Abstract 1122‐000065: Hospital Cost of DTAS Compared to ED Transfers for LVOs Undergoing Mechanical Thrombectomy

Author(s):  
Joshua S Catapano ◽  
Andrew Ducruet ◽  
Felipe Albuquerque ◽  
Ashutosh Jadhav

Introduction : Direct‐to‐angiography‐suite (DTAS) transfer for patients with large vessel occlusions (LVOs) undergoing mechanical thrombectomy is associated with decreased workflow times and improved neurological outcomes. Herein, we sought to demonstrate a decrease in hospital cost associated with DTAS compared to emergency department (ED) transfers for patient undergoing mechanical thrombectomy for an LVO. Methods : A retrospective analysis was performed on all patients who underwent mechanical thrombectomy for an LVO at a single comprehensive stroke center between January 1st, 2017, and March 31st, 2021. All patients who were either transferred DTAS or ED were included and compared. Total hospital cost (sum of overhead, professional, diagnostic, and room charges throughout the entire index patient admission) was obtained from the hospital financial department for the index treatment admission. A propensity adjusted (matched for age, sex, vessel occluded, co‐morbidities, BMI, admission NIHSS, access site, and use of a stent retriever) was implemented. Mean difference in hospital cost following adjustment was the primary outcome. Results : During the study period, 341 patients underwent mechanical thrombectomy for an LVO. Of these patients, 140 (41%) were transferred DTAS and 96 (28%) to the ED. There were no significant differences between cohorts in terms of age, sex, vessel occluded, admission NIHSS, co‐morbidities, number of passes, TICI score, access site, stent retriever, major complications, or in‐hospital mortality. The DTAS cohort ($33,061, sD $17,258) had a significantly lower hospital cost compared to ED transferred patients ($38,030, sD $18,572) (p = 0.04). There was no significant difference between the ED (12.2, sD 11.8) and DTAS (11.6, sD 11.1) cohorts in discharge NIHSS. Following propensity score adjustment, linear regression analysis found DTAS (compared to ED transfer) to be significantly associated with a decrease in hospital cost ($‐6,344; 95% CI: $‐11,067 to $‐1,623; p = 0.009). Conclusions : DTAS transfer for patients undergoing an acute mechanical thrombectomy for a LVO was associated with a greater than $6,000 decrease total hospital cost compared to patients first transferred to the ED. The present study further supports DTAS transfer for patients undergoing mechanical thrombectomy for LVO.

Author(s):  
Stephen Thomas ◽  
Ankur Patel ◽  
Corey Patrick ◽  
Gary Delhougne

AbstractDespite advancements in surgical technique and component design, implant loosening, stiffness, and instability remain leading causes of total knee arthroplasty (TKA) failure. Patient-specific instruments (PSI) aid in surgical precision and in implant positioning and ultimately reduce readmissions and revisions in TKA. The objective of the study was to evaluate total hospital cost and readmission rate at 30, 60, 90, and 365 days in PSI-guided TKA patients. We retrospectively reviewed patients who underwent a primary TKA for osteoarthritis from the Premier Perspective Database between 2014 and 2017 Q2. TKA with PSI patients were identified using appropriate keywords from billing records and compared against patients without PSI. Patients were excluded if they were < 21 years of age; outpatient hospital discharges; evidence of revision TKA; bilateral TKA in same discharge or different discharges. 1:1 propensity score matching was used to control patients, hospital, and clinical characteristics. Generalized Estimating Equation model with appropriate distribution and link function were used to estimate hospital related cost while logistic regression models were used to estimate 30, 60, and 90 days and 1-year readmission rate. The study matched 3,358 TKAs with PSI with TKA without PSI patients. Mean total hospital costs were statistically significantly (p < 0.0001) lower for TKA with PSI ($14,910; 95% confidence interval [CI]: $14,735–$15,087) than TKA without PSI patients ($16,018; 95% CI: $15,826–$16,212). TKA with PSI patients were 31% (odds ratio [OR]: 0.69; 95% CI: 0.51–0.95; p-value = 0.0218) less likely to be readmitted at 30 days; 35% (OR: 0.65; 95% CI: 0.50–0.86; p-value = 0.0022) less likely to be readmitted at 60 days; 32% (OR: 0.68; 95% CI: 0.53–0.88; p-value = 0.0031) less likely to be readmitted at 90 days; 28% (OR: 0.72; 95% CI: 0.60–0.86; p-value = 0.0004) less likely to be readmitted at 365 days than TKA without PSI patients. Hospitals and health care professionals can use retrospective real-world data to make informed decisions on using PSI to reduce hospital cost and readmission rate, and improve outcomes in TKA patients.


