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Background: Falls can result in injuries that require rehabilitation and long-term care after hospital discharge. Identifying factors that contribute to prediction of discharge disposition is crucial for efficient resource utilization and reducing cost. Several factors may influence discharge location after hospitalization for a fall. The aim of this study was to examine clinical and non-clinical factors that may predict discharge disposition after a fall. We hypothesized that age, injury type, insurance type, and functional status would affect discharge location., Methods: This two-year retrospective study was performed at an urban, adult level-1 trauma center. Fall patients who were discharged home or to a facility after hospital admission were included in the study. Data was obtained from the trauma registry and electronic medical records. Logistic regression modeling was used to assess independent predictors., Results: A total of 1,121 fallers were included in the study. 621 (55.4%) were discharged home and 500 (44.6%) to inpatient rehabilitation (IRF)/skilled nursing facility (SNF). The median age was 64 years (IQR: 49-79) and 48.4% (543) were male. The median length of hospital stay was 5 days (IQR: 2.5-8). Increasing age (p < 0.001), length of stay in the ICU (p < 0.001), injury severity (p < 0.001), number of comorbidities (p = 0.038), having Medicare insurance (p = 0.025), having a fracture at any body region (p < 0.001), and ambulation status (p = 0.025) significantly increased the odds of being discharged to IRF/SNF compared to home. The removal of injury severity score and ICU length of stay from the "late/regular discharge" model, to create an "early discharge" model, decreased the accuracy of the prediction rate from 78.5% to 74.9% (p < 0.001)., Conclusion: A combination of demographic, clinical, social, economic, and functional factors can together predict discharge disposition after a fall. The majority of these factors can be assessed early in the hospital stay, which may facilitate a timely discharge plan and shorter stays in the hospital., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Objectives: This study aimed to examine the 30-day unplanned readmissions rate, predictors of readmission, causes of readmissions, and clinical impact of readmissions after percutaneous coronary intervention (PCI)., Background: Unplanned rehospitalizations following PCI carry significant burden to both patients and the local health care economy and are increasingly considered as an indicator of quality of care., Methods: Patients undergoing PCI between 2013 and 2014 in the U.S. Nationwide Readmission Database were included. Incidence, predictors, causes, and cost of 30-day unplanned readmissions were determined., Results: A total of 833,344 patients with PCI were included, of whom 77,982 (9.3%) had an unplanned readmission within 30 days. Length of stay for the index PCI was greater (4.7 vs. 3.9 days) and mean total hospital cost ($23,211 vs. $37,524) was higher for patients who were readmitted compared with those not readmitted. The factors strongly independently associated with readmissions were index hospitalization discharge against medical advice (odds ratio [OR]: 1.91; 95% confidence interval [CI]: 1.65 to 2.22), transfer to short-term hospital for inpatient care (OR: 1.62; 95% CI: 1.38 to 1.90), discharge to care home (OR: 1.57; 95% CI: 1.51 to 1.64), and chronic kidney disease (OR: 1.50; 95% CI: 1.44 to 1.55). Charlson Comorbidity Index score (OR: 1.28; 95% CI: 1.27 to 1.29) and number of comorbidities (OR: 1.18; 95% CI: 1.17 to 1.18) were independently associated with unplanned readmission. The majority of readmissions were due to noncardiac causes (56.1%)., Conclusions: Thirty-day readmissions after PCI are relatively common and relate to baseline comorbidities and place of discharge. More than one-half of the readmissions were due to noncardiac causes., (Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Prior studies suggest that low-risk ST-segment-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention can be considered for early discharge. We describe the implementation of an STEMI risk score to decrease cost while maintaining optimal patient outcomes., Methods and Results: We determined the impact of risk-guided STEMI care on healthcare value through the retrospective application of the Zwolle Risk Score to 967 patients receiving primary percutaneous coronary intervention between 2009 and 2011. Of these patients, 540 (56%) were categorized as low risk, indicating they may be safely triaged directly to a telemetry unit rather than the intensive care unit and targeted for early discharge. We subsequently developed and implemented a modified Zwolle Risk Calculator into the electronic medical record to support application of the fast-track protocol for low-risk STEMI patients. Among 549 prospective patients with STEMI, 62% were low risk, and the fast-track protocol was followed in 75% of cases. Prospective results confirmed lower rates of complications (low risk 8.3% versus high risk 38.7%; P <0.001) and in-hospital mortality (low risk 0.4% versus High risk 12.5%; P <0.001) in the low-risk cohort. Low-risk patients had a shorter median length of stay (median and [25th, 75th percentiles]: low risk 2 [2, 3] versus high risk: 3 [2, 6]; P <0.001) and lower overall costs (low risk $6720 [$5280-$9030] versus high risk $11 783 [$7953-$25 359]; P <0.001). Low-risk patients treated on-protocol had shorter median length of stay (on-protocol 2 [1, 2] versus off-protocol 2 [2, 3]; P <0.001) and hospital costs (on-protocol $6090 [$4730, $7356] versus off-protocol $11 783 [$7953, $25 359]; P <0.001) than those treated off-protocol. On-protocol low-risk patients in the prospective cohort also had lower costs and shorter length of stay than low-risk patients in the retrospective cohort ( P <0.001 for both)., Conclusions: In our study, risk-guided triage and discharge after primary percutaneous coronary intervention for STEMI improved healthcare value by reducing costs of care without compromising quality of care or patient outcomes., (© 2018 American Heart Association, Inc.)

