Annie N. Simpson

The one-year attributable cost of post-stroke dysphagia.

With the recent emphasis on evidence-based practice and healthcare reform, understanding the cost of dysphagia management has never been more important. It is helpful for clinicians to understand and objectively report the costs associated with dysphagia when they advocate for their services in this economy. Having carefully estimated cost of illness, inputs are needed for cost-effectiveness analyses that help support the value of treatments. This study sought to address this issue by examining the 1-year cost associated with a diagnosis of dysphagia post-stroke in South Carolina. Furthermore, this study investigated whether ethnicity and residence differences exist in the cost of dysphagia post-stroke. Data on 3,200 patients in the South Carolina Medicare database from 2004 who had ICD-9 codes for ischemic stroke, 434 and 436, were retrospectively included in this study. Differences between persons with and without dysphagia post-stroke were compared with respect to age, gender, ethnicity, mortality, length of stay, comorbidity, rurality, discharge disposition, and cost to Medicare. Univariate analyses and a gamma-distributed generalized linear multivariable model with a log link function were completed. We found that the 1-year cost to Medicare for persons with dysphagia post ischemic stroke was

A Severe Sepsis Mortality Prediction Model and Score for Use With Administrative Data.

4,510 higher than that for persons without dysphagia post ischemic stroke when controlling for age, comorbidities, ethnicity, and proportion of time alive. Univariate analysis revealed that rurality, ethnicity, and gender were not statistically significantly different in comparisons of individuals with or without dysphagia post-stroke. Post-stroke dysphagia significantly increases post-stroke medical expenses. Understanding the expenditures associated with post-stroke dysphagia is helpful for optimal allocation and use of resources. Such information is needed to conduct cost-effectiveness studies.

Asthma medication ratio predicts emergency department visits and hospitalizations in children with asthma.

Objective:Administrative data are used for research, quality improvement, and health policy in severe sepsis. However, there is not a sepsis-specific tool applicable to administrative data with which to adjust for illness severity. Our objective was to develop, internally validate, and externally validate a severe sepsis mortality prediction model and associated mortality prediction score. Design:Retrospective cohort study using 2012 administrative data from five U.S. states. Three cohorts of patients with severe sepsis were created: 1) International Classification of Diseases, 9th Revision, Clinical Modification codes for severe sepsis/septic shock, 2) Martin approach, and 3) Angus approach. The model was developed and internally validated in International Classification of Diseases, 9th Revision, Clinical Modification, cohort and externally validated in other cohorts. Integer point values for each predictor variable were generated to create a sepsis severity score. Setting:Acute care, nonfederal hospitals in New York, Maryland, Florida, Michigan, and Washington. Subjects:Patients in one of three severe sepsis cohorts: 1) explicitly coded (n = 108,448), 2) Martin cohort (n = 139,094), and 3) Angus cohort (n = 523,637) Interventions:None. Measurements and Main Results:Maximum likelihood estimation logistic regression to develop a predictive model for in-hospital mortality. Model calibration and discrimination assessed via Hosmer-Lemeshow goodness-of-fit and C-statistics, respectively. Primary cohort subset into risk deciles and observed versus predicted mortality plotted. Goodness-of-fit demonstrated p value of more than 0.05 for each cohort demonstrating sound calibration. C-statistic ranged from low of 0.709 (sepsis severity score) to high of 0.838 (Angus cohort), suggesting good to excellent model discrimination. Comparison of observed versus expected mortality was robust although accuracy decreased in highest risk decile. Conclusions:Our sepsis severity model and score is a tool that provides reliable risk adjustment for administrative data.

Trends in bariatric surgery, 2002-2012: do changes parallel the obesity trend?

OBJECTIVEnTo determine if the asthma medication ratio predicts subsequent emergency department (ED) visits and hospital admissions in children.nnnDESIGNnRetrospective cohort with two year pairs.nnnSETTING/PARTICIPANTSn2007-2009 South Carolina Medicaid recipients with persistent asthma age 2-18.nnnMAIN EXPOSUREnController-to-total asthma medication ratios were calculated for each patient in 2007 and 2008. Ratios range from 0-1 (1 = ideal, 0 = no controller).nnnOUTCOME MEASURESn2008 and 2009 asthma related ED visits, hospitalizations, and a combined outcome of ED visit or hospitalization in the subsequent 3, 6, and 12 month time periods.nnnRESULTSn19,512 patients were included. Mean age 8.9 years, 58% male, and 55% black. The ratio significantly predicted ED visits and hospitalizations over subsequent 3, 6, and 12 month time periods. The cut-point that maximized the ability to predict visits ranged from 0.4-0.6. A cutpoint of 0.5 was used in the final models. After controlling for age, race, gender, and rurality, patients with a ratio <0.5 were significantly more likely to have a subsequent emergent healthcare visit (OR 1.5-2.0). The ratio retained its predictive ability in both year-pairs for all three outcome variables, in all three time periods, with the exception of the 2008 ratio not predicting 2009 3-month and 6-month hospitalizations.nnnCONCLUSIONSnThe asthma medication ratio is a significant predictor of ED visits and hospitalizations in children. Using a cutoff of <0.5 to signal at-risk patients may be an effective way for populations who would benefit from increased use of controller medications to reduce future emergent asthma visits. CPT only copyright XXXX-2012 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. See attached CMS CPT 2013 end user license.