2021 ◽  
Vol 11 (4) ◽  
pp. 504
Author(s):  
Dalibor Sila ◽  
Markus Lenski ◽  
Maria Vojtková ◽  
Mustafa Elgharbawy ◽  
František Charvát ◽  
...  

Background: Mechanical thrombectomy is the standard therapy in patients with acute ischemic stroke (AIS). The primary aim of our study was to compare the procedural efficacy of the direct aspiration technique, using Penumbra ACETM aspiration catheter, and the stent retriever technique, with a SolitaireTM FR stent. Secondarily, we investigated treatment-dependent and treatment-independent factors that predict a good clinical outcome. Methods: We analyzed our series of mechanical thrombectomies using a SolitaireTM FR stent and a Penumbra ACETM catheter. The clinical and radiographic data of 76 patients were retrospectively reviewed. Using binary logistic regression, we looked for the predictors of a good clinical outcome. Results: In the Penumbra ACETM group we achieved significantly higher rates of complete vessel recanalization with lower device passage counts, shorter recanalization times, shorter procedure times and shorter fluoroscopy times (p < 0.001) compared to the SolitaireTM FR group. We observed no significant difference in good clinical outcomes (52.4% vs. 56.4%, p = 0.756). Predictors of a good clinical outcome were lower initial NIHSS scores, pial arterial collateralization on admission head CT angiography scan, shorter recanalization times and device passage counts. Conclusions: The aspiration technique using Penumbra ACETM catheter is comparable to the stent retriever technique with SolitaireTM FR regarding clinical outcomes.


2021 ◽  
Vol 10 (9) ◽  
pp. 1802
Author(s):  
Grzegorz Meder ◽  
Paweł Żuchowski ◽  
Wojciech Skura ◽  
Violetta Palacz-Duda ◽  
Milena Świtońska ◽  
...  

Endovascular treatment is a rapidly evolving technique; therefore, there is a constant need to evaluate this method and its modifications. This paper discusses a single-center experience and the results of switching from the stent retriever only (SO) mechanical thrombectomy (MT) to the combined approach (CA), with a stent retriever and aspiration catheters. Methods: The study involved a retrospective analysis of 70 patients undergoing MT with the use of either SO or CA. The primary endpoint was the frequency of perfect reperfusion defined as grade 3 of the modified Thrombolysis in Cerebral Infarction scale (mTICI) after the first pass. The secondary endpoints were the procedure success, defined as mTICI grades 2b-3; time of the procedure; clinical outcome, measured by 90 days’ modified Rankin Scale (mRS) score; Δ NIHSS, defined as the difference between National Institutes of Health Stroke Scale (NIHSS) score at patients’ admission and discharge; and the total number of device passes. Results: Out of the 70 patients included, 33 were treated with SO and 37 with CA. In both groups, a total number of 42 patients received intravenous recombined tissue plasminogen activator (iv-rTPA: 20 patients (60.6%) in the SO group and 22 patients (59.5%) in the CA group (p = 1.000). There was a significant difference between the groups regarding first-pass success rate, with 46% in the CA group and 18% in the SO group, (OR 3.83, 95% CI 1.28 to 11.44, p = 0.016). Complete procedure success tended to be more frequent in the CA group than in the SO group—94.6% vs. 84.8% (OR 3.13, 95% CI 0.56 to 17.34, p = 0.193)—and CA tended to require a lower number of passes than SO (mean 1.76 vs. 2.09 passes per procedure, p = 0.114), yet these differences did not reach statistical significance. Mean duration of the procedure was significantly shorter in the CA group than in the SO group (49 min vs. 64 min, p = 0.017). There was a significant difference in clinical outcomes, with higher Δ NIHSS (9.3 in the CA group vs. 6.7 in the SO group, p = 0.025) after the procedure and 90-day mRS (median 2 in the CA group vs. 4 in the SO group, p = 0.031). Conclusions: Combining stent retrievers with aspiration catheters may offer a beneficial effect on angiographic results and clinical outcomes in stroke patients undergoing endovascular treatment.


