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Key Points Question What is the association of patients who are diagnosed with a postoperative neurocognitive disorder with total Medicare health care expenditures in the year after their surgical procedure? Findings In this retrospective cohort study including nearly 2.4 million Medicare patients, after adjusting for patient and hospital characteristics, the presence of a postoperative neurocognitive disorder was associated with an increase of $17 275 in payments in the 1 year after the index surgical procedure. Meaning These findings suggest that in older patients who underwent surgical treatment, a diagnosis of a postoperative neurocognitive disorder was associated with an increase in health care costs for up to 1 year after treatment, emphasizing the economic burden associated with this potentially modifiable complication., This cohort study examined the association of postoperative neurocognitive disorders with health care expenditures among US Medicare patients., Importance Postoperative neurocognitive disorders (PNDs) after surgical procedures are common and may be associated with increased health care expenditures. Objective To quantify the economic burden associated with a PND diagnosis in 1 year following surgical treatment among older patients in the United States. Design, Setting, and Participants This retrospective cohort study used claims data from the Bundled Payments for Care Improvement Advanced Model from 4285 hospitals that submitted Medicare Fee-for-service (FFS) claims between January 2013 and December 2016. All Medicare patients aged 65 years or older who underwent an inpatient hospital admission associated with a surgical procedure, did not experience a PND before index admission, and were not undergoing dialysis or concurrently enrolled in Medicaid were included. Data were analyzed from October 2019 and May 2020. Exposures PND, defined as an International Classification of Diseases, Ninth or Tenth Revision, diagnosis of delirium, mild cognitive impairment, or dementia within 1 year of discharge from the index surgical admission. Main Outcomes and Measures The primary outcome was total inflation-adjusted Medicare postacute care payments within 1 year after the index surgical procedure. Results A total of 2 380 473 patients (mean [SD] age, 75.36 (7.31) years; 1 336 736 [56.1%] women) who underwent surgical procedures were included, of whom 44 974 patients (1.9%) were diagnosed with a PND. Among all patients, most were White (2 142 157 patients [90.0%]), presenting for orthopedic surgery (1 523 782 patients [64.0%]) in urban medical centers (2 179 893 patients [91.6%]) that were private nonprofits (1 798 749 patients [75.6%]). Patients with a PND, compared with those without a PND, experienced a significantly longer hospital length of stay (mean [SD], 5.91 [6.01] days vs 4.29 [4.18] days; P

Introduction: Intensive Care Unit (ICU) length of stay is a strong indicator of severity of illness and cost in the care of sepsis patients. In this case study, we examine the difference between an electronic health record (EHR) based submissions with Centers for Medicare and Medicaid Services (CMS) payment data.Methods: Member submitted EHR data contained 26,733 unique patient’s records. The CMS data contained demographics, diagnosis, and revenue codes. After linking EHR data to CMS data, we found a discrepancy in ICU days from CMS claims vs. EHR data. Our hypothesis was that removing intermediate ICU LOS would result in a closer match from CMS claims with EHR data. We suspected the use of Intermediate ICU stays in our CMS ICU definition contaminated our ICU LOS data. This resulted in a review of the sepsis specification, further investigation of the data, and follow up conversations with the Member organizations.Results: Agreement between EHR and CMS data improved from 73 percent to 86 percent once the Intermediate ICU time had been removed.Discussion and Conclusions: The inclusion of Intermediate ICU in the analysis of severely ill sepsis patients from CMS data diluted the importance of using an ICU LOS for estimating the severity of illness and the cost to the healthcare system. We must ensure that clinical definitions are consistent between data sources that were built for different purposes. Additionally, we learned that engaging with clinicians, analysts, and clinical coders early in the process is required to fully understand the complexities from different sources.

Background—Trauma registries may contain records without a codable trauma diagnosis, creating a “data gap” that multiplies the number of invalid registry data fields. We designed an investigation intended to determine the incidence of registry records with non-codable trauma diagnoses, characterize those records, and determine the reasons for inadequate diagnosis data. Methods—We utilized a retrospective cohort design. A query of trauma registry records spanning a five-year period yielded 129 records with no injury severity score. Each patient’s medical record was reviewed, sources of diagnostic information were noted and diagnoses were categorized. Results—In 57% of cases, we found documentation that the patient had sustained an injury, but the injury was inadequately documented in the discharge summary. In 19% of cases, although the registry record was valid, the diagnosis was not codable as trauma. In 17% of cases, clinical documentation was adequate, but the diagnosis was inadequately recorded in the trauma registry. In 13% of cases, no traumatic injury was sustained, although the registry record was valid. In 2% of cases, the trauma registry record itself was invalid. In 1% of cases, a coding error occurred. Conclusions—Particularly prominent among records with inadequate discharge documentation were cases of head and spine injury for which there was no radiographic evidence. The incidence of records with uncodable diagnoses might best be reduced through improved physician documentation, revision of trauma registry inclusion criteria, increased attention by trauma registrars to key sources of documentation, and direct communication with the attending physician when necessary.

Importance Unnecessary interfacility transfer of minimally injured patients to a level I trauma center (secondary overtriage) can cause inefficient use of resources and personnel within a regional trauma system. Objective To describe the burden of secondary overtriage in a rural trauma system with a single level I trauma center. Design Retrospective analysis of institutional trauma registry data. Setting Dartmouth Hitchcock Medical Center, a rural level I trauma center. Patients A total of 7793 injured patients evaluated by the trauma service at Dartmouth Hitchcock Medical Center from January 1, 2007, to December 31, 2011. Exposure Evaluation by the trauma service. Main Outcomes and Measures Patients transferred from another hospital to Dartmouth Hitchcock Medical Center who did not require an operation, had an Injury Severity Score lower than 15, and were discharged alive within 48 hours of admission. Results Of the 7793 evaluated patients, 4796 (62%) were transferred from other facilities. When compared with scene calls (n = 2997), transferred patients had a similar median Injury Severity Score of 9, but 24% of transferred adult patients and 49% of transferred pediatric patients met our definition of secondary overtriage. The overtriaged patients were most likely to have injuries of the head and neck (56%), followed by skin and soft-tissue injuries (41%). Seventy-two unique institutions transferred trauma patients to Dartmouth Hitchcock Medical Center, but 36% of the overtriaged patients were from 5 institutions. Conclusions and Relevance The incidence of secondary overtriage in our rural trauma center is 26%, with head and neck injuries being the most common reason for transfer. Costs for transportation and additional evaluation for such a significant percentage of patients has important resource utilization implications. Effective regionalization of rural trauma care should include methods to limit secondary overtriage.