William E. Encinosa

Healthcare utilization and outcomes after bariatric surgery.

Objective:Bariatric surgery is one of the fastest growing hospital procedures. Our objective is to examine the safety outcomes and utilization of resources in the 6 months after bariatric surgery using a nationwide, population-based sample. Data/Design:We examine insurance claims for 2522 bariatric surgeries, at 308 hospitals, among a population of 5.6 million nonelderly people covered by large employers in the 2001–2002 MarketScan data. Outcomes and costs were risk-adjusted using multivariate regression methods. Principal Findings:Although the complication rate was 21.9% during the initial surgical stay, the rate increased by 81% (P < 0.01) to 39.6% (95% confidence interval, 37.7–41.5%) over the 180 days after discharge. A total of 10.8% of the patients without 30-day complications developed a complication between 30 days and 180 days. Overall, 18.2% of the patients had some type of postoperative visit to the hospital with a complication (through readmission, outpatient hospital visit, or emergency room visit) within 180 days. Although there was no difference between men and women, the near-elderly had a 26% (P < 0.01) higher risk-adjusted complication rate than those age 18 to 39 years. Total 6-month risk-adjusted healthcare payments were

Recent improvements in bariatric surgery outcomes.

65,031 for those with 180-day readmissions compared with

The Impact of Medical Errors on Ninety-Day Costs and Outcomes: An Examination of Surgical Patients

27,125 for those without readmissions (P < 0.01). Conclusion:In contrast to current bariatric studies, which report a 20% in-hospital complication rate, we find a significantly higher complication rate over the 6 months after surgery, resulting in costly readmissions and emergency room visits. Thus, a clear way to reduce the costs and improve outcomes of bariatric surgery is to address the high rate of postoperative complications.

Hospital finances and patient safety outcomes.

Objective:Bariatric surgery is one of the fastest growing hospital procedures, but with a 40% complication rate in 2001. Between 2001 and 2005 bariatric surgeries grew by 113%. Our objective is to examine how 6-month complications improved between 2001 and 2006, using a nationwide, population-based sample. Data/Design:We examined insurance claims in 2001–2002 and 2005–2006 for 9582 bariatric surgeries, at 652 hospitals, among a population of 16 million nonelderly people. Outcomes and costs were risk-adjusted using multivariate regression methods with hospital fixed effects. Principal Findings:Between 2001 and 2006, while older and sicker patients underwent the surgery, the 180-day risk-adjusted complication rate declined 21% from 41.7% to 32.8%. Most of the improvement was in the initial hospital stay, where the risk-adjusted inpatient complication rate declined 37%, from 23.6% to 14.8%. Risk-adjusted rates of readmissions with complications declined 31%, from 9.8% to 6.8%. Risk-adjusted hospital days declined from 6 to 3.7 days, and risk-adjusted and inflation-adjusted payments declined 6%. Improvements in complication rates and readmission rates were associated with a within-hospital 30% increase in hospital volume. Volume had no impact on costs. The use of laparoscopy, which increased from 9% to 71%, reduced costs by 12%, while gastric banding decreased costs by 20%. Laparoscopy had no impact on readmissions, but the increase in banding without bypass reduced readmissions. Conclusions:Improvements in bariatric outcomes and costs were due to a mix of within-hospital volume increases, a move to a laparoscopic technique, and an increase in banding without bypass.

The impact of state laws limiting malpractice damage awards on health care expenditures.

