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In a population-based study, we examined time trends in chronic liver disease (CLD)-related hospitalizations in a large and diverse metroplex. We examined all CLD-related inpatient encounters (2000-2015) in Dallas-Fort Worth (DFW) using data from the DFW council collaborative that captures claims data from 97% of all hospitalizations in DFW (10.7 million regional patients). There were 83,539 CLD-related hospitalizations in 48,580 unique patients across 84 hospitals. The age and gender standardized annual rate of CLD-related hospitalization increased from 48.9 per 100,000 in 2000 to 125.7 per 100,000 in 2014. Mean age at hospitalization increased from 54.0 (14.1) to 58.5 (13.5) years; the proportion of CLD patients above 65 years increased from 24.2% to 33.1%. HCV-related hospitalizations plateaued, whereas an increase was seen in hospitalizations related to alcohol (9.1 to 22.7 per 100,000) or fatty liver (1.4 per 100,000 to 19.5 per 100,000). The prevalence of medical comorbidities increased for CLD patients: coronary artery disease (4.8% to 14.3%), obesity (2.8% to 14.6%), chronic kidney disease (2.8% to 18.2%), and diabetes (18.0% to 33.2%). Overall hospitalizations with traditional complications of portal hypertension (ascites, varices, and peritonitis) remained stable over time. However, hospitalization with complications related to infection increased from 54.7% to 66.4%, and renal failure increased by sevenfold (2.7% to 19.5%). CLD-related hospitalizations have increased twofold over the last decade. Hospitalized CLD patients are older and sicker with multiple chronic conditions. Traditional complications of portal hypertension have been superseded by infection and renal failure, warranting a need to redefine what it means to have decompensated CLD.

A better understanding of the consequences of spine surgery complications is warranted to optimize patient-reported outcomes and contain the rising health care costs associated with the management of adult spinal deformity (ASD). We systematically searched PubMed and Scopus databases using keywords “adult spinal deformity surgery,” “complications,” and “cost” for published studies on costs of complications associated with spinal surgery, with a particular emphasis on ASD and scoliosis. In the 17 articles reviewed, we identified 355,354 patients with 11,148 reported complications. Infection was the most commonly reported complication, with an average treatment cost ranging from$15,817 to $ 38,701. Hospital costs for patients with deep venous thrombosis, pulmonary thromboembolism, and surgical site infection were 2.3 to 3.1 times greater than for patients without those complications. An effort to collect and characterize data on cost of complications is encouraged, which may help health care providers to identify potential resources to limit complications and overall costs.

Objective: Our objectives were two-fold: 1) To evaluate the benefits of population health strategies focused on social de­terminants of health and integrated into the primary care medical home (PCMH) and 2) to determine how these strategies impact diabetes and cardiovascular disease outcomes among a low-income, primarily minority community. We also investigated associations between these outcomes and emergency department (ED) and inpatient (IP) use and costs.Design: Retrospective cohort.Setting: Community-based PCMH: Baylor Scott & White Health and Wellness Center (BSW HWC).Patients/Participants: All patients who attended at least two primary care visits at BSW HWC within a 12-month time span from 2011-2015.Methods: Outcomes for patients participat­ing in PCMH only (PCMH) as compared to PCMH plus population health services (PCMH+PoPH) were compared using elec­tronic health record data.Main Outcomes: Diastolic and systolic blood pressure, hemoglobin A1c, ED visits and costs, and IP hospitalizations and costs were examined.Results: From 2011-2015, 445 patients (age=46±12 years, 63% African American, 61% female, 69.5% uninsured) were includ­ed. Adjusted regression analyses indicated PCMH+PoPH had greater improvement in diabetes outcomes (prediabetes HbA1c= -.65[SE=.32], P=.04; diabetes HbA1c= -.74 [SE=.37], P<.05) and 37% lower ED costs than the PCMH group (P=.01). Worsening chronic disease risk factors was associated with 39% higher expected ED visits (P<.01), whereas improved chronic disease risk was associated with 32% fewer ED visits (P=.04).Conclusions: Integrating population health services into the PCMH can improve chron­ic disease outcomes, and impact hospital utilization and cost in un- or under-insured populations. Ethn Dis. 2022;32(2):91-100; doi:10.18865/ed.32.2.91