Author(s):  
Eileen Fonseca ◽  
David R Walker ◽  
Gregory P Hess

Background: Warfarin and dabigatran etexilate (DE) are oral anticoagulants (OAC) used to reduce the risk of stroke among patients with nonvalvular atrial fibrillation (AF). However, DE does not require titration and INR monitoring. This study examined whether hospital length of stay (LOS) and total hospital costs differed between the two therapies among treatment-naive, newly-diagnosed AF patients. Methods: LOS and total hospital costs were evaluated for hospitalizations with a primary or secondary discharge diagnosis of atrial fibrillation (AF) between 1/1/2011-3/31/2012, with DE or warfarin administered during hospitalization, and excluding hospitalizations of patients with valvular AF, previously diagnosed with AF, or previously treated with OAC. Hospitalizations were identified from a Charge Detail Masters database containing 397 qualified hospitals. Samples were propensity score matched using nearest neighbor within a caliper of 0.20 standard deviations of the logit, without replacement and a 2:1 match. Differences in LOS and hospital cost were then estimated using generalized linear models, fitted by generalized estimating equations (clustered by hospital) to account for possible correlation between observations. The hospitalization’s charged amount was multiplied by the hospital’s inpatient cost-to-charge ratio to estimate the total hospital cost. Covariates estimating the propensity score, LOS, and costs included patient age, payer type, CHADS 2 and HAS-BLED scores, use of bridging agents, comorbid conditions, and hospital attributes. As a sensitivity analysis, LOS and costs were estimated with the same parameters and covariates among the raw, unbalanced sample. Results: Matched samples included 1,292 warfarin and 646 DE hospitalizations of treatment-naive, newly diagnosed patients out of 4,619 and 715 hospitalizations, respectively. No covariates used in matching had standardized mean differences > 10% after matching. Two comorbidities (thromboembolism, coronary artery disease) had statistically different distributions after matching (DE: 3% vs. warfarin: 8%, p<0.001 and DE: 40% vs. warfarin: 45%, p=0.048); these were included as model covariates. Among the sample, DE had an estimated 0.7 days shorter stay compared to warfarin (DE: 4.8 days vs. warfarin: 5.5 days, p<0.01) and a $2,031 lower estimated total cost (DE: $14,794 vs warfarin: $16,826, p=0.007). Sensitivity analysis confirmed a shorter DE LOS (DE: 5.5 days vs. warfarin: 6.6 days, delta=1.1 days, p<0.01) and a lower DE hospital cost (DE: $18,362 vs. warfarin: $22,602, delta=$4,240, p<0.01). Conclusions: Among hospitalizations of treatment-naive patients newly diagnosed with nonvalvular AF, the hospitalizations during which DE was administered had a shorter LOS and at least a 12% lower total hospital cost compared to hospitalizations where warfarin was administered.


Author(s):  
Ashutosh Mahapatra ◽  
Yasaman Moazeni ◽  
Thomas Patterson ◽  
Ramez Abdalla ◽  
Jenny Tsai ◽  
...  

