Evaluation of costs associated with tolvaptan-mediated length-of-stay reduction among heart failure patients with hyponatremia in the US,based on the EVEREST trial

Abstract

Background:

The Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study with Tolvaptan (EVEREST) trial showed that tolvaptan use improved heart failure (HF) signs and symptoms without serious adverse events.

Objective:

To evaluate the potential cost savings associated with tolvaptan usage among hospitalized hyponatremic HF patients.

Methods:

The Healthcare Cost and Utilization Project (HCUP) 2008 Nationwide Inpatient Sample (NIS) database was used to estimate hospital cost and length of stay (LOS), for diagnosis-related group (DRG) hospitalizations of adult (age ≥18 years) HF patients with complications and comorbidities or major complications and comorbidities. EVEREST trial data for patients with hyponatremia were used to estimate tolvaptan-associated LOS reductions. A cost offset model was constructed to evaluate the impact of tolvaptan on hospital cost and LOS, with univariate and multivariate Monte Carlo sensitivity analyses.

Results:

Tolvaptan use among hyponatremic EVEREST trial HF patients was associated with shorter hospital LOS than placebo patients (9.72 vs 11.44 days, respectively); 688,336 hospitalizations for HF DRGs were identified from the HCUP NIS database, with a mean LOS of 5.4 days and mean total hospital costs of $8415. Using an inpatient tolvaptan treatment duration of 4 days with a wholesale acquisition cost of $250 per day, the cost offset model estimated a LOS reduction among HF hospitalizations of 0.81 days and an estimated total cost saving of $265 per admission. Univariate and multivariate sensitivity analysis demonstrated that cost reduction associated with tolvaptan usage is consistent among variations of model variables.

Conclusions:

The estimated LOS reduction and cost savings projected by the cost offset model suggest a clinical and economic benefit to tolvaptan use in hyponatremic HF patients.

Study Limitations:

The EVEREST trial data may not generalize well to the US population. Clinical trial patient profiles and relative LOS reductions may not be applicable to real-world patient populations.     

Hospital cost and length of stay in idiopathic pulmonary fibrosis

Objective: To provide a detailed picture of the economic impact of hospitalization in idiopathic pulmonary fibrosis (IPF) and to identify factors associated with cost and length of stay (LOS).

Methods: In this retrospective cross-sectional study using the Nationwide Inpatient Sample (NIS), this study included hospitalizations for IPF (ICD-9-CM 516.3) with a principal diagnosis of respiratory disease (ICD-9-CM 460-519) from 2009–2011; lung transplant admissions were excluded. Total inpatient cost, LOS, in-hospital death, and discharge disposition were reported. Linear regression models were used to determine variables predictive of LOS and cost.

Results: From 2009–2011, 22,350 non-transplant IPF patients with a principal diagnosis of respiratory disease were admitted: mean (±SE) age was 70.0 (0.32), and 49.1% were female. While in hospital, 11.4% of patients received mechanical ventilation and 8.9% received non-invasive ventilation. Mean (±SE) LOS was 7.4 (0.15) days overall (p?Limitations: The positive predictive value of the algorithm used to identify IPF is not optimal. The NIS database does not follow patients longitudinally, and claims after admission are not available. Claims do not indicate whether listed diagnoses were present on admission or developed during hospitalization. The exclusion of transplant-related expenditures lead to under-estimation of cost.

Conclusion: Using a nationally-representative database, we found IPF respiratory-related hospitalizations represent a significant economic burden with ～7,000 non-transplant IPF admissions per year, at a mean cost of $16,000 per admission. Mechanical ventilation is associated with statistically significant increases in LOS and cost. Therapeutic advances that reduce rates and costs of IPF hospitalizations are needed.     

Length of stay and hospital costs among high-risk patients with hospital-origin Clostridium difficile-associated diarrhea

Abstract

Objective:

Hospital-onset Clostridium difficile-associated diarrhea (HO-CDAD) has been associated with longer length of stay (LOS) and higher hospital costs among patients in general. The burden of HO-CDAD is unknown among patients who may be at particular risk of poor outcomes: older patients, those with complex or chronic conditions (renal disease, cancer, inflammatory bowel disease [IBD]), and those with concomitant antibiotic (CAbx) use during treatment for CDAD.

