National trend in prevalence, cost, and discharge after subdural hematoma from 1998-2007
ABSTRACT Subdural hematoma is a common type of intracranial hemorrhage, particularly among the elderly, yet, despite the aging U.S. population, little has been published in the last 10 yrs. This study aimed to determine national trends in prevalence, discharge disposition, length of stay, and cost of subdural hematoma over time.
Retrospective cohort study.
Adult patients hospitalized in the United States between 1998 and 2007 identified in the Nationwide Inpatient Sample.
Seven hundred twenty thousand, two hundred ninety-seven adult patients hospitalized in subdural hematoma.
Discharge disposition, hospital length of stay, and national cost (adjusted to 2007 dollars) were examined. Hospitalizations for subdural hematoma increased from 59,373 (30 per 100,000 hospitalizations) in 1998 to 91,935 (42 per 100,000) in 2007, constituting a 39% per-capita increase. The prevalence of subdural hematoma increased with age (p < .001), particularly among those >80 yrs of age (36% of subdural hematoma cohort), in lower income patients, in patients with acquired abnormalities of the coagulation cascade, and in patients with trauma. Inhospital mortality decreased from 15% to 12% (p = .001), but unsatisfactory discharge disposition increased from 17% to 20% (p < .001). National cost increased from $1.0 to $1.6 billion (p < .001). Unsatisfactory discharge disposition and cost were both independently predicted by higher comorbidity index, alcohol abuse, history of trauma, and acquired abnormal coagulation or platelet factors (p < .05). Neurosurgical intervention for subdural hematoma decreased from 41% in 1998 to 31% in 2007 (p < .001). Subdural hematoma evacuation was associated with decreased mortality but did not significantly protect against poor discharge disposition and was associated with significantly higher cost.
The prevalence and total cost for subdural hematoma has increased significantly in the last decade nationwide. Health resource consumption for subdural hematoma is increasing without clear evidence that management practices are leading to improved outcomes.
- Critical care medicine 07/2011; 39(7):1822-3. DOI:10.1097/CCM.0b013e31821e83a2 · 6.15 Impact Factor
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ABSTRACT: Background: Traditionally, thyroid surgery has been an inpatient procedure due to the risk of several well-documented complications. Recent research suggests that for selected patients, outpatient thyroid surgery is safe and feasible, with the additional potential benefit of cost savings. In recognition of these observations, we hypothesized that there would be an increase in U.S. outpatient thyroidectomies with a concurrent decline in inpatient thyroidectomies over time. Methods: Comparative cross-sectional analyses of the National Survey of Ambulatory Surgery (NSAS) and Nationwide Inpatient Sample (NIS) databases from 1996 and 2006 were performed. All cases of thyroid surgery were extracted, as well as data on age, gender, and insurance status. Diagnoses and surgical cases were identified using International Classification of Diseases, Ninth Revision (ICD-9) diagnostic and treatment codes. Hospital charges were acquired from the NIS 1996 and 2006 and NSAS 2006 releases, plus imputed data where necessary. After survey weights were applied, patient characteristics, diagnoses, and procedures were compared for inpatient versus outpatient procedures. Results: The total number of thyroidectomies increased 39% from 66,864 to 92,931 cases per year during the study timeframe. Outpatient procedures increased by 61%, while inpatient procedures increased by 30%. The proportion of privately-insured inpatients declined slightly from 63.8% to 60.1%, while those covered by Medicare increased from 22.8% to 25.8%. In contrast, the proportion of privately-insured outpatients declined sharply from 76.8% to 39.9%, while those covered by Medicare rose from 17.2% to 45.7%. These trends coincided with a small increase in mean inpatient age from 50.2 to 52.3 years and larger increase in mean outpatient age from 50.7 to 58.1 years. Inflation-adjusted per capita charges for inpatient thyroidectomies more than doubled from $9,934 in 1996 to $22,537 in 2006, while aggregate national inpatient charges tripled from $464 million to $1.37 billion. By comparison, in 2006 per capita charges for outpatient thyroidectomy totaled $7,222. Conclusions: From 1996 to 2006, there has been a concurrent modest increase in inpatient and pronounced increase in outpatient thyroidectomies in the U.S., with a consequential demographic shift and economic impact.Thyroid: official journal of the American Thyroid Association 11/2012; 23(6). DOI:10.1089/thy.2012.0218 · 3.84 Impact Factor
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ABSTRACT: Object A positive correlation between outcomes and the volume of patients seen by a provider has been supported by numerous studies. Volume-outcome relationships (VORs) have been well documented in the setting of both neurosurgery and trauma care and have shaped regionalization policies to optimize patient outcomes. Several authors have also investigated the correlation between patient volume and cost of care, known as the volume-cost relationship (VCR), with mixed results. The purpose of the present study was to investigate VORs and VCRs in the treatment of common intracranial injuries by testing the hypotheses that outcomes suffer at small-volume centers and costs rise at large-volume centers. Methods The authors performed a cross-sectional cohort study of patients with neurological trauma using the 2006 Nationwide Inpatient Sample, the largest nationally representative all-payer data set. Patients were identified using ICD-9 codes for subdural, subarachnoid, and extradural hemorrhage following injury. Transfers were excluded from the study. In the primary analysis the association between a facility's neurotrauma patient volume and patient survival was tested. Secondary analyses focused on the relationships between patient volume and discharge status as well as between patient volume and cost. Analyses were performed using logistic regression. Results In-hospital mortality in the overall cohort was 9.9%. In-hospital mortality was 14.9% in the group with the smallest volume of patients, that is, fewer than 6 cases annually. At facilities treating 6-11, 12-23, 24-59, and 60+ patients annually, mortality was 8.0%, 8.3%, 9.5%, and 10.0%, respectively. For these groups there was a significantly reduced risk of in-hospital mortality as compared with the group with fewer than 6 annual patients; the adjusted ORs (and corresponding 95% CIs) were 0.45 (0.29-0.68), 0.56 (0.38-0.81), 0.63 (0.44-0.90), and 0.59 (0.41-0.87), respectively. For these same groups (once again using < 6 cases/year as the reference), there were no statistically significant differences in either estimated actual cost or duration of hospital stay. Conclusions A VOR exists in the treatment of neurotrauma, and a meaningful threshold for significantly improved mortality is 6 cases per year. Emergency and interfacility transport policies based on this threshold might improve national outcomes. Cost of care does not differ significantly with patient volume.Journal of Neurosurgery 12/2012; 118(3). DOI:10.3171/2012.10.JNS12682 · 3.15 Impact Factor