Tricia J. Johnson

Impact of early human milk on sepsis and health-care costs in very low birth weight infants

Objective:To study the incidence of sepsis and neonatal intensive care unit (NICU) costs as a function of the human milk (HM) dose received during the first 28 days post birth for very low birth weight (VLBW) infants.Study design:Prospective cohort study of 175 VLBW infants. The average daily dose of HM (ADDHM) was calculated from daily nutritional data for the first 28 days post birth (ADDHM-Days 1–28). Other covariates associated with sepsis were used to create a propensity score, combining multiple risk factors into a single metric.Result:The mean gestational age and birth weight were 28.1±2.4 weeks and 1087±252 g, respectively. The mean ADDHM-Days 1–28 was 54±39 ml kg−1 day−1 (range 0–135). Binary logistic regression analysis controlling for propensity score revealed that increasing ADDHM-Days 1–28 was associated with lower odds of sepsis (odds ratio 0.981, 95% confidence interval 0.967–0.995, P=0.008). Increasing ADDHM-Days 1–28 was associated with significantly lower NICU costs.Conclusion:A dose–response relationship was demonstrated between ADDHM-Days 1–28 and a reduction in the odds of sepsis and associated NICU costs after controlling for propensity score. For every HM dose increase of 10 ml kg−1 day−1, the odds of sepsis decreased by 19%. NICU costs were lowest in the VLBW infants who received the highest ADDHM-Days 1–28.

Effects of an Enhanced Discharge Planning Intervention for Hospitalized Older Adults: A Randomized Trial

PURPOSE OF THE STUDY To identify needs encountered by older adult patients after hospital discharge and assess the impact of a telephone transitional care intervention on stress, health care utilization, readmissions, and mortality. DESIGN AND METHODS Older adult inpatients who met criteria for risk of post-discharge complications were randomized at discharge through the electronic medical record. Intervention group participants received the telephone-based Enhanced Discharge Planning Program intervention that included biopsychosocial assessment and an individualized plan following program protocols to address identified transitional care needs. All patients received a follow-up call at 30 days post discharge to assess psychosocial needs, patient and caregiver stress, and physician follow-up. RESULTS 83.3% of intervention group participants experienced significant barriers to care. For 73.3% of this group, problems did not emerge until after discharge. Intervention patients were more likely than usual care patients to have scheduled and completed physician visits by 30 days post discharge. There were no differences between groups on patient or caregiver stress or hospital readmission. IMPLICATIONS At-risk older adults may benefit from transitional care programs to ensure delivery of care as ordered and address unmet needs. Although patients who received the intervention were more likely to communicate and follow up with their physicians, the absence of impact on readmission suggests that more intensive efforts may be indicated to affect this outcome.

Cost Savings of Human Milk as a Strategy to Reduce the Incidence of Necrotizing Enterocolitis in Very Low Birth Weight Infants

Background: Necrotizing enterocolitis (NEC) is a costly morbidity in very low birth weight (VLBW; <1,500 g birth weight) infants that increases hospital length of stay and requires expensive treatments. Objectives: To evaluate the cost of NEC as a function of dose and exposure period of human milk (HM) feedings received by VLBW infants during the neonatal intensive care unit (NICU) hospitalization and determine the drivers of differences in NICU hospitalization costs for infants with and without NEC. Methods: This study included 291 VLBW infants enrolled in an NIH-funded prospective observational cohort study between February 2008 and July 2012. We examined the incidence of NEC, NICU hospitalization cost, and cost of individual resources used during the NICU hospitalization. Results: Twenty-nine (10.0%) infants developed NEC. The average total NICU hospitalization cost (in 2012 USD) was USD 180,163 for infants with NEC and USD 134,494 for infants without NEC (p = 0.024). NEC was associated with a marginal increase in costs of USD 43,818, after controlling for demographic characteristics, risk of NEC, and average daily dose of HM during days 1-14 (p < 0.001). Each additional ml/kg/day of HM during days 1-14 decreased non-NEC-related NICU costs by USD 534 (p < 0.001). Conclusions: Avoidance of formula and use of exclusive HM feedings during the first 14 days of life is an effective strategy to reduce the risk of NEC and resulting NICU costs in VLBW infants. Hospitals investing in initiatives to feed exclusive HM during the first 14 days of life could substantially reduce NEC-related NICU hospitalization costs.