Research design and methods:

A retrospective analysis (2005–2011) of the Health Facts® database (Cerner Corp., Kansas City, MO) containing comprehensive clinical records from 186 US hospitals identified hospitalized adult patients with HO-CDAD based on a positive C. difficile toxin collected >48?h after admission. Control patients were required to have total hospital LOS ≥2 days. Separate logistic regression models to estimate propensities were developed for each study group, with HO-CDAD vs controls as the outcome. Differences in LOS and costs were calculated between cases and controls for each group.

Results:

A total of 4521 patients with HO-CDAD were identified. Mean age was 70 years, 54% were female, and 13% died. After matching, LOS was significantly greater among HO-CDAD patients (vs controls) in each group except IBD. The significant difference in LOS ranged from 3.0 (95% CI?=?1.4–4.6) additional days in older patients to 7.8 (95% CI?=?5.7–9.9) days in patients with CAbx exposure. HO-CDAD was associated with significantly higher costs among older patients (p?<?0.001) and among those with renal impairment (p?=?0.012) or CAbx use (p?<?0.001).

Limitations:

Missing cost data and potential misclassification of colonized patients as infected.

Conclusions:

Renal impairment, advanced age, cancer, and CAbx use are associated with significantly longer LOS among HO-CDAD patients, with CAbx users being the most resource intensive. Early identification and aggressive treatment of HO-CDAD in these groups may be warranted.     

Medical resource utilization and costs among Australian patients with genotype 1 chronic hepatitis C: results of a retrospective observational study

Objective: To evaluate medical resource utilization (MRU) and associated costs among Australian patients with genotype 1 chronic hepatitis C (GT1 CHC), including both untreated patients and those receiving treatment with first-generation protease inhibitor-based regimens (telaprevir, boceprevir with pegylated interferon and ribavirin).

Methods: Medical records were reviewed for a stratified random sample of GT1 CHC patients first attending two liver clinics between 2011–2013 (principal population; PP), supplemented by all GT1 CHC patients attending one transplant clinic in the same period (transplant population; TP). CHC-related MRU and associated costs are reported for the PP by treatment status (treated/not treated) stratified by baseline fibrosis grade; and for the TP for the pre-transplant, year of transplant and post-transplant periods.

Results: A total 1636 patients were screened and 590 patients (36.1%) were included. Comprehensive MRU data were collected for 276 PP patients (F0–1 n?=?59, F2 n?=?58, F3 n?=?53, F4 n?=?106; mean follow-up?=?17.3 months). Thirty-eight (13.8%) were treatment-experienced prior to enrolment; 55 (19.9%) received triple therapy during the study. Data were collected for 112 TP patients (mean follow-up?=?29.9 months), 33 (29.5%) received a transplant during the study, and 51 (45.5%) beforehand. The annual direct medical costs, excluding drug costs, were higher among treated PP vs untreated PP (AU$: $1,954 vs $1,202); and year of transplant TP vs pre-/post-transplant TP (AU$: pre-transplant $32,407, transplant $155,138, post-transplant $7,358).

Limitations: To aid interpretation of results, note that only patients with GT1 CHC who are actively managed are included, and MRU data were collected specifically from liver outpatient clinics. That said, movement of patients between hospitals is rare, and any uncaptured MRU is expected to be minimal.

Conclusions: CHC-related MRU increases substantially with disease severity. These real-world MRU data for GT1 CHC will be valuable in assessing the impact of new hepatitis C treatments.     

Cost-benefits of incorporating levosimendan into cardiac surgery practice: German base case

Objective:

To evaluate the cost-benefit of using levosimendan compared with dobutamine, in the perioperative treatment of patients undergoing cardiac surgery who require inotropic support.

Methods:

A two-part Markov model was designed to simulate health-state transitions of patients undergoing cardiac surgery, and estimate the short- and long-term health benefits of treatment. Hospital length of stay (LOS), mortality, medication, and adverse events were key clinical- and cost-inputs. Cost-benefits were evaluated in terms of costs and bed stays within the German healthcare system. Drug prices were calculated from the German Drug Directory (€/2014) and published literature, with a 3% annual discount rate applied. The base case analysis was for a 1-year time horizon.

Results:

The use of levosimendan vs dobutamine was associated with cost savings of €4787 per patient from the German hospital perspective due to reduced adverse events and shorter hospital LOS, leading to increased bed capacity and hospital revenue.

