Research Spotlight

Yeramaneni, S., J. L. Gum, L. Y. Carreon, E. O. Klineberg, J. S. Smith, A. Jain and R. A. Hostin (2018). “Impact of Readmissions in Episodic Care of Adult Spinal Deformity: Event-Based Cost Analysis of 695 Consecutive Cases.” J Bone Joint Surg Am 100(6): 487-495.

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BACKGROUND: Readmissions following adult spinal deformity surgical procedures frequently occur, placing a substantial burden on patients and providers. Existing literature on readmission costs, including reason-specific readmission costs, is limited. The purposes of this study were to determine the most expensive reasons for readmission, to assess the impact of reasons and timing on readmission costs, and to estimate the drivers of total costs associated with adult spinal deformity surgical procedures. METHODS: We performed a retrospective review of 695 patients with adult spinal deformity (>/=18 years of age) who underwent a corrective spine surgical procedure at a single center from 2005 to 2013. Demographic, surgical, and direct cost data expressed in 2010 dollars for the entire inpatient episode of care were obtained from the hospital administrative database. A multivariable linear regression model with a gamma distribution and log-link function was used to estimate the impact of reasons and timing on readmission costs and to identify the primary drivers of long-term costs. RESULTS: The mean age (and standard deviation) of the patients was 50.6 +/- 15.8 years, 589 patients (85%) were women, and 637 patients (92%) were Caucasian. The observed readmission rates were 24% overall (costing $10.1 million), 8.8% for 30 days (costing $3.2 million), and 11.7% for 90 days (costing $4.6 million). The most expensive readmissions and their mean readmission cost were pseudarthrosis ($92,755), infection ($75,172), and proximal junctional kyphosis ($66,713), after adjusting for patient and surgical factors. The mean readmission cost after 2 years was $86,081. Older age (p = 0.001), >/=8 levels fused (p = 0.01), and length of index stay at the hospital (p < 0.0001) were independently associated with higher total cost. Surgical procedures in patients with a thoracic-only curve (p = 0.004) or a double curve (p = 0.05) and a surgical approach that was anterior-only (p < 0.0001) or posterior-only (p = 0.01) were independently associated with lower total costs. CONCLUSIONS: Compared with readmission cost due to medical reasons, readmission due to pseudarthrosis increases mean readmission cost by 105%, readmission due to infection increases mean readmission cost by 72%, and readmission due to proximal junctional kyphosis increases mean readmission cost by 63%. Together, these 3 reasons accounted for 73% of readmission costs. This study identifies potential areas for cost reduction and opportunities for reducing readmission rates. CLINICAL RELEVANCE: Although reducing the 30-day and 90-day readmission rates and costs are important; adult spinal deformity surgery is unique, because the most common and most expensive complications occur after 1 year. We believe that our paper is clinically relevant as it will help to guide clinical focus on the most impactful complications.

Yeramaneni, S., C. P. Ames, S. Bess, D. Burton, J. S. Smith, S. Glassman, J. L. Gum, L. Carreon, A. Jain, C. Zygourakis, I. Avramis and R. Hostin (2018). “Center variation in episode-of-care costs for adult spinal deformity surgery: results from a prospective, multicenter database.” Spine J Mar 22. [Epub ahead of print].

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BACKGROUND CONTEXT: Adult spinal deformity surgery (ASD) is associated with significant resource utilization, costing more than $958 million in charges for Medicare patients and over $1.7 billion in charges for managed care population in the last decade. Given the recent move towards bundled payment models, it is important to understand the various care components a patient receives over the course of a defined clinical episode, its associated cost, and the proportion of cost for each component towards the bundled payment. PURPOSE: To examine the degree and determinants of variation in inpatient episode-of-care (EOC) cost, resource utilization, and patient reported outcomes for patients undergoing ASD surgery across four spine deformity centers in the United States. STUDY DESIGN/SETTING: Retrospective analysis of prospective, multicenter database. PATIENT SAMPLE: Consecutive patients enrolled in an ASD database from four spinal deformity centers. OUTCOME MEASURES: Total in-patient EOC costs and short form (SF)-6D. METHODS: The study used a multicenter database of 210 consecutively enrolled operative patients from 2008 to 2013 at four participating centers in the United States. Demographic, surgical, and direct cost data, expressed in 2013 dollars, for the entire inpatient EOC were obtained from administrative databases from the respective hospitals. Mixed models and multivariable linear regression were used to evaluate the impact of center on total costs adjusting for patient characteristics, length of stay (LOS), and surgical factors. RESULTS: A total of 126 patients with complete baseline and 2-year follow-up data were included. The percentages of patients from each center were: 36.5%, 7.1%, 24.6%, and 31.7%. Overall, the mean patient age was 58.4+12.6 years, 86% were women, and 94% were Caucasian. The proportion of total cost variation explained by the center at which the patient was treated was 17%. After adjusting for patient, LOS, and surgical factors the cost variation reduced to 4%. In multivariable analysis, each additional level fused increased total cost variation by $2500. While, recombinant human bone morphogenetic protein-2 (BMP) use and posterior-only surgical approach lowered total EOC costs by $10,500 and $9,400, respectively. No significant difference was observed in 2-year quality-adjusted life year across centers. CONCLUSIONS: Total EOC costs for ASD surgery varied significantly by center. Levels fused, BMP use, and surgical approach were the primary drivers of cost variation across centers. Differences in resource utilization had no impact on 2-year quality-adjusted life year improvement across centers.