Twelve-Month Clinical and Quality-of-Life Outcomes in the Interventional Management of Stroke III Trial

BACKGROUNDnIt is well documented that bariatric surgery is an effective weight loss intervention, and bariatric procedure rates have increased over time. However, there was a period of plateau in procedure rates in the mid to late 2000s. Recent literature has not identified current trends in procedure rates or associations between bariatric surgery and population factors, such as obesity and diabetes.nnnOBJECTIVESnThe purpose of this study was to determine trends in statewide rates of bariatric operations, obesity, and diabetes over an 11-year period and to determine if population factors are associated with procedure rates.nnnSETTINGnData from the Agency for Healthcare Research and Quality (AHRQ) Healthcare Cost and Utilization Project (HCUP) State Inpatient Database (SID) were utilized to identify a study sample population of patients who underwent bariatric procedures from 2002-2012.nnnMETHODSnState level population characteristics were obtained from the Behavioral Risk Factor Surveillance System and Census Bureau Data for the 11-year period. Statistical analyses determined rates of surgery, obesity, and diabetes over time, as well as associations between surgery rates and population factors.nnnRESULTSnFrom 2002-2012, bariatric procedure rates increased, with an exponential rise in laparoscopic surgical methods. Procedure rates reached a peak value in 2009 and then plateaued. Statewide obesity and diabetes rates increased over time, although there was no association between these population factors and procedure rates. Women had consistently higher rates of bariatric operations.nnnCONCLUSIONnAlthough bariatric procedures are an evidenced-based effective treatment for obesity, procedure rates were not associated with the increasing obesity and diabetes rates in the United States. Further research is needed to identify factors that affect the adoption and diffusion of bariatric operations to increase diffusion of beneficial innovations and improve overall quality of care and health outcomes.

A Cost-Effectiveness Analysis of Obtaining Blood Cultures in Children Hospitalized for Community-Acquired Pneumonia

Background and Purpose— Randomized trials have indicated a benefit for endovascular therapy in appropriately selected stroke patients at 3 months, but data regarding outcomes at 12 months are currently lacking. Methods— We compared functional and quality-of-life outcomes at 12 months overall and by stroke severity in stroke patients treated with intravenous tissue-type plasminogen activator followed by endovascular treatment as compared with intravenous tissue-type plasminogen activator alone in the Interventional Management of Stroke III Trial. The key outcome measures were a modified Rankin Scale score ⩽2 (functional independence) and the Euro-QoL EQ-5D, a health-related quality-of-life measure. Results— 656 subjects with moderate-to-severe stroke (National Institutes of Health Stroke Scale ≥8) were enrolled at 58 centers in the United States (41 sites), Canada (7), Australia (4), and Europe (6). There was an interaction between treatment group and stroke severity in the repeated measures analysis of modified Rankin Scale ⩽2 outcome (P=0.039). In the 204 participants with severe stroke (National Institutes of Health Stroke Scale ≥20), a greater proportion of the endovascular group had a modified Rankin Scale ⩽2 (32.5%) at 12 months as compared with the intravenous tissue-type plasminogen activator group (18.6%, P=0.037); no difference was seen for the 452 participants with moderately severe strokes (55.6% versus 57.7%). In participants with severe stroke, the endovascular group had 35.2 (95% confidence interval: 2.1, 73.3) more quality-adjusted-days over 12 months as compared with intravenous tissue-type plasminogen activator alone. Conclusions— Endovascular therapy improves functional outcome and health-related quality-of-life at 12 months after severe ischemic stroke. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT00359424.

Adherence to outpatient epilepsy quality indicators at a tertiary epilepsy center

OBJECTIVEnTo determine the clinical utility and cost-effectiveness of universal vs targeted approach to obtaining blood cultures in children hospitalized with community-acquired pneumonia (CAP).nnnSTUDY DESIGNnWe conducted a cost-effectiveness analysis using a decision tree to compare 2 approaches to ordering blood cultures in children hospitalized with CAP: obtaining blood cultures in all children admitted with CAP (universal approach) and obtaining blood cultures in patients identified as high risk for bacteremia (targeted approach). We searched the literature to determine expected proportions of high-risk patients, positive culture rates, and predicted bacteria and susceptibility patterns. Our primary clinical outcome was projected rate of missed bacteremia with associated treatment failure in the targeted approach. Costs per 100 patients and annualized costs on the national level were calculated for each approach.nnnRESULTSnThe model predicts that in the targeted approach, there will be 0.07 cases of missed bacteremia with treatment failure per 100 patients, or 133 annually. In the universal approach, 118 blood cultures would need to be drawn to identify 1 patient with bacteremia, in which the result would lead to a meaningful antibiotic change compared with 42 cultures in the targeted approach. The universal approach would cost

Marginal costing methods highlight the contributing cost of comorbid conditions in Medicare patients: a quasi-experimental case–control study of ischemic stroke costs

5178 per 100 patients or

Impact of Outpatient Rehabilitation Medicare Reimbursement Caps on Utilization and Cost of Rehabilitation Care After Ischemic Stroke: Do Caps Contain Costs?

9,214,238 annually. The targeted approach would cost

Dexamethasone may be a viable alternative to prednisone/ prednisolone for the treatment of acute asthma exacerbation in the paediatric emergency department

1992 per 100 patients or