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Utilization and Cost of Inpatient Dermatologic Procedures: A Cross-sectional Analysis

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  • University Hospitals Cleveland Medical Center/Case Western Reserve University
Article

Utilization and Cost of Inpatient Dermatologic Procedures: A Cross-sectional Analysis

Abstract

Knowledge surrounding inpatient dermatologic procedure costs is limited; therefore to learn more, we performed a cross-sectional analysis of dermatologic procedures contained in a publicly available Washington State Comprehensive Hospital Abstract Reporting System database from 2014. Dermatologic procedure utilization and cost were evaluated based on several parameters including demographics, length of hospital stay, payments, and payers. SAS 9.4 was used for the analysis. A total of 14,768 patients underwent dermatologic procedures in 2014 and 81.0% were white. The average age was 53 years (SD = 0.17), and the average payment for all patients who underwent dermatologic procedures was $85,059.48 (SD = $1,284.34). The average hospital length of stay was 8.91 days (SD = 0.07). The most common admission type was elective (66.2%), the most common admit source was a non-healthcare facility point of origin (78.2%), the most common primary payer was Medicare (36.2%), and the most common procedure was incision and drainage of skin and subcutaneous tissue (26.5%), followed by closure of skin and subcutaneous tissue of other sites (20%). This analysis demonstrated that inpatient dermatologic procedures are a significant driver of inpatient health care costs, and it is critical to determine factors that increase inpatient costs related to dermatologic procedures in order to develop strategies for reducing healthcare costs.
Received 03/18/2019
Review began 03/19/2019
Review ended 04/29/2019
Published 05/02/2019
© Copyright 2019
Schrom et al. This is an open access article
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Utilization and Cost of Inpatient Dermatologic
Procedures: A Cross-sectional Analysis
Kory P. Schrom , Raghav Tripathi , Harib H. Ezaldein , Jeffrey F. Scott
1. Dermatology, University Hospitals Cleveland Medical Center, Cleveland, USA 2. Dermatology, Case Western Reserve
University, Cleveland, USA 3. Dermatology, University Hospitals Cleveland Medical Center / Case Western Reserve
University, Cleveland, USA
Corresponding author: Kory P. Schrom, kory.schrom@gmail.com
Disclosures can be found in Additional Information at the end of the article
Abstract
Knowledge surrounding inpatient dermatologic procedure costs is limited; therefore to learn more, we
performed a cross-sectional analysis of dermatologic procedures contained in a publicly available
Washington State Comprehensive Hospital Abstract Reporting System database from 2014. Dermatologic
procedure utilization and cost were evaluated based on several parameters including demographics, length
of hospital stay, payments, and payers. SAS 9.4 was used for the analysis. A total of 14,768 patients
underwent dermatologic procedures in 2014 and 81.0% were white. The average age was 53 years (SD =
0.17), and the average payment for all patients who underwent dermatologic procedures was $85,059.48 (SD
= $1,284.34). The average hospital length of stay was 8.91 days (SD = 0.07). The most common admission
type was elective (66.2%), the most common admit source was a non-healthcare facility point of origin
(78.2%), the most common primary payer was Medicare (36.2%), and the most common procedure was
incision and drainage of skin and subcutaneous tissue (26.5%), followed by closure of skin and subcutaneous
tissue of other sites (20%). This analysis demonstrated that inpatient dermatologic procedures are a
significant driver of inpatient health care costs, and it is critical to determine factors that increase inpatient
costs related to dermatologic procedures in order to develop strategies for reducing healthcare costs.
Categories: Dermatology, Miscellaneous, Epidemiology/Public Health
Keywords: inpatients, outpatients, cost, dermatologic procedures, admissions, payers
Introduction
Health care spending accounted for 17.9% of the nation’s gross domestic product (GDP) in 2017, or $3.5
trillion [1]. The contribution of inpatient dermatologic procedures to this total is poorly understood. For
example, the cost of dermatologic procedures among Medicare beneficiaries was $2.21 billion in 2017, with a
portion arising from inpatient care [2]. We examined discharge records from community hospital visits to
better understand the utilization and cost of non-disease-specific inpatient dermatologic procedures.
Materials And Methods
We performed a cross-sectional analysis of the Washington State Comprehensive Hospital Abstract
Reporting System (CHARS) database to analyze the utilization and cost of inpatient dermatologic
procedures performed in 2014 [3]. This database contains record-level data pertaining to inpatient and
observation community hospital visits and abstracted information on discharges for civilian hospitals in the
state. CHARS database collection methods have been described elsewhere [4]. This study was IRB exempt
due to the de-identified and publicly available data.
All patients were adults (>18 years of age) hospitalized in Washington in 2014 who underwent a variety of
dermatologic procedure. Descriptive analyses were performed on patient demographics, length of hospital
stay, admission type, payment amount, and primary payer. All statistical analyses were performed using SAS
9.4 (Cary, NC).