Background: As healthcare costs rise, home health care represents an opportunity to reduce preventable adverse events and costs following hospital discharge. No studies have investigated the utility of home health care within the context of a large and diverse patient population., Methods: A retrospective cohort study was conducted between 1/1/2013 and 6/30/2015 at a single tertiary care institution to assess healthcare utilization after discharge with home health care. Control patients discharged with "self-care" were matched by propensity score to home health care patients. The primary outcome was total healthcare costs in the 365-day post-discharge period. Secondary outcomes included follow-up readmission and death. Multivariable linear and Cox proportional hazards regression were used to adjust for covariates., Results: Among 64,541 total patients, 11,266 controls were matched to 6,363 home health care patients across 11 disease-based Institutes. During the 365-day post-discharge period, home health care was associated with a mean unadjusted savings of $15,233 per patient, or $6,433 after adjusting for covariates (p < 0.0001). Home health care independently decreased the hazard of follow-up readmission (HR 0.82, p < 0.0001) and death (HR 0.80, p < 0.0001). Subgroup analyses revealed that home health care most benefited patients discharged from the Digestive Disease (death HR 0.72, p < 0.01), Heart & Vascular (adjusted savings of $11,453, p < 0.0001), Medicine (readmission HR 0.71, p < 0.0001), and Neurological (readmission HR 0.67, p < 0.0001) Institutes., Conclusions: Discharge with home health care was associated with significant reduction in healthcare utilization and decreased hazard of readmission and death. These data inform development of value-based care plans., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: The objective was to test the hypothesis that in-hospital outcomes are worse among children admitted during a return ED visit than among those admitted during an index ED visit., Methods: This was a retrospective analysis of ED visits by children age 0 to 17 to hospitals in Florida and New York in 2013. Children hospitalized during an ED return visit within 7 days were classified as "ED return admissions" (discharged at ED index visit and admitted at return visit) or "readmissions" (admission at both ED index and return visits). In-hospital outcomes for ED return admissions and readmissions were compared to "index admissions without return admission" (admitted at ED index visit without 7-day return visit admission)., Results: Among 1,886,053 index ED visits to 321 hospitals, 75,437 were index admissions without return admission, 7,561 were ED return admissions, and 1,333 were readmissions. ED return admissions had lower intensive care unit admission rates (11.0% vs. 13.6%; adjusted odds ratio = 0.78; 95% confidence interval [CI] = 0.71 to 0.85), longer length of stay (3.51 days vs. 3.38 days; difference = 0.13 days; incidence rate ratio = 1.04; 95% CI = 1.02 to 1.07), but no difference in mean hospital costs (($7,138 vs. $7,331; difference = -$193; 95% CI = -$479 to $93) compared to index admissions without return admission., Conclusions: Compared with children who experienced index admissions without return admission, children who are initially discharged from the ED who then have a return visit admission had lower severity and similar cost, suggesting that ED return visit admissions do not involve worse outcomes than do index admissions., (© 2017 by the Society for Academic Emergency Medicine.)