Abstract Background Global metabolic dysfunction-associated steatotic liver disease (MASLD) prevalence is estimated at 30% and projected to reach 55.7% by 2040. In the Veterans Affairs (VA) healthcare system, an estimated 1.8 million veterans have metabolic dysfunction-associated steatohepatitis (MASH). Methods Adult patients at risk for MASLD in a VA healthcare system underwent Fibrosis-4 (FIB-4) and Enhanced Liver Fibrosis (ELF®) testing. Referral rates and cost savings were compared among 6 noninvasive testing (NIT) strategies using these 2 tests independently or sequentially at various cutoffs. Results Enrolled patients (N = 254) had a mean age of 65.3 ± 9.3 years and mean body mass index (BMI) of 31.7 ± 6, 87.4% male: 78.3% were non-Hispanic/Latino, and 96.5% had type 2 diabetes mellitus (T2DM). Among the 6 evaluated strategies, using FIB-4 followed by ELF at a 9.8 cutoff yielded the highest proportion of patients retained in primary care without need of referral to hepatology clinic (165/227; 72.7%), and was associated with the lowest costs ($407.62). Compared to the FIB-4 only strategy, FIB-4/ELF with a 9.8 cutoff strategy resulted in 26% fewer referrals and 8.47% lower costs. In the subgroup of patients with BMI >32, there were 25.17% fewer referrals and costs were 8.31% lower. Conclusions Our study suggests that sequential use of ELF with a 9.8 cutoff following indeterminate FIB-4 tests results in lower referral rates and lower care costs in a veteran population at risk of MASLD. Adding ELF as a sequential test after indeterminate FIB-4 might help reduce the number of referrals and overall cost of care.

BackgroundPrior studies of early antibiotic use and growth have shown mixed results, primarily on cross-sectional outcomes. This study examined the effect of oral antibiotics before age 24 months on growth trajectory at age 2–5 years.MethodsWe captured oral antibiotic prescriptions and anthropometrics from electronic health records through PCORnet, for children with ≥1 height and weight at 0–12 months of age, ≥1 at 12–30 months, and ≥2 between 25 and 72 months. Prescriptions were grouped into episodes by time and by antimicrobial spectrum. Longitudinal rate regression was used to assess differences in growth rate from 25 to 72 months of age. Models were adjusted for sex, race/ethnicity, steroid use, diagnosed asthma, complex chronic conditions, and infections.Results430,376 children from 29 health U.S. systems were included, with 58% receiving antibiotics before 24 months. Exposure to any antibiotic was associated with an average 0.7% (95% CI 0.5, 0.9, p < 0.0001) greater rate of weight gain, corresponding to 0.05 kg additional weight. The estimated effect was slightly greater for narrow-spectrum (0.8% [0.6, 1.1]) than broad-spectrum (0.6% [0.3, 0.8], p < 0.0001) drugs. There was a small dose response relationship between the number of antibiotic episodes and weight gain.ConclusionOral antibiotic use prior to 24 months of age was associated with very small changes in average growth rate at ages 2–5 years. The small effect size is unlikely to affect individual prescribing decisions, though it may reflect a biologic effect that can combine with others.