Limitations:

A pharmacoeconomic calculation for the specific situation of the German healthcare system that is based on international clinical trial carries a substantial risk of disregarding potentially relevant but unknown confounding factors (i.e., ICU-staffing, co-medications, standard-ICU care vs fast-tracking, etc.) that may either attenuate or increase the outcome pharmacoeconomic effects of a drug; however, since these conditions would also apply for patients treated with comparators, their net effects may not necessarily influence the conclusions.

Conclusions:

The use of levosimendan in patients undergoing cardiac surgery who require inotropic support appears to be cost-saving. The results of the analysis provide a strong rationale to run local clinical studies with pharmacoeconomic end-points which would allow a much more precise computation of the benefits of levosimendan.     

Medical resource utilization and costs for total hip arthroplasty: benchmarking an anterior approach technique in the Medicare population

Aims: The anterior approach (AA) for total hip arthroplasty (THA) is associated with more rapid recovery when compared to traditional approaches. The purpose of this study was to benchmark healthcare resource utilization and costs for patients with THA via AA relative to matched patients.

Materials and methods: This study queried Medicare claims data (2012–2014) to identify patients who received THA via an AA from experienced surgeons, and matched these patients to a control cohort (all THA approaches). Direct and propensity-score matching were employed to maximize similarity between patients and hospitals in the two cohorts. Hospital length of stay (LOS), the proportion of patients discharged to home or home health, and post-acute claim payments during the 90-day episode were assessed. Generalized estimating equations were applied to control for imbalances between the cohorts and clustering of outcomes within hospitals.

Results: A total of 1,794 patients were included after patient matching. Patients who received AA had significantly lower mean hospital LOS vs patients in the control group (2.06?±?1.36 vs 2.98?±?1.58 days, p?<?.0001). The adjusted proportion of patients discharged to home was nearly 20 percentage points higher in the AA cohort vs the control cohort (87.3% vs 68.7%, p?<?.0001). Post-acute claim payments for AA patients were nearly 50% lower than those for control patients ($4,139 vs $7,465, p?<?.0001).

Conclusion: AA patients had significantly lower post-acute care resource use when compared to control patients. Further research is warranted to evaluate the cost effectiveness of AA among surgeons of varying experience levels.     

Comparison of hospital length of stay and hospitalization costs among patients with non-valvular atrial fibrillation treated with apixaban or warfarin: An early view

Objective: To quantify and compare hospital length of stay (LOS) and costs between hospitalized non-valvular atrial fibrillation (NVAF) patients treated with either apixaban or warfarin via a large claims database.

Methods: Adult patients hospitalized with AF were selected from the Premier Perspective Claims Database (01JAN2013-31MARCH2014). Patients with evidence of valvular heart disease, valve replacement procedures, or pregnancy during the index hospitalization were excluded. Patients treated with apixaban or warfarin during hospitalization were identified. Propensity score matching (PSM) was performed to control for baseline imbalances between patients treated with apixaban or warfarin. Primary outcomes were hospital LOS (days), post-medication administration LOS, and index hospitalization costs, and were compared using paired t-tests in the matched sample.

Results: Before PSM, 2894 apixaban and 124,174 warfarin patients were identified. Patients treated with warfarin were older and sicker compared to those treated with apixaban. After applying PSM, a total of 2886 patients were included in each cohort, and baseline characteristics were balanced. The mean (standard deviation [SD] and median) hospital LOS was significantly (p?=?0.002) shorter for patients treated with apixaban for 5.1 days (5.7 and 3) compared to warfarin for 5.5 days (4.8 and 4). The trend appeared consistent in the hospital LOS from point of apixaban or warfarin administration to discharge (4.5 vs 4.7 days, p?=?0.051). Patients administered apixaban incurred significantly lower hospitalization costs compared to those administered warfarin ($11,262 vs $12,883; p?<?0.001).

Conclusions: Among NVAF patients, apixaban treatment was associated with significantly shorter hospital LOS and lower costs when compared to warfarin treatment.     

Cost-effectiveness of everolimus plus reduced tacrolimus in de novo liver-recipients in the Italian setting

Introduction: Long-term exposure to calcineurin inhibitor-based immunosuppressant (IS) therapy in liver transplant (LT) recipients is associated with renal complications. In the randomized trial H2304, everolimus?+?reduced-dose tacrolimus (EVR?+?rTAC) demonstrated equivalent efficacy and superior renal function compared to standard-dose tacrolimus.