Xing, G., R. Gillespie, B. Bedri, A. Quan, P. Zhang and X. J. Zhou (2018). “Proliferative glomerulonephritis with monoclonal IgG deposits in children and young adults.” Pediatr Nephrol Apr 3. [Epub ahead of print].

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BACKGROUND: Proliferative glomerulonephritis with monoclonal IgG deposits (PGNMID) has been recognized as a distinct entity in recent years. To the best of our knowledge, all patients with PGNMID reported thus far were older than 20 years of age. We now report five cases of PGNMID in patients under 20 years of age. METHODS: The clinical database was searched for patients with native kidney biopsies from 9/2011 to 8/2017, and cases with a diagnosis of PGNMID were retrieved. Light microscopy specimens and immunofluorescence and electron microscopy images were revisited. Clinical data and kidney biopsy findings for patients under the age of 20 were recorded. RESULTS: Five (0.78%) of a total of 637 patients younger than 20 with native renal biopsies had a diagnosis of PGNMID, including three males and two females with an average age of 14 years old (range 10-19). All five patients presented with microscopic hematuria and proteinuria. Three patients were nephrotic and their C3 levels were low. All five cases showed a membranoproliferative pattern with abundant mesangial and subendothelial monoclonal IgG3 deposits (3 kappa and 2 lambda light chain, respectively). The patients were followed up to 56 months. Two patients had re-biopsies 28 and 18 months after initial diagnosis and both showed similar morphologic changes. Various treatments were attempted including prednisone, mycophenolate mofetil, tacrolimus, rituximab, and eculizmab, with mixed responses. CONCLUSIONS: PGNMID does occur in children and young adults. Membranoproliferative glomerulonephritis pattern with monoclonal IgG3 deposits is a common feature. Despite various immunosuppressive treatments, the disease appears slowly progressive.

Wesson, D., H. Kitzman, K. H. Halloran and K. Tecson (2018). “Innovative Population Health Model Associated With Reduced Emergency Department Use And Inpatient Hospitalizations.” Health Aff (Millwood) 37(4): 543-550.

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Population health strategies that improve access to health care and address social determinants of health may reduce the use of costly emergency services. Here we describe a strategy adopted by Baylor Scott & White Health to reduce rising rates of emergency department use and inpatient hospitalizations in an underserved Dallas community that is home to many people with low socioeconomic status. Baylor Scott & White partnered with the Dallas Park and Recreation Department to create a level-three primary care clinic integrating wellness and prevention programs in a city recreational center. The clinic, known as the Baylor Scott & White Health and Wellness Center, exemplifies the integration of social determinants of health within a population health strategy. Emergency department (ED) and inpatient care use was examined over twelve months after initiation of services at the center. People who used the center’s services showed a reduction in ED use of 21.4 percent and a reduction in inpatient care use of 36.7 percent, with an average cost decrease of 34.5 percent and 54.4 percent, respectively. These data support the use of population health strategies to reduce the use of emergency services.

Van Meter, C., A. Vasudevan, J. M. Cuccerre and J. M. Schussler (2018). “Time to discharge following diagnostic coronary procedures via transradial artery approach: A comparison of Terumo band and StatSeal hemostasis.” Cardiovasc Revasc Med Mar 24. [Epub ahead of print].

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BACKGROUND: The transradial artery (TRA) approach for cardiac catheterization is associated with fewer complications, earlier mobilization and a shorter stay at the hospital. The objective of this study was to determine whether hemostasis with a combination of a compression band (Terumo TR band) and a hemostatic patch (StatSeal) decreases the time to discharge from the hospital compared to the Terumo (TR) band alone in patients undergoing diagnostic coronary catheterizations through a TRA approach. METHODS: We retrospectively looked at 445 patients who underwent diagnostic coronary angiography through the TRA approach at the Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas between July 2016 and June 2017. The difference in the time to discharge between the two groups was assessed by a Wilcoxon Rank-sum test. RESULTS: The combination of a TR band and a StatSeal hemostatic patch was used in 70.3% (313) of the patients. Comparison of the two groups demonstrated a statistically significant reduction in time from the end of the procedure to discharge (p<0.001), with no significant alteration in safety among those with a combination of TR band and a StatSeal hemostatic patch. CONCLUSION: With increasing frequency of TRA procedures in the United States, we demonstrate one effective method to significantly reduce the time to radial hemostasis and reduce the time to patient discharge from the hospital.