Introduction:Infants with single ventricle following stage I palliation are at risk for poor nutrition and growth failure. We hypothesise a standardised enteral feeding protocol for these infants that will result in a more rapid attainment of nutritional goals without an increased incidence of gastrointestinal co-morbidities.Materials and methods:Single-centre cardiac ICU, prospective case series with historical comparisons. Feeding cohort consisted of consecutive patients with a single ventricle admitted to cardiac ICU over 18 months following stage I palliation (n = 33). Data were compared with a control cohort and admitted to the cardiac ICU over 18 months before feeding protocol implementation (n = 30). Feeding protocol patients were randomised: (1) protocol with cerebro-somatic near-infrared spectroscopy feeding advancement criteria (n = 17) or (2) protocol without cerebro-somatic near-infrared spectroscopy feeding advancement criteria (n = 16).Results:Median time to achieve goal enteral volume was significantly higher in the control compared to feeding cohort. There were no significant differences in enteral feeds being held for feeding intolerance or necrotising enterocolitis between cohorts. Feeding cohort had significant improvements in discharge nutritional status (weight, difference admit to discharge weight, weight-for-age z score, volume, and caloric enteral nutrition) and late mortality compared to the control cohort. No infants in the feeding group with cerebro-somatic near-infrared spectroscopy developed necrotising enterocolitis versus 4/16 (25%) in the feeding cohort without cerebro-somatic near-infrared spectroscopy (p = 0.04).Conclusions:A feeding protocol is a safe and effective means of initiating and advancing enteral nutrition in infants following stage I palliation and resulted in improved nutrition delivery, weight gain, and nourishment status at discharge without increased incidence of gastrointestinal co-morbidities.

Objective: Firefighters (FFs) are chronically exposed to smoke and products of incomplete combustion, which frequently contain polycyclic aromatic hydrocarbons (PAHs). This study examined the possibility of an association between PAH-induced epigenetic alterations and occupational firefighting exposure. Methods: Promoter methylation was analyzed in four genes in blood DNA from 18 FFs and 20 non-FFs(controls). Jurkat and human normal prostate epithelial cells were treated with benzo[a]pyrene to ascertain the epigenetic effects of this type of agent. Results: Firefighters had a higher prevalence of dual specificity phosphatase 22-promoter hypomethylation in blood DNA (P = 0.03) and the extent of hypomethylation correlated with duration of firefighting service (P = 0.04) but not with age. Benzo[a]pyrene reduced promoter methylation and increased gene expression of the same gene in Jurkat and normal prostate epithelial cells. Conclusions: Cumulative occupational exposure to combustion-derived PAHs during firefighting can cause epigenetic changes in promoters of specific genes.

Abstract INTRODUCTION CMS has recently implemented 90-day cost bundles for joint replacement surgery, and taken steps to expand bundled payment programs. Our goal is to determine the 90-day costs associated with cervical spinal deformity cases across two major spinal deformity centers in order to guide the development of reasonable bundled payment plans. METHODS Retrospective evaluation of adults who underwent cervical deformity surgery 2013–2016 at two major spinal deformity centers (UCSF, Baylor). Inclusion criteria included adult patients with cervical kyphosis (C2-7 Cobb angle >10°°) or cervical scoliosis (coronal Cobb able >10°). Direct hospital costs for the index surgery and all visits within the first 90 days after surgery were determined from hospital billing data. Direct costs include surgical supplies/implants, room/care, pharmacy; they exclude indirect costs like overhead, administration, and utilities. RESULTS >38 patients (25F, 13M; mean age = 60.4 ± 9.8 years) underwent fusions for cervical deformity. 29 procedures were posterior, 1 anterior, 7 anterior-posterior, and 1 posterior-anterior-posterior. Average number of levels fused was 9.3 ± 3.3. Average direct hospital cost for the 90-day period including surgery was $64,480 ± 23,816, and was similar between institutions ($62,569 versus $70,638). 4 of 38 patients (10.5%) were re-admitted within 90-days: re-admission costs constitute the majority of these patients' post-index surgery costs. 2 of 38 (5.3%) patients had catastrophic 90-day costs, greater than two standard deviations above the mean (>$112,112). CONCLUSION The average 90-day direct hospital costs for patients undergoing cervical deformity surgery are $64,480. Readmissions and a greater number of operated levels contribute to higher costs; reasonable 90-day cost bundle plans must account for both of these issues. A limitation is that our analysis includes costs at our main hospital only; it does not include post-operative outpatient medications, physical therapy, rehabilitation, or admissions to outside hospitals. It is therefore imperative that further studies utilizing national databases are performed to understand the full scope of 90-day costs.