OBJECTIVE To estimate the effect of medical errors on medical expenditures, death, readmissions, and outpatient care within 90 days after surgery. DATA SOURCES 2001-2002 MarketScan insurance claims for 5.6 million enrollees. STUDY DESIGN The Agency for Healthcare Research and Quality Patient Safety Indicators (PSIs) were used to identify 14 PSIs among 161,004 surgeries. We used propensity score matching and multivariate regression analyses to predict expenditures and outcomes attributable to the 14 PSIs. PRINCIPAL FINDINGS Excess 90-day expenditures likely attributable to PSIs ranged from

Health care expenditure burdens among adults with diabetes in 2001

646 for technical problems (accidental laceration, pneumothorax, etc.) to

Annual Report on Health Care for Children and Youth in the United States: National Estimates of Cost, Utilization and Expenditures for Children With Mental Health Conditions

28,218 for acute respiratory failure, with up to 20 percent of these costs incurred postdischarge. With a third of all 90-day deaths occurring postdischarge, the excess death rate associated with PSIs ranged from 0 to 7 percent. The excess 90-day readmission rate associated with PSIs ranged from 0 to 8 percent. Overall, 11 percent of all deaths, 2 percent of readmissions, and 2 percent of expenditures were likely due to these 14 PSIs. CONCLUSIONS The effects of medical errors continue long after the patient leaves the hospital. Medical error studies that focus only on the inpatient stay can underestimate the impact of patient safety events by up to 20-30 percent.

Does Prescription Drug Adherence Reduce Hospitalizations and Costs? The Case of Diabetes

Hospitals recently have experienced greater financial pressures. Whether these financial pressures have led to more patient safety problems is unknown. Using the Healthcare Cost and Utilization Project (HCUP) State Inpatient Data for Florida from 1996 to 2000, this study examines whether financial pressure at hospitals is associated with increases in the rate of patient safety events (e.g., medical errors) for major surgeries. Findings show that patients have significantly higher odds of having adverse patient safety events (nursing-related patient safety events, surgery-related patient safety events, and all likely preventable patient safety events) when hospital profit margins decline over time. The finding that a within-hospital erosion of hospital operating profits increases the rate of adverse patient safety events suggests that any cost-cutting efforts be carefully designed and managed.

Optimal health insurance: the case of observable, severe illness.

Twenty-eight states have laws that limit payments in malpractice cases, and several studies indicate that these laws reduce the frequency and severity of malpractice claims and lower premiums. Moreover, proponents believe that such laws reduce health care expenditures by reducing the practice of defensive medicine. However, there is a dearth of empirical evidence about the impact of these laws on the cost of health care. We used multivariate models and relatively recent data to estimate the impact of state tort reform laws that directly limit malpractice damage payments on health care expenditures. Estimates from these models suggest that laws limiting malpractice payments lower state health care expenditures by between 3% and 4%.

Do Patient Safety Events Increase Readmissions

Objective:High out-of-pocket costs can pose a significant burden on patients with chronic conditions such as diabetes and contribute to decreased treatment adherence. We examined financial burdens among adults with diabetes using nationally representative data. Methods:We estimated how frequently adults with diabetes live in families in which spending on health insurance premiums and health care services exceed a specified percentage of family-level after-tax disposable income. Results:We found that adults with diabetes face greater risks of high burdens compared with adults with any other highly prevalent medical condition. Adults with diabetes have lower incomes and pay a higher share of total expenditures out-of-pocket compared with adults with heart disease, hypertension, and cancer. Among adults with diabetes, women, those who live in poverty, and those with coexisting conditions are more likely to bear high burdens. Among nonelderly adults, those with public coverage and the uninsured have greater risk of high burdens compared with those with private insurance. More than 23% of the uninsured and more than 20% of those with public coverage spend more than half of their disposable income on health care. Among the elderly, those with private nonemployment related insurance have the greatest risk of high burdens followed by those with Medicare only, those with private employment-related coverage, and those enrolled in Medicaid. Prescription medications and diabetic supplies account for 63% to 70% of out-of-pocket expenditures among the nonelderly and 62% to 69% among the elderly. Conclusions:Our study identifies the subpopulations among adults with diabetes who are more likely to have high burdens, so that intervention measures can be targeted to help reduce treatment noncompliance. Our analysis also emphasizes the role of medications and diabetic supplies in contributing to high out-of-pocket burdens.