Results
A total of 14,768 patients underwent dermatologic procedures in 2014. Descriptive characteristics of the
sample are provided in Table 1. The majority of admissions were elective (66.2%). The most common primary
payer was Medicare (36.2%) followed by Medicaid (28.5%). The mean total hospitalization payment for
patients undergoing dermatologic procedures was $85,059.48, and the average length of hospital stay was
8.9 days. The most common procedure was incision and drainage of skin and subcutaneous (SC) tissue
(26.5%).
1 2 3 1
Open Access Original
Article DOI: 10.7759/cureus.4586
How to cite this article
Schrom K P, Tripathi R, Ezaldein H H, et al. (May 02, 2019) Utilization and Cost of Inpatient Dermatologic
Procedures: A Cross-sectional Analysis. Cureus 11(5): e4586. DOI 10.7759/cureus.4586
Sample Size, N 14,768
Age (years), mean (SD) 52.6 (0.17)
Payment (USD), mean (SD) $85,059.48 ($1,284.34)
Length of stay (days), mean (SD) 8.9 (0.07)
Sex, N (%)
Female 6,560 (44.4)
Male 8,201 (55.6)
Race, N (%)
Hispanic 812 (5.5)
White 11,965 (81.0)
Black 718 (4.9)
Other 1,273 (8.6)
Admit type, N (%)
Elective 9,781 (66.2)
Emergency 2,071 (14.0)
Urgent 2,290 (15.5)
Other 626 (4.2)
Admit source, N (%)
Non-healthcare facility point of origin 11,547 (78.2)
Clinic 1,346 (9.1)
Transfer from a hospital (different facility) 1,468 (9.9)
Other 407 (2.8)
Primary payer, N (%)
Medicare 5,349 (36.2)
Medicaid 4,205 (28.5)
Health maintenance organization (HMO) 704 (4.8)
Commercial Insurance 2,575 (17.4)
Health Service Contractors 819 (5.6)
Other 1,116 (7.6)
Procedure, N (%)
Skin & SC tissue aspiration 327 (2.2)
Injection or tattooing of skin lesion or defect 16 (0.1)
Incision & drainage of skin & SC tissue 3,891 (26.5)
Incision & removal of foreign body from skin and SC tissue 957 (6.5)
Incision of skin & SC tissue 199 (1.4)
Skin and SC tissue closed biopsy 539 (3.7)
Skin & SC tissue diagnostic procedures 2 (0.01)
Excisional debridement 1,918 (13.7)
2019 Schrom et al. Cureus 11(5): e4586. DOI 10.7759/cureus.4586 2 of 5
Removal of nail anatomy 112 (0.8)
Skin chemosurgery 7 (0.1)
Dermal appendage ligation 35 (0.2)
Nail anatomy debridement 212 (1.4)
Non-excisional debridement 2,265 (15.4)
Skin & SC tissue closure 2,934 (20)
TABLE 1: Characteristics of patients undergoing an inpatient dermatologic procedure
N, number; HMO, health maintenance organization; USD, United States dollar; SC, subcutaneous
Characteristics of patients undergoing each of the identified procedures are provided in Table 2. Medicaid
was the most common payer when incision and drainage of skin and SC tissue was performed. Skin
chemosurgery had the highest average admission cost ($548,535.70) and excisional debridement had the
highest aggregate cost ($5,333,677.80).
Skin &
SC tissue
aspiration
Injection
or
tattooing
of skin
lesion or
defect
Incision &
drainage
of skin &
SC tissue,
other
Incision &
removal of
foreign
body from
skin and
SC tissue
Incision
of skin &
SC
tissue,
other
Skin and
SC tissue
closed
biopsy
Skin & SC
tissue
diagnostic
procedures,
other
Excisional
debridement
Removal
of nail
anatomy
Skin
chemosurgery
Dermal
appendage
ligation
Nail
anatomy
debridement
Non-
excisional
debridement
Skin & SC
tissue
closure,
other sites
Total
number of
patients
undergoing
procedure
327 16 3,891 957 199 539 2 1,918 112 7 35 212 2265 2934
Age
Mean 52.6 30.1 46.8 51.8 51.5 53.9 54 56.4 57.5 6.9 0.9 67.1 54.8 54.8
Std error 0.16 0.14 0.16 0.16 0.18 0.17 0.07 0.14 0.15 0.09 0.05 0.1 2 0.16 0.20
Length
Stayed
(Days)
Mean 8.9 6.8 5.7 11.8 10.1 14. 5 10.8 9.9 47.4 5.7 16.9 11.5 7.2
Std error 0.10 0.10 0.07 0.21 0.12 0.18 0.01 0.12 0.09 0.49 0.12 0.1 5 0.15 0.09
Payment
(USD)
Mean 73,634.1 42,483.6 49,238.9 122,616.768 118,240.1 147,213.4 68,133.7 93,204 75,586.9 548,535.7 49,128.7 82,065.4 101,226.7 82,687.4
Min 3455 10855.9 1838 1699 7942.4 4176.3 68130.7 4248.3 7502.6 18255.9 1807.6 8343.3 2738.7 1,826.6
Max 1,158,397 172,812.3 2,248,144.1 4,586,665.2 982,935.6 362,0874.3 68,136.7 5,333,677.8 459,992.4 2,069,643.2 821,520.6 1,263,769.1 2,173,662.7 1,601,295.5
Std Err 50.1 106.5 12.4 69.6 97.3 112.1 0 35.4 71.2 2227.5 236.9 63.6 24.8 17.1
Sex
Female 159 15 1718 548 85 258 0 819 41 3 15 73 926 1110
Male 168 1 2173 409 114 281 2 1099 71 4 20 139 1339 1824