Introduction : Mechanical thrombectomy for large‐vessel acute ischemic stroke has been adopted as the standard of care treatment across the world, with dramatic improvements in long‐term functional outcomes for an otherwise debilitating disease process. Timely and complete recanalization are paramount in achieving good outcomes. Though several revascularization techniques have been described, direct contact aspiration and clot removal via stent‐retriever remain the foundation of endovascular stroke therapy. Utilizing the NeuroVascular Quality Initiative – Quality Outcomes Database (NVQI‐QOD), we present our data on real‐world, first‐line practice for treatment of large vessel occlusions (LVOs), and compare angiographic and clinical outcomes between direct contact aspiration and stent‐retriever mechanical thrombectomy techniques. Methods : Retrospective analysis of the NVQI‐QOD was performed. We included patients with LVOs that underwent mechanical thrombectomy who were older than 18 and whose baseline NIHSS ≥ 6. We compared procedural times, rate of revascularization, and outcomes, including in‐hospital mortality and discharge NIHSS. Results : We identified a total of 2381 patients who met the inclusion criteria, of which 998 (41.9%) underwent treatment with direct contact aspiration alone and 1383 (58.1%) underwent treatment utilizing a stent‐retriever (with or without local aspiration). There were no significant differences in the baseline median NIHSS scores (16 vs 17, p = 0.25) or baseline median ASPECTS scores (9 vs 9, p = 0.7). No significant difference was seen in time metrics, including last known well to puncture (282 min vs. 280 min, p = 0.22) or recanalization (323 min vs. 322 min, p = 0.39), ED to puncture (75 min vs. 71 min, p = 0.25) or recanalization (158 min vs. 160 min, p = 0.55), or median procedure times between the two groups (23 vs 23 min, p = 0.64). The median number of passes required for recanalization was lower in the direct aspiration group (1 vs 2, p = 0.01). Though there was no difference in successful recanalization (TICI 2B‐3) between the two groups (86.1% vs 88%, p = 0.71), there was a lower rate of complete recanalization (TICI 2C‐3) in the direct aspiration group (46% vs 51.7%, p = 0.007). There was also a lower rate of adjunct treatments (defined as the use of GP IIb/IIIa inhibitors, P2Y12 inhibitors, and/or salvage angioplasty and/or stenting) required in the direct contact aspiration group (36.1% vs 44.4%, p < 0.001). There were no differences noted in discharge NIHSS scores (5 vs 4, p = 0.21) or in‐hospital mortality (22.2% vs 22.5%, p = 0.92). Conclusions : In the NVQI‐QOD, stent‐retriever techniques were associated with higher rates of complete recanalization when compared to direct contact aspiration alone, although acceptable (TICI 2B‐3) recanalization rates were similar. There were no statistically significant differences in procedure times or clinical outcomes at discharge.


Author(s):  
Joshua S Catapano ◽  
Andrew Ducruet ◽  
Felipe C Albuquerque ◽  
Ashutosh Jadhav

Introduction : The transradial artery (TRA) approach for neuroendovascular procedures has been demonstrated as a safe and effective alternative to the transfemoral artery (TFA) approach. The present study compares the efficiency and periprocedural outcomes of the TRA and TFA approach for acute stroke interventions in patients receiving intravenous alteplase. Methods : The study was designed as a retrospective analysis of patients who underwent acute mechanical thrombectomy at a large cerebrovascular center between January 2014 and March 2021. Intervention cohorts (TRA and TFA) were compared on baseline characteristics, periprocedural efficiency/efficacy, and in‐hospital outcomes. Results : A total of 314 patients underwent acute mechanical thrombectomy following IV tPA via TRA (6.7%, 21/314) or TFA (93.3%, 293/314) approach. The overall complication rate appeared higher in TFA (6.8%, 20/314) compared to TRA (4.8%,1/21) patients. Access site complications were present in 4.1%(12/293) of TFA patients and 0.0%(0/21) of TRA patients. The average length of stay (days ± standard deviation) was significantly greater in TFA (8.8 ± 8.5) vs. TRA (4.8 ± 2.9) patients (P = 0.02). Linear regression analysis found femoral access (p = 0.046), Medicaid (p = 0.004) insurance, and discharge NIHSS >10 (p = 0.045) as predictors of increased length of stay. However, when time to initial physical/occupation session was added to the model, access site was no longer significant. Conclusions : The TRA (vs. TFA) approach for acute stroke interventions following IV tPA administration may potentially reduce periprocedural complications and hospital length of stay. The reduction in length of stay with TRA access appears to be associated with earlier initiation of therapies.


2019 ◽  
Vol 131 (3) ◽  
pp. 903-910 ◽  
Author(s):  
Jian Guan ◽  
Michael Karsy ◽  
Andrea A. Brock ◽  
William T. Couldwell ◽  
John R. W. Kestle ◽  
...  

