998/1999 to 14,960 ± 2107 in 2008/2009 (P < .0001). The proportion of aortic valve repair or replacement including concomitant thoracic aortic surgery increased from 12.8% ± 1.4% in 1998/1999 to 28.5% ± 1.6% in 2008/2009, which mirrored an increasing proportion of patients with a diagnosis of thoracic aortic aneurysm. Mortality was equivalent for patients undergoing aortic valve repair or replacement with thoracic aortic surgery and those undergoing isolated aortic valve repair or replacement (1.8% ± 0.3% vs 1.5% ± 0.2%; multivariable odds ratio, 1.02; 95% confidence interval, 0.67-1.57), with decreasing mortality over the study period (from 2.5% ± 0.6% in 1998/1999 to 1.5% ± 0.2% in 2008/2009; multivariable odds ratio per 2-year increment, 0.89; 95% confidence interval, 0.81-0.99; P = .03). Total charges for BAV surgical hospitalizations increased more than 7.5-fold from approximately $156 million in 1998 to $1.2 billion in 2009 (inflation-adjusted 2009 dollars)., Conclusions: There was a marked increase in the use of thoracic aortic surgery among patients with BAV., (Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: To investigate whether children in Michigan with private insurance have better hospitalization-related outcomes than those with public or no insurance., Study Design: Population-based hospitalization rates were calculated for newborns and children aged <18 years in Michigan for the years 2001-2006 and stratified by age, disease grouping, and health insurance status using inpatient records from the Michigan Inpatient Database and population estimates from the US Census Current Population Survey., Results: Michigan children with public/no insurance had significantly higher overall hospital admission rates and admission rates for ambulatory-sensitive conditions, and were more likely to be admitted through the emergency room, compared with those with private health insurance. Similarly, newborns with public/no insurance had significantly higher rates of hospitalization-related outcomes. Hospital charges per child were higher in the public/no insurance population, translating to potential excess charges of between $309.8 and $401.8 million in 2006., Conclusions: There are disparities in health outcomes and charges between Michigan children and newborns with public/no insurance and those with private health insurance, presenting a significant opportunity to improve the efficiency and efficacy of care., (Copyright © 2011 Mosby, Inc. All rights reserved.)

Background: Kidney disease is common among patients with heart failure, but relationships between worsening renal function (WRF) and outcomes after hospitalization for heart failure are poorly understood, especially among patients with preserved systolic function. We examined associations between WRF and 30-day readmission, mortality, and costs among Medicare beneficiaries hospitalized with heart failure., Methods: We linked data from a clinical heart failure registry to Medicare inpatient claims for patients >or=65 years old hospitalized with heart failure. We defined WRF as a change in serum creatinine >or=0.3 mg/dL from admission to discharge. Main outcome measures were readmission and mortality at 30 days after hospitalization and total inpatient costs., Results: Among 20,063 patients hospitalized with heart failure, WRF was common (17.8%) and more likely among patients with higher baseline comorbidity and more impaired renal function. In unadjusted analyses, WRF was associated with similar subsequent mean inpatient costs (USD 3,255 vs USD 3,277, P = .2) but higher readmission (21.8% vs 20.6%, P = .01) and mortality (10.0% vs 7.2%, P < .001). The differences persisted after adjustment for baseline patient and hospital characteristics (hazard of readmission 1.10 [95% CI 1.02-1.18], hazard of mortality 1.53 [95% CI 1.34-1.75]). Associations of WRF with readmission and mortality were similar between patients with reduced and preserved systolic function., Conclusions: Worsening renal function during hospitalization for heart failure is an independent predictor of early readmission and mortality in patients with reduced and preserved systolic function., (Copyright (c) 2010 Mosby, Inc. All rights reserved.)

