Financial implications of trauma patients at a Canadian level 1 trauma center: a retrospective cohort study

BackgroundTrauma is a cause of significant morbidity and mortality globally, and patients with major trauma require specialized settings for multidisciplinary care. We sought to enumerate the variability of costs of caring for patients at a Canadian level 1 trauma center.MethodsA retrospective analysis of all adult patients admitted to The Ottawa Hospital trauma service between June 2013 and June 2018 was conducted. Hospital costs and clinical data were collected. Descriptive statistics and multivariable regression analysis using generalized linear model were performed to assess cost variation with patient characteristics. Quintile-based analyses were used to characterize patients in different cost categories. Hospital costs were reported in 2018 Canadian dollars.ResultsA total of 2381 admissions were identified in the 5-year cohort. The mean age of patients was 50.2 years, the mean Injury Severity Score (ISS) was 18.7, the mean Charlson Comorbidity Index (CCI) score was 0.35, and the median total cost was $10 048.54. ISS and CCI score were associated with higher costs (ISS >15; p<0.0001). The most expensive mechanisms of injury (MOIs) were those involving heavy machinery (median total cost $24 074.38), pedestrians involved in road traffic collisions ($20 965.45), patients in motor vehicle collisions ($17 621.01) and motorcycle collisions ($16 220.89), and acts of self-injury ($13 903.69). Patients who experienced in-hospital adverse events were associated with higher costs (p<0.0001). Our multivariable regression analysis showed variation in costs related to male gender, penetrating/violent MOI, ISS, adverse hospital events, CCI score, urgent admission status, hospital 1-year mortality risk score, and alternate level of care designation (p<0.05). Quintile-based analyses demonstrated clinically significant differences between the highest and lowest cost groups.DiscussionMajor trauma was associated with high hospital costs. Modifiable and non-modifiable patient factors were shown to correlate with differing total hospital costs. These findings can aid in the development of funding strategies and resource allocation for this complex patient population.Level of evidenceLevel III evidence for economic and value-based evaluations.

The Economic burden of Neonatal Intensive Care Unit Admission at a Community Hospital of Central Nepal

Introduction: Neonatal sepsis is the commonest cause of neonatal morbidity and mortality and remains a major public health problem especially in developing countries. It is one of the most common causes for admission to neonatal units. The objective of this study was to evaluate the cost of care of neonates admitted in Neonatal Intensive Care Unit. It also compared the cost of care of neonates with sepsis and those with non-sepsis along with the duration of hospital stay and its correlation. Method: A hospital based prospective cross-sectional observational study was carried out over a period of one year. All the neonates admitted at NICU and fulfilling the inclusion criteria formed the study population. Total cost was calculated as the summation of direct and indirect cost. Normally distributed data was analyzed using the Student’s t-test, non-normally distributed data using Mann-Whitney U test. P-value < 0.05 was taken to be statistically significant. Result: Direct cost comprises more than two third of the cost. The median total cost of care of neonates admitted in NICU was USD 222.66 (Range 169.52-280.03). The cost for the ones with sepsis was USD 226.30 (Range 172.19-291.34) and 174.02 (Range 99.67-221.96) in non-sepsis. The mean duration of stay in NICU of the ones having sepsis was 6.6 days and 4.4 days in non-sepsis. Conclusion: The median total cost of care of neonates admitted in NICU was USD 222.66 (Range 169.52-280.03). The duration of stay and the total cost of treatment with sepsis are higher than those with non-sepsis.

Analisis Cost of Illness Stevens Johnson Syndrome (SJS)/Toxic Epidermal Necrolysis (TEN)