Methods: To evaluate the cost-effectiveness of EVR?+?rTAC vs TAC, in de novo LT patients, a Markov model simulating both liver and kidney function was developed and estimated the long-term outcomes of IS following LT. The analysis used the Italian healthcare payer perspective.

Results: Patients treated with EVR?+?rTAC gained on average 1.92 years and 1.62 quality-adjusted life years (QALYs). The incremental cost-effectiveness ratios (ICER) were €35,851 and €42,567 for LY gained and QALY gained, respectively. For the hepatitis-c sub-population, the ICERs decreased to €22,519 and €30,658, respectively.

Conclusion: EVR?+?rTAC improves survival and quality-of-life and is a cost-effective alternative to calcineurin-inhibitor monotherapy for patients requiring LT.     

Length of stay and economic consequences with rivaroxaban vs enoxaparin/vitamin K antagonist in patients with DVT and PE: findings from the North American EINSTEIN clinical trial program

Objective:

Venous thromboembolism (VTE) (deep vein thrombosis [DVT] and pulmonary embolism [(PE]) represents a substantial economic burden to the healthcare system. Using data from the randomized EINSTEIN DVT and PE trials, this North American sub-group analysis investigated the potential of rivaroxaban to reduce the length of initial hospitalization in patients with acute symptomatic DVT or PE.

Methods:

A post-hoc analysis of hospitalization and length-of-stay (LOS) data was conducted in the North American sub-set of patients from the randomized, open-label EINSTEIN trial program. Patients received either rivaroxaban (15?mg twice daily for 3 weeks followed by 20?mg once daily; n?=?405) or dose-adjusted subcutaneous enoxaparin overlapping with (guideline-recommended ‘bridging’ therapy) and followed by a vitamin K antagonist (VKA) (international normalized ratio?=?2.0–3.0; n?=?401). The open-label study design allowed for the comparison of LOS between treatment arms under conditions reflecting normal clinical practice. LOS was evaluated using investigator records of dates of admission and discharge. Analyses were carried out in the intention-to-treat population using parametric tests. Costs were applied to the LOS based on weighted mean cost per day for DVT and PE diagnoses obtained from the Healthcare Cost and Utilization Project dataset.

Results:

Of 382 patients hospitalized, 321 (84%), had acute symptomatic PE; few DVT patients required hospitalization. Similar rates of VTE patients were hospitalized in the rivaroxaban and enoxaparin/VKA treatment groups, 189/405 (47%) and 193/401 (48%), respectively. In hospitalized VTE patients, rivaroxaban treatment produced a 1.6-day mean reduction in LOS (median?=?1 day) compared with enoxaparin/VKA (mean?=?4.5 vs 6.1; median?=?3 vs 4), translating to total costs that were $3419 lower in rivaroxaban-treated patients.

Conclusion:

In hospitalized North American patients with VTE, treatment with rivaroxaban produced a statistically significant reduction in LOS. When treating DVT and PE patients, clinicians should consider newer anti-coagulants with less complex treatment regimens.     

A comparison of healthcare resource use for rotavirus and RSV between vulnerable children with co-morbidities and healthy children: a case control study

Abstract

Objective:

To quantify the differences in hospital length of stay (LOS) and cost between healthy and vulnerable children with cystic fibrosis (CF), insulin-dependent diabetes mellitus (IDDM), cancer, and epilepsy who contract rotavirus (RVGE) or respiratory syncytial virus (RSV).

Methods:

Hospital Episode Statistics (HES) data were collected for England, for children <5 years old, admitted between April 2001 and March 2008, using ICD-10 codes for RVGE and RSV. Cases were identified as having RVGE and/or RSV plus CF, IDDM, cancer, or epilepsy. Healthy controls had RVGE and/or RSV only, additional controls had eczema only. Cost, hospital LOS, and demographics were collected.

Results:

Four hundred and eighty-six (0.5%) cases and 101,784 (99.5%) healthy controls were admitted with RVGE or RSV, with 17,420 eczema controls. RVGE was present in 153 (31.5%) cases and 7532 (7.4%) healthy controls, and RSV in 333 (68.5%) cases and 94,252 (92.6%) healthy controls. Cases were older (1.1 years, SD?=?1.3 years), had greater LOS (9.9 days, SD?=?19.9), and cost more (£3477, SD?=?£7765) than healthy controls (age?=?0.2, SD?=?0.5, p?<?0.001; LOS?=?1.9 days, SD?=?3.1, p?<?0.001; cost?=?£595, SD?=?£727, p?<?0.001). Cost for cases was 6-times greater than healthy controls (p?<?0.001). Controls had a 0.3 day greater LOS (p?<?0.001) with RSV, but a £17 (p?=?0.085) lower mean cost than RVGE.