Purpose Adult spinal deformity (ASD) patients with sagittal plane deformity (N) or structural lumbar/thoraco-lumbar (TL) curves can be treated with fusions stopping at the TL junction or extending to the upper thoracic (UT) spine. This study evaluates the impact on cost/cumulative quality-adjusted life year (QALY) in patients treated with TL vs UT fusion. Methods ASD patients with > 4-level fusion and 2-year follow-up were included. Index and total episode-of-care costs were estimated using average itemized direct costs obtained from hospital records. Cumulative QALY gained were calculated from preoperative to 2-year postoperative change in Short Form Six-Dimension (SF-6D) scores. The TL and UT groups comprised patients with upper instrumented vertebrae (UIV) at T9-T12 and T2-T5, respectively. Results Of 566 patients with type N or L curves, mean age was 63.2 ± 12.1 years, 72% were female and 93% Caucasians. Patients in the TL group had better sagittal vertical axis (7.3 ± 6.9 vs. 9.2 ± 8.1 cm, p  = 0.01), lower surgical invasiveness (− 30; p  < 0.001), and shorter OR time (− 35 min; p  = 0.01). Index and total costs were 20% lower in the TL than in the UT group ( p  < 0.001). Cost/QALY was 65% lower (492,174.6 vs. 963,391.4), and 2-year QALY gain was 40% higher, in the TL than UT group (0.15 vs. 0.10; p  = 0.02). Multivariate model showed TL fusions had lower total cost (p = 0.001) and higher QALY gain ( p  = 0.03) than UT fusions. Conclusion In Schwab type N or L curves, TL fusions showed lower 2-year cost and improved QALY gain without increased reoperation rates or length of stay than UT fusions. Level of evidence III.

Study designRetrospective multicenter cost analysis.ObjectiveTo (1) determine if index episode of care (iEOC) costs of Adult Spinal Deformity (ASD) surgeries are below the Medicare Allowable (MA) threshold, and (2) identify variables that can predict iEOC cases that are below MA.Summary of background dataPrevious studies have suggested that actual direct hospital cost of Adult Spinal Deformity (ASD) surgery is higher than Medicare Allowable (MA) rates, which has become the benchmark reimbursement target for hospital accounting systems.MethodsFrom a prospective, multicenter ASD surgical database, patients undergoing long instrumented fusions (> 5 level) with cost data were identified. iEOC cost was calculated utilizing actual direct hospital cost. MA rates were calculated using hospital specific, year-appropriate CMS Inpatient Pricer Payment System. Recursive partitioning identified potentially modifiable variables that can predict iEOC cost < MA.ResultsAdministrative direct cost data from 210 patients were obtained from 4 of 11 centers. Ninety-five (45%) patients had iEOC cost < MA. There was significant variation across the four centers in both iEOC cost ( $56,788–$ 78,878, p < 0.0001) and reimbursement ( $40,623–$ 91,351, p < 0.0001) across deformity-specific DRGs (453,454,456,457). Academic centers were more likely to have iEOC costs < MA (67.2% vs 8.9%, p < 0.0001). Recursive partitioning (r2 = 0.309) identified rhBMP-2 use of < 24 mg, sagittal plane deformity, a combined anterior/posterior approach, and an SF36-MCS < 39 as predictive for iEOC cost < MA. Performing an anterior/posterior approach reimburses between 14.7% and 121.1% more (2.2-fold) than posterior-only approach. This change in DRG allows iEOC cost to be more likely below the MA threshold.ConclusionThere is significant institutional (private vs academic) variation in ASD reimbursement. BMP use, deformity type, approach, and baseline mental health impact ASD surgery cost being below Medicare reimbursement. ASD surgeries with anterior/posterior approaches are in DRGs that can potentially reimburse 2.2-fold the posterior-only surgery, making it more likely to fall below the MA threshold.Level of evidenceIII.