ABSTRAK SJS/TEN merupakan reaksi yang melibatkan kulit dan mukosa yang berat dan mengancam jiwa. SJS dan TEN merupakan kejadian yang jarang terjadi, yaitu 1,4 – 12,7 kasus per 1 juta orang per tahun mengalami SJS dan TEN, dengan angka mortalitas 5% pada SJS dan 30-35% pada TEN. Obat merupakan penyebab utama SJS (50-80% dari kasus) dan TEN (80%). Tujuan: Mengetahui median total biaya per hari pasien SJS/TEN, serta pengaruh lama rawat inap terhadap total biaya SJS/TEN. Penelitian observasional analitik dengan sudut pandang masyarakat. Pengambilan data secara retrospektif menggunakan total sampling pasien rawat inap SJS dan TEN di RSUP Dr. Sardjito Yogyakarta tahun 2014-2018. Analisis data dengan menghitung median (range) dan regresi linear pada SPSS IBM versi 22.0 untuk mengetahui pengaruh lama rawat inap terhadap biaya SJS/TEN. Terdapat 29 pasien yang dianalisis. Median total biaya per hari pasien SJS/TEN Rp 1.139.963 (Rp 665.294-Rp 8.776.895), dengan Rp 1.139.963 (Rp 740.267-Rp 8.776.895) pada SJS dan Rp 1.166.084 (Rp 665.294-Rp 1.514.607) pada TEN. Hasil signifikansi uji regresi linear lama rawat inap terhadap total biaya SJS/TEN adalah 0,093 (p>0,05). Median biaya per hari SJS/TEN adalah Rp 1.139.963 (Rp 665.294-Rp 8.776.895), dan lama rawat inap tidak mempengaruhi total biaya SJS/TEN. Kata Kunci—Stevens Johnson Syndrome, Toxic Epidermal Necrolysis, analisis biaya, cost of illness ABSTRACT SJS/TEN is a reaction that involves heavy and life-threatening skin and mucosa. SJS and TEN are rare events, 1,4 – 12,7 cases per 1 million people per year experiencing SJS and TEN, with a mortality rate of 5% in SJS and 30-35% in TEN. Drugs are the main cause of SJS (50-80% of cases) and TEN (80%). Objective: To determine the median total cost per day of SJS and TEN patients, and the effect of length of stay on the total cost of SJS/TEN. This study used an observational analytic with cross sectional design and societal perspective. The data was collected retrospectively using total sampling of SJS and TEN inpatients at RSUP Dr. Sardjito Yogyakarta in 2014-1018. The data was analyzed by calculating the median (range) and linear regression in IBM SPSS version 22.0, to determine the effect of length of stay on SJS/TEN costs . There were 29 patients analysed. The median total cost per SJS/TEN patient was IDR 1.139.963 (IDR 665.294-8.776.895), with IDR 1.139.963 (IDR 740.267-8.776.895) on SJS and IDR 1.166.084 (IDR 665.294-1.514.607) on TEN patients. The significance linear regression of the length of stay in SJS/TEN was 0,093 (p> 0,05). The median cost per SJS/TEN day was IDR 1.139.963 (665.294-8.776.895), and the length of stay does not affect the total cost of SJS/TEN. Keywords— Stevens Johnson Syndrome, Toxic Epidermal Necrolysis, cost analysis, cost of illness

Healthcare Resource Utilization Among Patients With Non-Surgical Refractory Low Back Pain in the United States: A Retrospective Analysis of Health Insurance Claims Data

INTRODUCTION The economic burden of low back pain (LBP) in the US is estimated between $84.1 and $624.8 billion. Some patients with LBP that persists despite conventional medical management are ineligible for spine surgery and are considered to have non-surgical refractory back pain (NSRBP). We investigated the healthcare resource utilization (HCRU) of patients with NSRBP. METHODS The IBM MarketScan® Research databases were queried for adult patients with a diagnosis of LBP, excluding instability (eg, spondylolisthesis) and non-mechanical etiologies, and negative history of failed back surgery syndrome or spine surgery within the study period (2009-2016). For a patient to qualify as refractory, we required utilization for >30 d of pain medications (prescribed within 2 wk of diagnosis) or non-pharmacologic therapies within the 3 to 24 mo following initial diagnosis. Annual total costs, including inpatient and outpatient service costs and outpatient medication costs, were calculated for 2 yr. RESULTS Among 50 801 patients, median total cost was $3,755 (IQR $1,299, $9,108) at 1 yr pre-diagnosis, reached $6,622 (IQR $2,723, $13,978) at 1 yr, and decreased to $5,977 (IQR $2,311, $13,307) at 2 yr. Costs were highest for patients with Medicare Supplemental (N = 7,053): median total cost was $10,198 (IQR $5,517, $18,584) at 1 yr, decreasing in the second year to $9,407 (IQR $4,737, $18,330). Outpatient services accounted for the majority of all costs. The proportion of patients with ≥4 outpatient visits for LBP was 56.6% within the first 6 mo, 50.0% in the 1st year, and 68.5% in the 2nd year. CONCLUSION For patients with NSRBP, the median annual total cost at 1 yr almost doubled the 1-yr prediagnosis cost and decreased for the 2nd year; most costs were due to outpatient services. Patients with Medicare Supplemental incurred the highest total costs. Most patients saw outpatient providers multiple times in the first 6 mo and throughout the 2 yr.