Conclusion:

RVGE and RSV are more serious diseases in vulnerable children, requiring more intense resource use. The importance of preventing infection in vulnerable children is underlined by hygiene and appropriate isolation and vaccination strategies. When universal vaccination is under consideration, as for rotavirus vaccines, evaluation of a vaccination programme should consider the potentially positive impact on vulnerable children.

Limitations:

Limitations of the study include a dependency on accurate coding, an expectation that patients are identified through laboratory testing, and the possibility of unidentified underlying conditions affecting the burden.     

Relationship of hospital-associated bleeding with length of stay and total hospitalization costs in patients hospitalized for atrial fibrillation

Background:

While literature has focused on the impact of bleeding beginning outside the hospital setting among patients with atrial fibrillation (AF), there is little information regarding bleeding that first occurs within a hospital setting. This study was performed to determine the association between hospital-associated bleeding in patients admitted for AF on outcomes of length of stay (LOS) and total hospitalization cost.

Methods and results:

The Premier research database was queried to identify adult inpatients discharged between 2008–2011 having a primary diagnosis code for AF where a bleeding diagnosis code was not present on admission. Regression was used to adjust for baseline differences in patients to estimate outcomes comparing patients with and without a hospital-associated bleed. There were 143,287 patients that met the study criteria. There were 2991 (2.1%) patients identified with a hospital associated bleed. After adjustment for covariates, the mean estimated LOS was significantly greater in the bleed group, at 6.0 days (95% CI?=?5.8–6.1) vs the no bleed group at 3.3 days (95% CI?=?3.3–3.3) (p?<?0.0001). Similarly, the adjusted mean estimated total hospitalization cost was also significantly greater in the bleed group, $12,069 (95% CI?=?$11,779–$12,366) vs $6561 (95% CI?=?$6538–$6583) in the no bleed group (p?<?0.0001).

Conclusions:

After adjustments for baseline differences the data show that the 2.1% (n?=?2991) of patients with hospital associated bleeding accounted for an estimated additional 8106 hospitalization days and $16.4 million dollars in cost over the study period compared to non-bleeders.     

Evaluating the length of stay and value of time in a pediatric emergency department with two models by comparing two different albuterol delivery systems

Abstract

Objective:

Asthma is one of the most common childhood illnesses and accounts for a substantial amount of pediatric emergency department visits. Historically, acute exacerbations are treated with a beta agonist via nebulizer therapy (NEB). However, with the advent of the spacer, the medication can be delivered via a metered dose inhaler (MDI?+?S) with the same efficacy for mild-to-moderate asthma exacerbations. To date, no study has been done to evaluate emergency department (ED) length of stay (LOS) and opportunity cost between nebulized vs MDI?+?S. The objective of this study was to compare ED LOS and associated opportunity cost among children who present with a mild asthma exacerbation according to the delivery mode of albuterol: MDI?+?S vs NEB.

Methods:

A structured, retrospective cross-sectional study was conducted. Medical records were reviewed from children aged 1–18 years treated at an urban pediatric ED from July 2007 to June 2008 with a discharge diagnosis International Classification of Disease-9 of asthma. Length of stay was defined: time from initial triage until the time of the guardian signature on the discharge instructions. An operational definition was used to define a mild asthma exacerbation; those patients requiring only one standard weight based albuterol treatment. Emergency department throughput time points, demographic data, treatment course, and delivery method of albuterol were recorded.

Results:

Three hundred and four patients were analyzed: 94 in the MDI?+?S group and 209 in the NEB group. Mean age in years for the MDI?+?S group was 9.57 vs 5.07 for the NEB group (p?<?0.001). The percentage of patients that received oral corticosteroids was 39.4% in the MDI?+?S group vs 61.7% in the NEB group (p?<?0.001). There was no difference between groups in: race, insurance status, gender, or chest radiographs. The mean ED LOS for patients in the MDI?+?S group was 170 minutes compared to 205 minutes in the NEB group. On average, there was a 25.1 minute time savings per patient in ED treatment time (p?<?0.001; 95% CI?=?3.8–31.7). Significant predictors of outcome for treatment time were chest radiograph, steroids, and treatment mode. Opportunity cost analysis estimated a potential cost savings of $213,532 annually using MDI?+?S vs NEB.