OBJECTIVEOverlapping surgery remains a controversial topic in the medical community. Although numerous studies have examined the safety profile of overlapping operations, there are few data on its financial impact. The authors assessed direct hospital costs associated with neurosurgical operations during periods before and after a more stringent overlapping surgery policy was implemented.METHODSThe authors retrospectively reviewed the records of nonemergency neurosurgical operations that took place during the periods from June 1, 2014, to October 31, 2014 (pre–policy change), and from June 1, 2016, to October 31, 2016 (post–policy change), by any of the 4 senior neurosurgeons authorized to perform overlapping cases during both periods. Cost data as well as demographic, surgical, and hospitalization-related variables were obtained from an institutional tool, the Value-Driven Outcomes database.RESULTSA total of 625 hospitalizations met inclusion criteria for cost analysis; of these, 362 occurred prior to the policy change and 263 occurred after the change. All costs were reported as a proportion of the average total hospitalization cost for the entire cohort. There was no significant difference in mean total hospital costs between the prechange and postchange period (0.994 ± 1.237 vs 1.009 ± 0.994, p = 0.873). On multivariate linear regression analysis, neither the policy change (p = 0.582) nor the use of overlapping surgery (p = 0.273) was significantly associated with higher total hospital costs.CONCLUSIONSA more restrictive overlapping surgery policy was not associated with a reduction in the direct costs of hospitalization for neurosurgical procedures.


1998 ◽  
Vol 31 ◽  
pp. 172-173 ◽  
Author(s):  
W.S. Weintraub ◽  
S. Connolly ◽  
D. Canup ◽  
C. Deaton ◽  
S. Culler ◽  
...  

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Shabnam Nasserifar ◽  
Kam Sing Ho

Abstract PURPOSE: To determine the relationship between diabetes and thirty-days readmission, mortality, morbidity, and health care resource utilization in patients who were admitted with ST-Elevation Myocardial Infarction (STEMI) in the United States. METHOD: A retrospective study was conducted using the AHRQ-HCUP Nationwide Readmission Database for the year 2014. Adults (≥ 18 years) with a primary diagnosis of STEMI (1), along with a secondary diagnosis of diabetes were identified using ICD-9 codes as described in the literature (2). The primary outcome was the rate of all-cause readmission within 30 days of discharge. Secondary outcomes were reasons for readmission, readmission mortality rate, morbidity, and resource use (length of stay and total hospitalization costs and charges). Propensity score (PS) using the 1:1 nearest neighbor matching without replacement was utilized to adjust for confounders (3). Independent risk factors for readmission were identified using a Cox proportional hazards model (4). RESULTS: In total, 116,124 hospital admissions among adults with a primary diagnosis of STEMI were identified, of which 18.05% were diabetics. 1:1 PS matching was performed based on demographic (age, gender, hospital status, etc.) and clinical characteristics (Charlson comorbidity score. The 30-day rate of readmission among diabetics and non-diabetics with STEMI were 9.31% vs. 6.18% (p &lt;0.001). The most common readmission for both groups was recurrent myocardial infarction. During the index admission for STEMI, the length of stay (LOS) among diabetics and non-diabetics patients were not statistically different (4.74 vs 4.58 days, p=0.12). However, the total hospital cost for the diabetic patients was statistically different ($27,027 vs $24,807, p &lt;0.001). Most importantly, diabetics patients’ in-hospital mortality rate during their index admission was significant higher (10.20% vs 5.92%, p &lt;0.001). Amongst those readmitted, the LOS, total hospital cost, or in-hospital mortality among diabetics were not statistically different when compared to their counterparts during their readmission. Diabetes (HR 1.60, CI 1.27-2.02, p &lt;0.001) was an independent predictor associated with higher risks of readmission. Other independent predictors associated with increased 30-day readmission include acute exacerbation of CHF, acute exacerbation of COPD, acute kidney injury, secondary diagnosis of pneumonia, history of COPD, history of ischemic stroke, history of atrial fibrillation & atrial flutter, history of chronic kidney disease, history of iron deficiency, and use of mechanical ventilator. CONCLUSION: In this study, diabetics patients admitted with STEMI have a higher 30 days of readmission rate, total hospital cost, and in-hospital mortality (p &lt;0.001) than their non-diabetic counterparts.


2021 ◽  
Vol 116 (1) ◽  
pp. S517-S518
Author(s):  
Rajesh Essrani ◽  
Muhammad Usman Zafar ◽  
Zahid I. Tarar ◽  
Umer Farooq ◽  
Jiten Kothadia

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