Economic Burden of Venous Thromboembolism in Cancer Patients — a Comparative Analysis between Matched Patients with Cancer with and without a Diagnosis of Venous Thromboembolism

Background:Venous thromboembolism (VTE) is a major health problem occurring at a rate of 1/1000 adults in general population. Cancer patients have a much higher risk of VTE with an annual rate of 24.6/1000 patients and this contributes to significant morbidity and mortality in this patient population. The body of evidence related to the economic burden for VTE in cancer patients is limited to small institutional studies. With increasing burden of cost for cancer care there is a significant push for cost containment measures, physicians taking care of these patients should be more aware of the economic outcomes of their patient cares. Methods: We used a large claims based data set US database MarketScan (Truven Health Analytics) to explore the economic burden of VTE in cancer patients. Between January 1, 2013 and September 30, 2015 we identified 614,577 patients with cancer of these 195,290 were deemed to have active cancer out of which 6,569 had a VTE code in their medical claims. This study was conducted to assess the economic burden of VTE in cancer patients in comparison their non-VTE peers with similar cancer type. All-cause costs over 3-year period were used and included the costs of all services. These were further explored to compare the total cost of care, cost based on the site of utilization of care and pharmacy cost between the patients with VTE with their matched peers. VTE-related costs were identified with a primary or secondary diagnosis of DVT or PE, and were evaluated for the entire follow-up period, starting from the initiation of the anticoagulant therapy until end of eligibility or end of data, whichever was earlier. Continuous factors were summarized by the median. Wilcoxon signed-rank tests were used to test for differences in the distribution between the VTE and non-VTE groups for cost and number of visits. Overall costs as well as total cost per day/visit were compared between groups. The costs were also evaluated by site of utilization (Emergency room vs inpatient vs outpatient) and by cancer subtype. Results: Among active cancer enrollees, there were 6,569 (3.4%) enrollees with VTE and 188,721 (96.6%) without. Average age was around 60 years in both groups. There were approximately 50 % females in each group and breast cancer was the most common type of cancer in the non-VTE group while gastrointestinal cancers were more common in the VTE group. Incidence of comorbid conditions like diabetes, hypertension and chronic kidney disease was similar in both cohorts but chronic liver disease was found more often in the VTE cohort. The median total cost over the study period for the VTE group ($136,976) was 2.0 times that of the non-VTE group ($67,115). This pattern holds for the inpatient, emergency, and outpatient costs. Total median drug costs were about 4 times that of the VTE group ($10,457) than the non-VTE group ($2,621). The difference the cost between groups for these measures were all highly statistically significant (<0.001). However, the VTE group also had 1.7 times the median number of days/visits than the non-VTE group (p < 0.001 for all categories). After adjusting for the number of days, the median total cost per visit was still statistically significant (p<0.001); however the cost difference is much smaller ($1,132 in VTE vs. $984 in non-VTE,). The overall total cost in the VTE groups ranges from 1.3 (pancreatic) to 3.4 (other cancers) times that of the non-VTE patients for the various cancer types, all were statistically significant (p<0.001). After adjusting for the number of visits, the relative cost difference decreased for all cancer groups it ranges from 0.97 (gynecological) to 1.5 (other cancer) times that of the non-VTE patients for the various cancer groups. Lung, breast, gastrointestinal, and other types were statistically significant (p < 0.01). Discussion: Based on the real world information from a large insurance claims database, this study quantifies the incremental health care cost burden associated with VTE in cancer patients. It is clear from this study the patients with cancer and VTE seek medical care more frequently than their non-VTE counterparts leading to higher healthcare costs in all settings. It was also interesting to note that when only the drug costs were taken into consideration, enrollees with VTE had up to 4 times higher drug costs, not all of which was attributable to the anticoagulant cost. Disclosures Khorana: Bayer: Consultancy; Sanofi: Consultancy; Pfizer: Consultancy; Janssen: Consultancy.