Conclusion:

In mild asthma exacerbations, administering albuterol via MDI?+?S decreases ED treatment time when compared to administering nebulized albuterol. A metered dose inhaler with spacer utilization may enhance opportunity cost savings and decrease the left without being seen population with improved throughput.

Limitations:

The key limitations of this study include its retrospective design, the proxy non-standard definition of mild asthma exacerbation, and the opportunity cost calculation, which may over-estimate the value of ED time saved based on ED volume.     

Treatment of candidemia with echinocandins: data on hospital resource use from a real world setting

Abstract

Objective:

Real-world data on patients treated with echinocandins for candidemia are limited. This study examined the effect of three echinocandin-based treatment regimens on resource utilization in patients with Candida infection.

Research design and methods:

A retrospective cohort study of patients hospitalized between 2005 and 2010 with a blood culture positive for Candida. Length of stay (LOS) following AF initiation (post-AF LOS) and total days with AF treatment were compared in patients treated with three different echinocandin regimens: patients with echinocandin only, patients who received fluconazole prior to an echinocandin (fluconazole-echinocandin), and patients who received an echinocandin prior to fluconazole (echinocandin-fluconazole). Generalized linear models were used to adjust for confounders.

Results:

A total of 647 patients met inclusion criteria. Patients treated with echinocandin only were more acutely ill, having more organ dysfunction and sepsis. Unadjusted post-AF LOS was significantly greater in the groups that received both echinocandin and fluconazole (mean, 13.1 days for echinocandin-only vs 25.5 and 21.2 days for fluconazole-echinocandin and echinocandin-fluconazole groups, respectively, p?<?0.001). These groups also had a higher total number of days with AF orders. These differences remained after multivariate adjustment and in survivor-only analyses. Compared with echinocandin-only treatment, the average marginal effect of fluconazole-echinocandin and echinocandin-fluconazole regimens were associated with significantly longer adjusted post-AF LOS (by 7.2 days and 9.3 days, respectively, p?<?0.001) and significantly more adjusted total AF days (by 5.3 days for fluconazole-echinocandin and 6.5 days for echinocandin-fluconazole patients, p?<?0.001). Limitations included lack of visibility to specific reasons for therapy changes.

Conclusions:

Fluconazole before or after echinocandin was associated with significantly greater resource utilization than echinocandin use alone.     

Modeling operational quality metrics and costs of long-acting antibiotics for acute bacterial skin and skin structure infection treatment in the emergency department

Aims: To model implementation of a new treatment pathway leveraging long-acting antibiotics (LAs) for treatment of acute bacterial skin and skin structure infections (ABSSSIs) in a hospital emergency department (ED) with an observation unit, and to quantify health resource utilization and economic outcomes versus standard care (intravenous vancomycin).

Materials and methods: Discrete-event simulation was used to model implementation of the LA treatment pathway in the ED versus standard care from the US Medicare perspective. Model inputs were derived from published sources to simulate a real-world hospital ED with an observation unit. Outcomes included key ED metrics such as patient throughput rate and length of stay (LOS) and cost (estimated through reimbursed amounts in 2017 USD).

Results: Implementation of an LA pathway in the ED improved ABSSSI patient throughput rate by 350% (+5.8 dispositions/ED and observation unit day) and reduced LOS by 68% (?7.2?h/patient). These improvements in patient outcomes are driven by the reduced infusion time required for LA antibiotics and are greater for dalbavancin than oritavancin owing to the shorter infusion duration (30?min vs. 3?h).

Limitations: External validity of the model was not assessed. The model was limited to care received in EDs; therefore, certain clinical variables outside the ED were not captured for this analysis.

Conclusions: LA pathway implementation for ABSSSI treatment in the ED supported improved efficiency, which may translate to economic value. As EDs continue to focus on improving key metrics such as throughput rate and LOS, LA pathway implementation should be considered as a potential approach for abbreviated ABSSSI treatment in the ED.     