Race
Hispanic 13 2 199 50 10 36 0 6 0 5 10 108 175 8123
2019 Schrom et al. Cureus 11(5): e4586. DOI 10.7759/cureus.4586 3 of 5
White 270 11 3177 743 151 411 1 1589 83 4 10 182 1866 2374
Black 20 1 202 57 11 21 0 74 14 0 8 11 126 126
Other 18 3 245 70 19 53 1 122 7 2 4 4 115 188
Admit Type
Elective 237 8 3,100 522 1 08 314 2 1,200 80 5 0 101 1,423 2,116
Emergency 62 6 412 174 30 146 0 349 18 0 0 28 201 201
Urgent 24 1 361 251 59 7 0 348 13 1 1 83 150 150
Other 4 1 18 10 2 72 0 21 1 1 34 0 491 467
Primary
Payer
Medicare 123 1 1,036 394 68 202 0 839 51 0 0 132 872 1,114
Medicaid 90 9 1,701 185 61 130 1 482 30 5 19 32 561 648
Health
Maintenance
Organization
(HMO)
22 0 175 45 11 18 0 91 5 0 1 2 2 119 114
Commercial
Insurance
46 5 494 224 35 120 1 263 10 1 10 11 418 621
Health
Service
Contractors
19 0 185 69 11 45 0 114 8 0 2 10 115 105
Other 27 1 300 40 13 24 0 129 8 1 3 5 180 332
TABLE 2: Characteristics of dermatologic procedures
USD, United States Dollar; SC, subcutaneous
Discussion
The majority (55.2%) of financial costs related to dermatologic care, including procedural costs, are
experienced in the outpatient setting [5]. While inpatient costs contribute significantly to overall healthcare
expenditures (20.1%), understanding of these costs is limited [1]. Moreover, data related to dermatologic
costs in the inpatient setting primarily focus on disease-specific aggregate costs. For example, inpatient
costs for care for psoriasis have been shown to be cost-prohibitive when compared to outpatient treatment
(13,042 € versus 2,984 €), especially when accounting for biologic therapy use [6].
This current analysis is unique in that it identifies dermatologic procedures performed during an inpatient
admission independent of dermatologic diagnosis and reveals potential factors that may be used to stratify
patients undergoing a dermatologic procedure and suggest opportunities for cost reduction. This study is
limited by its regional geographic encashment. Co-morbid diagnoses and direct cost of dermatologic
procedures could not be analyzed, and aggregate cost reporting may have overestimated the relative cost
contribution. Finally, provider specialty and level of training were not available.
Most patients received a dermatologic procedure during an elective admission and the primary payer was
either Medicare or Medicaid. Additionally, our findings support dermatologic consultation when
dermatologic procedures are considered. Diagnostic procedures recommended by an appropriately consulted
dermatologist yield a definitive diagnosis in up to 80% of cases. Moreover, 45% to 80% of diagnoses will
change after dermatology consultation preventing unnecessary therapy and costly hospital stays [7]. Finally,
dermatology consultation may also facilitate outpatient follow-up for a procedure rather than performing it
during admission.
Conclusions
2019 Schrom et al. Cureus 11(5): e4586. DOI 10.7759/cureus.4586 4 of 5
Inpatient dermatologic procedures are a significant driver of inpatient health care costs. It is critical to
determine factors that increase inpatient costs related to dermatologic procedures to develop strategies for
reducing healthcare costs. A good initial cohort for future study would be patients receiving a dermatologic
procedure during an elective admission who have Medicare or Medicaid.
Additional Information
Disclosures
Human subjects: All authors have confirmed that this study did not involve human participants or tissue.
Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue.
Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the
following: Payment/services info: All authors have declared that no financial support was received from
any organization for the submitted work. Financial relationships: All authors have declared that they have
no financial relationships at present or within the previous three years with any organizations that might
have an interest in the submitted work. Other relationships: All authors have declared that there are no
other relationships or activities that could appear to have influenced the submitted work.
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  • Schrom
Schrom et al. Cureus 11(5): e4586. DOI 10.7759/cureus.4586 5 of 5