Early HIV Diagnosis Leads to Significantly Decreased Costs in the First 2 Years of HIV Care in an Urban Charity Hospital in New Orleans

We undertook a retrospective cohort study of patients with a positive HIV test in the emergency department who were then linked to care. Inpatient, outpatient, and emergency costs were collected for the first 2 years after HIV diagnosis. Fifty-six patients met the inclusion criteria; they were predominantly uninsured (73%) and African American (89%). The median total cost for a newly diagnosed patient over the first 2 years was US$36 808, driven predominantly by outpatient costs of US$17 512. Median inpatient and total costs were significantly different between the lowest (<200 cells/mm3) and highest (>499 cells/mm3) CD4 count categories (US$21 878 vs US$6607, P <.05; US$61 378 vs US$18 837, P <.05, respectively). Total costs were significantly different between viral load categories <100 000 HIV-RNA copies/mL and ≥100 000 HIV-RNA copies/mL (US$28 219 vs US$49 482, P <.05). Costs were significantly lower among patients diagnosed earlier in their disease. Decreased cost is another factor supporting early diagnosis and linkage to care for patients with HIV.

The Cost of Pediatric Unrelated Donor Transplantation

Abstract 4711 Allogeneic unrelated hematopoietic stem cell transplants (HSCT) are complex procedures that need adequate hospital infrastructure, a competent team, high-cost procedures and medications. Most transplants that are performed in Brazil are paid by the government. The national health system reimburses the hospital U$ 35,801.00 as a flat rate. The government has recently increased this amount by 60% but there are not national studies to use to evaluate the appropriateness of this amount. The objective of this study was to retrospectively evaluate the cost of ten consecutive unrelated donor HSCT performed in our institution. Methods: The project was approved by our IRB (CEP-UNIFESP #1875/11) and granted waiver to request consent. The costs were evaluated from the first appointment until one year after transplant or death divided as 1) pre-HSCT, 2) conditioning therapy, 3) from the day of transplant until first discharge, 4) until D+100, 5) until D+180, and 6) until D+360. The costs included medications, supplies, blood transfusions, laboratory, imaging and the cost of the ward. Housing and out-of pocket costs or loss of income were not evaluated. Patients were evaluated according to the Pediatric EBMT score (1–3). Results: Ten consecutive children 2–14 years of age underwent unrelated donor HSCT from June, 2010 to May, 2011. Diagnoses were ALL (4). AML (3), lymphoma (2), and aplastic anemia (1). Three patients had early disease and others were in advanced phases of the diseases. Eight were CMV positive. Five had marrow and five cord blood transplants. The median time was 3.7 years from diagnosis to transplant and 80 days from referral to transplant. The patients remained in the unit for a median of 80 days (21–50). Median time to engraftment was D+22 (12–56) and six had complications and needed Intensive Care support. Of the 10 children, seven were discharged but three relapsed; overall survival is 50%. The median total cost during the first year was U$112,130.00 (mean U$ 174,000.00) – 44% of that spent within the first 100 days post HSCT. The first admission had a median total cost of U$ 60,700.00 (13,580 – 157,840). Total costs were approximately 40% higher than the direct cost. The highest costs were blood products and medications. No relationship was found between cost and age, gender, graft source of Pediatric EBMT-score. Conclusion: Unrelated-donor HSCT are expensive procedures and the government only partially reimburses its cost. Even with the 60% increase in reimbursement there will be a deficit in more than half of the procedures. We are working to increase this amount paid in patients who have complications and will have to continue to find alternative resources to finance the transplants. Disclosures: No relevant conflicts of interest to declare.