Use of the THERMOCOOL SMARTTOUCH catheter for ablation of atrial fibrillation: the relationship between hospital procedure volume,re-admissions,and economic outcomes

Objective: The purpose of this study was to examine the relationship between hospital volume of prior THERMOCOOL SMARTTOUCH catheter use and health and economic outcomes among hospitalized patients with atrial fibrillation (AF) undergoing ablation using this device.

Materials and methods: Patients aged ≥18 years with a primary diagnosis of AF undergoing ablation treatment using the THERMOCOOL SMARTTOUCH catheter between January 2014 and June 2016 were identified from the Premier hospital database with the first date of such a procedure being defined as the index date. Hospital volume of prior THERMOCOOL SMARTTOUCH catheter use was determined during the 12-month pre-index period, and was classified into five groups: no volume (0), low volume (1–50), mid volume (51–100), high volume (101–150), and very high volume (≥151). Outcomes, including length of stay (LOS; for inpatient procedure only), hospital costs (total, hospital pharmacy, supply), and all-cause re-admission were evaluated. A generalized estimating equation (GEE) with exchangeable correlation structure was used to examine the impact of hospital volume on LOS, hospital costs, and re-admissions controlling for hospital clustering and other covariates.

Results: The study population included 640 hospitalized AF patients. The adjusted mean LOS was significantly shorter in very high-volume hospitals than hospitals with no volume (mean LOS 2.30 vs 4.33 days; p?=?.0377). As volume increased, the mean adjusted supply cost tended to decrease, although these changes emerged as non-significant. The 12-month all-cause re-admission was significantly lower among patients undergoing ablation in low (Odds ratio [OR]?=?0.27; confidence interval [CI]?=?0.08–0.85) and mid (OR?=?0.12; CI?=?0.02–0.61) volume hospitals compared to hospitals with no volume.

Limitations: Study results may not be generalizable to all US hospitals.

Conclusions: Among AF patients undergoing ablation, increased hospital volume of prior THERMOCOOL SMARTTOUCH catheter use was associated with shorter LOS and a lower likelihood of all-cause re-admission.     

Cost-effectiveness achieved through changing the composition of renal replacement therapy in Japan

Abstract

Objective:

The cost-effectiveness of renal replacement therapy (RRT) is affected by the composition of treatment. This study aimed to estimate the costs and outcomes associated with changing the composition of RRT modality over time.

Methods:

By using clinical and cost data from a systematic review, a Markov model was developed to assess the costs and benefits of the four main treatments available for RRT in Japan. The model included direct health service costs and quality-adjusted life years (QALY). Sensitivity analyses were performed to assess the robustness of the results.

Results:

Over the 15-year period of the model, the current composition of RRT (i.e., the base composition of RRT) was $84,008/QALY. The most cost-effective treatment was when the likelihood of a living donor transplant was increased by 2.4-times ($70,581/QALY). Compared with the base composition of RRT, dominant treatments with respect to cost-effectiveness were when the likelihood of a deceased donor transplant was increased by 22-times and when the likelihood of a pre-emptive living donor transplant was increased by 2.4-times. Little difference was found between these two treatments. One-way sensitivity analysis did not change the cost effectiveness except for costs of chronic hemodialysis and a living donor transplant in subsequent years.

Limitations:

It is difficult to increase the rate of transplant overall in the shorter term nationally and internationally.

Conclusions:

Appropriate distribution of all transplant options and hemodialysis is necessary to achieve the most cost-effective solution.     

Right anterior thoracotomy aortic valve replacement is associated with less cost than sternotomy-based approaches: a multi-institution analysis of ‘real world’ data

Background:

Large institutional analyses demonstrating outcomes of right anterior mini-thoracotomy (RAT) for isolated aortic valve replacement (isoAVR) do not exist. In this study, a group of cardiac surgeons who routinely perform minimally invasive isoAVR analyzed a cross-section of US hospital records in order to analyze outcomes of RAT as compared to sternotomy.

Methods:

The Premier database was queried from 2007–2011 for clinical and cost data for patients undergoing isoAVR. This de-identified database contains billing, hospital cost, and coding data from >600 US facilities with information from >25 million inpatient discharges. Expert rules were developed to identify patients with RAT and those with any sternal incision (aStern). Propensity matching created groups adjusted for patient differences. The impact of surgical approach on outcomes and costs was modeled using regression analysis and, where indicated, adjusting for hospital size and geographical differences.