Impact of medical travel on imports and exports of medical services

OBJECTIVES Medical travel is travel outside of an individuals home region or country in pursuit of medical care that is more accessible, of higher quality and/or of lower cost. This paper estimates the inflows of foreign residents seeking medical care in the U.S. and outflows of U.S. residents seeking care abroad. METHODS Using data from the U.S. Bureau of Economic Analysis, U.S. International Trade Administration and a survey of domestic health care providers, we estimate the lower and upper bounds for the number of medical travelers into and out of the U.S. and the value of these services. RESULTS We estimate that between 43,000 and 103,000 foreigners came into the U.S. for medical care, and between 50,000 and 121,000 U.S. residents traveled abroad for care in 2007. Despite a net loss in the number of medical travelers flowing out of the U.S. for care, the trade surplus for medical travel could be as high as

Economic Benefits and Costs of Human Milk Feedings: A Strategy to Reduce the Risk of Prematurity-Related Morbidities in Very-Low-Birth-Weight Infants

1 billion. CONCLUSIONS While a slight net outflow of patients leaving the U.S. for medical care may exist, the resulting impact on exports is still positive for the U.S., due to a higher average spending per patient coming to the U.S. New mechanisms are needed to track the balance of mobility and trade for medical care on a regular basis.

Change in MS-DRG assignment and hospital reimbursement as a result of centers for medicare & medicaid changes in payment for hospital-acquired conditions: Is it coding or quality?

Infants born at very low birth weight (VLBW; birth weight <1500 g) are at high risk of mortality and are some of the most expensive patients in the hospital. Additionally, VLBW infants are susceptible to prematurity-related morbidities, including late-onset sepsis, bronchopulmonary dysplasia (BPD), necrotizing enterocolitis, and retinopathy of prematurity, which have short- and long-term economic consequences. The incremental cost of these morbidities during the neonatal intensive care unit (NICU) hospitalization is high, ranging from

Assessing the impact of electronic health records as an enabler of hospital quality and patient satisfaction.

10,055 (in 2009 US

The use of patient satisfaction surveys and alternative coding procedures to predict malpractice risk.

) for late-onset sepsis to

Evaluating the effect of resident involvement on physician productivity in an academic general internal medicine practice.

31,565 for BPD. Human milk has been shown to reduce both the incidence and severity of some of these morbidities and, therefore, has an indirect impact on the cost of the NICU hospitalization. Furthermore, human milk may also directly reduce NICU hospitalization costs, independent of the indirect impact on the incidence and/or severity of these morbidities. Although there is an economic cost to both the mother and institution for providing human milk during the NICU hospitalization, these costs are relatively low. This review describes the total cost of the initial NICU hospitalization, the incremental cost associated with these prematurity-related morbidities, and the incremental benefits and costs of human milk feedings during critical periods of the NICU hospitalization as a strategy to reduce the incidence and severity of these morbidities.

Quality Indicators for Human Milk Use in Very Low Birthweight Infants: Are We Measuring What We Should be Measuring?

Context In October 2008, the Centers for Medicare & Medicaid Services reduced payments to hospitals for a group of hospital-acquired conditions (HACs) not documented as present on admission (POA). It is unknown what proportion of Medicare severity diagnosis related group (MS-DRG) assignments will change when the International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis code for the HAC is not taken into account even before considering the POA status. Objectives The primary objectives were to estimate the proportion of cases that change MS-DRG assignment when HACs are removed from the calculation, the subsequent changes in reimbursement to hospitals, and the attenuation in changes in MS-DRG assignment after factoring in those that may be POA. Last, we explored the effect of the numbers of ICD-9-CM diagnosis codes on MS-DRG assignment. Methods We obtained 2 years of discharge data from academic medical centers that were members of the University HealthSystem Consortium and identified all cases with 1 of 7 HACs coded through ICD-9-CM diagnosis codes. We calculated the MS-DRG for each case with and without the HAC and, hence, the proportion where MS-DRG assignment changed. Next, we used a bootstrap method to calculate the range in the proportion of cases changing assignment to account for POA status. Changes in reimbursement were estimated by using the 2008 MS-DRG weights payment formula. Results Of 184 932 cases with at least 1 HAC, 27.6% (n = 52 272) would experience a change in MS-DRG assignment without the HAC factored into the assignment. After taking into account those conditions that were potentially POA, 7.5% (n = 14 176) of the original cases would change MS-DRG assignment, with an average loss in reimbursement per case ranging from