Background: Treatment options for patients with ventricular arrhythmias have undergone major changes in the last 2 decades. Trends in use of invasive procedures, clinical outcomes, and expenditures have not been well documented., Methods: We used administrative databases of Medicare beneficiaries from 1985 to 1995 to identify patients hospitalized with ventricular arrhythmias. We created a longitudinal patient profile by linking the index admission with all earlier and subsequent admissions and with death records., Results: Approximately 85,000 patients aged > or =65 years went to hospitals in the United States with ventricular arrhythmias each year, and about 20,000 lived to admission. From 1987 to 1995, the use of electrophysiology studies and implantable cardioverter defibrillators in patients who were hospitalized grew substantially, from 3% to 22% and from 1% to 13%, respectively. Hospital expenditures rose 8% per year, primarily because of the increased use of invasive procedures. Survival improved, particularly in the medium term, with 1-year survival rates increasing between 1987 and 1994 from 52.9% to 58.3%, or half a percentage point each year., Conclusion: Survival of patients who sustain a ventricular arrhythmia is poor, but improving. For patients who are admitted, more intensive treatment has been accompanied by increased hospital expenditures.

Background: The impact of recent developments in coronary angioplasty on the broad spectrum of patients treated in routine practice is largely undefined. Analysis of population-based data can provide insight into trends in clinical outcomes and associated costs of coronary angioplasty procedures., Methods and Results: With the use of a comprehensive hospital discharge database covering more than 11 million Canadians, we analyzed 12,748 first-time angioplasty procedures performed from 1992 to 1995 inclusive. Patient demographics and major adverse events were recorded. With the use of forward linkage, readmissions within 12 months were classified according to procedure performed and/or most responsible diagnosis. The proportion of patients readmitted, the number of readmissions per index procedure, and diagnosis-specific readmission costs were compared by calendar year. Over the 4-year study period, there was a 21% increase in the annual volume of index procedures. There were no statistically significant differences between 1992 and 1995 in sex distribution, mean age, comorbid conditions, length of stay, or need for coronary bypass surgery related to the index procedure. The all-cause readmission rate declined from 51.6% to 47.2% between 1992 and 1995 (P <.001), primarily because of a decline in the admission rate for repeat revascularization from 24.8% to 19.6% (P <.001). The 12-month readmission cost declined by $435 (1994 Canadian dollars) per patient., Conclusions: The clinical outcomes of coronary angioplasty in a broad cohort of patients have improved in recent years. Although readmissions within 1 year of an angioplasty procedure remain common, the number related to repeat revascularization has declined, with an associated decline in downstream costs.

Background: As stenting practice has evolved to include greater numbers of stents and adjunctive balloon catheters per case, concern has focused on the increasing costs of equipment for the delivery of stents., Methods and Results: To evaluate temporal changes in costs of intracoronary stenting, we examined total costs, catheterization laboratory equipment costs, equipment utilization, and nonlaboratory hospital costs for stent cases for two time periods: Period I (n = 46; 3 months in 1995 involving routine warfarin anticoagulation) and Period II (n = 129; 4 months during which warfarin was being abandoned). Overall costs declined from Period I ($11,293+/-$7672) to Period II ($9819+/-$3636) (p = 0.074). Catheterization laboratory equipment expenditures rose (Period I, $3823+/-$1394 vs Period II, $4278+/-$1533), whereas noncatheterization laboratory hospital costs declined significantly (Period I, $7281+/-$7179 vs Period II, $5560+/-$3420). The difference in costs was most notable when taking into account the deletion of warfarin anticoagulation. Costs declined by $2428 for patients in Period II in whom warfarin was not prescribed (p < 0.05 vs patients in Period I)., Conclusions: We conclude that despite the increasing costs for equipment of stent cases, our overall costs of providing stents declined as warfarin anticoagulation was abandoned.

Objective: An economic analysis was conducted for all patients with a primary diagnosis of tuberculosis admitted to a university hospital for a 1-year period in 1992., Design: The economic analysis was conducted by using the hospital billing system to capture resource use for patients with tuberculosis and cost-to-charge ratios to estimate hospital costs., Setting: A university teaching hospital., Patients: Patients with a primary diagnosis of tuberculosis were included in the study., Results: The average length of stay for patients was 22.7 days on initial admission to the hospital and 13.5 days on readmission. The average cost of care was $27,109 for initial admission, $13,094 for readmission, and $20,222 when all patients were included., Conclusion: Room costs were the most significant contributor to the total cost of care, followed by laboratory costs and ancillary hospital costs. We calculate the average cost for caring for a patient with tuberculosis at approximately $20,000 per year.