Results:

AVR was performed in 27,051 patients. Analysis identified isoAVR by RAT (n?=?1572) and by aStern (n?=?3962). Propensity matching created two groups of 921 patients. RAT was more likely performed in southern hospitals (63% vs 36%; p?p?p?p?p?Conclusions:

Outcomes analyses can be performed from hospital administrative collective databases. This real world analysis demonstrates comparable outcomes and less cost and ICU time with RAT for AVR.     

A cost-effectiveness analysis of reducing ventilator-associated pneumonia at a Danish ICU with ventilator bundle

Abstract

Background:

More than 100,000 patients each year in Denmark experience nosocomial infections, erroneous medication, or pressure ulcers while hospitalized. The Danish Safer Hospital Program includes 12 bundles for improving patient safety through the introduction and maintenance of evidence-based routine treatment or standard procedures.

Objective:

To determine cost-effectiveness of implementing the Ventilator bundle (VB), thereby reducing ventilator-associated pneumonia (VAP), when treating a ventilated patient, compared to standard procedure.

Setting and patients:

A hypothetical population of intensive care patients in a Danish ICU, ventilated for >48?h.

Methods:

Cost-effectiveness analysis of the implementation of VB. The outcomes were prevention of VAP and prevention of death. Model inputs were evidence based from literature along with data from Kolding Hospital. A hypothetical population of intensive care patients in a Danish ICU, ventilated for >48?h was used.

Results:

The cost per VAP episode prevented was ～€4451, and cost per death prevented was ～€31,792. The incremental cost-effectiveness scatter plot showed that VB was more effective in 99.9%, and 42.6% have lower cost and better outcome for prevention of VAP. The incremental cost-effectiveness scatter plot showed that VB was more effective in 85.9%, and 31.6% have lower cost and better outcome for death prevented.

Limitations:

The study was a retrospective cost analysis where incidence rates were based on best evidence, even if it did not cover all elements in the VB. The perspective of this study was seen from a third-party payer, e.g., the hospital, thus societal costs and direct medical costs post-hospitalization for patients with VAP were not considered.

Conclusion:

We found that implementation of VB is potentially cost-effective when considering prevention of one case of VAP or death, based on a Danish ICU as a case study.     

Costs of hospital visits among patients with deep vein thrombosis treated with rivaroxaban and LMWH/warfarin

Background:

For many years, the standard of care for patients diagnosed with deep vein thrombosis (DVT) has been low-molecular-weight heparin (LMWH) bridging to an oral Vitamin-K antagonist (VKA). The availability of new non-VKA oral anticoagulants (NOAC) agents as monotherapy may reduce the likelihood of hospitalization for DVT patients.

Objective:

To compare hospital visit costs of DVT patients treated with rivaroxaban and LMWH/warfarin.

Methods:

A retrospective claim analysis was conducted using the MarketScan Hospital Drug Database for care provided between January 2011 and December 2013. Adult patients using rivaroxaban or LMWH/warfarin with a primary diagnosis of DVT during the first day of a hospital visit were identified (i.e., index hospital visit). Based on propensity-score methods, historical LMWH/warfarin patients (i.e., patients who received LMWH/warfarin before the approval of rivaroxaban) were matched 4:1 to rivaroxaban patients. The hospital-visit cost difference between these groups was evaluated for the index hospital visit, as well as for total hospital-visit costs (i.e., including index and subsequent hospital visit costs).

Results:

All rivaroxaban users (n?=?134) in the database were well-matched with four LMWH/warfarin users (n?=?536). The mean hospital-visit costs were $5257 for the rivaroxaban cohort and $6764 in the matched-cohort of patients using LMWH/warfarin. The $1508 cost difference was statistically significant between cohorts (95% CI?=?[?$2296; ?$580]; p-value?=?0.002). Total hospital-visit costs were lower for rivaroxaban compared to LMWH/warfarin users within 1, 2, 3, and 6 months after index visit (significantly lower within 1 and 3 months, p-values <0.05)

Limitations:

Limitations were inherent to administrative-claims data, completeness of baseline characteristics, adjustments restricted to observational factors, and lastly the sample size of the rivaroxaban cohort.

Conclusion:

The availability of rivaroxaban significantly reduced the costs of hospital visits in patients with DVT treated with rivaroxaban compared to LMWH/warfarin.