Background: We aimed to characterize variability in cost after straightforward orthotopic liver transplant (OLT)., Methods: Using the University HealthSystem Consortium and Scientific Registry of Transplant Recipients databases, we identified patients who underwent OLT between 2011 and 2014. Patients meeting criteria for straightforward OLT, defined as length of stay < 14 days with discharge to home, were selected (n = 5763) and grouped into tertiles (low, medium, high) according to cost of perioperative stay., Results: Patients undergoing straightforward OLT were of similar demographics regardless of cost. High cost patients were more likely to require preoperative hemodialysis, had higher severity of illness, and higher model for end-stage liver disease (MELD) (p < 0.01). High cost patients required greater utilization of resources including lab tests, blood transfusions, and opioids (p < 0.01). Despite having higher burden of disease and requiring increased resource utilization, high cost OLT patients with a straightforward perioperative course were shown to have identical 2-year graft and overall survival compared to lower cost patients (p = 0.82 and p = 0.63), respectively., Conclusion: Providing adequate perioperative care for OLT patients with higher severity of illness and disease burden requires increased cost and resource utilization; however, doing so provides these patients with long term survival equivalent to more routine patients., (Copyright © 2017 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Context: The rate of live discharge from hospice and the proportion of hospices exceeding their aggregate caps have both increased for the last 15 years, becoming a source of federal scrutiny. The cap restricts aggregate payments hospices receive from Medicare during a 12-month period. The risk of repayment and the manner in which the cap is calculated may incentivize hospices coming close to their cap ceilings to discharge existing patients before the end of the cap year., Objective: The objective of this work was to explore annual cap-risk trends and live discharge patterns. We hypothesized that as a hospice comes closer to exceeding its cap, a patient's likelihood of being discharged alive increases., Methods: We analyzed monthly hospice outcomes using 2012-2013 Medicare claims., Results: Adjusted analyses showed a positive and statistically significant relationship between cap risk and live discharges., Conclusion: Policymakers ought to consider the unintended consequences the aggregate cap may be having on patient outcomes of care., (Copyright © 2017 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Supported Discharge Teams aim to help with the transition from hospital to home, whilst reducing hospital length-of-stay. Despite their obvious attraction, the evidence remains mixed, ranging from strong support for disease-specific interventions to less favourable results for generic services., Objective: To determine whether older people referred to a Supported Discharge Team have: (i) reduced length-of-stay in hospital; (ii) reduced risk of hospital readmission; and (iii) reduced healthcare costs., Methods: Randomised controlled trial with follow-up to 6 months; 103 older women and 80 men (n = 183) (mean age 79), in hospital, were randomised to receive either Supported Discharge Team or usual care. Home-based rehabilitation was delivered by trained Health Care Assistants up to four times a day, 7 days a week, under the guidance of registered nurses, allied health and geriatricians for up to 6 weeks., Results: Participants randomised to the Supported Discharge Team spent less time in hospital during the index admission (mean 15.7 days) in comparison to usual care (mean 21.6 days) (mean difference 5.9: 95% CI 0.6, 11.3 days: P = 0.03) and spent less time in hospital in the 6 months following discharge home. Supported discharge group costs were calculated at mean NZ$10,836 (SD NZ$12,087) compared to NZ$16,943 (SD NZ$22,303) in usual care., Conclusion: A Supported Discharge Team can provide an effective means of discharging older people home early from hospital and can make a cost-effective contribution to managing increasing demand for hospital beds., (© The Author 2017. Published by Oxford University Press on behalf of the British Geriatrics Society.All rights reserved. For permissions, please email: journals.permissions@oup.com)

Background: Recent policy efforts have focused on improving the value of acute myocardial infarction (AMI) care. Medicare payment programs, for example, increasingly evaluate hospital performance based on spending, as determined by payments made to institutions and providers, and outcome measures for a longitudinal episode of AMI care. Little is known about the relationship between total 30-day payments-both in the inpatient and immediate postdischarge timeframe-and outcomes after an admission for AMI., Methods and Results: Using Medicare claims data, we identified Medicare fee-for-service beneficiaries ≥65 years of age who were hospitalized at an acute-care hospital for AMI between July 1, 2011, and June 30, 2014, and examined the association between hospital-level 30-day payments for an episode of AMI care and patient 30-day mortality using mixed regression models with a logit link function and random hospital intercepts. Our cohort included 642 105 index hospitalizations for AMI at 2319 acute-care hospitals. Overall mean 30-day episode payments per beneficiary were $22 128 (SD, $1750). The observed 30-day mortality rate was 12.9%. Higher 30-day payments were associated with lower 30-day mortality after adjustment for patient characteristics and comorbidities (adjusted odds ratio for additional $1000 payments, 0.986; 95% confidence interval, 0.979-0.992; P <0.001). Additional adjustment for potential mediating factors, including hospital characteristics, coronary revascularization rates, and discharge disposition, did not significantly attenuate the relationship (adjusted odds ratio for additional $1000 payments, 0.987; 95% confidence interval, 0.980-0.994; P <0.001)., Conclusions: Higher hospital-level 30-day payments-both inpatient and in multiple settings after discharge-for AMI care were associated with lower 30-day mortality among beneficiaries. This may have implications for payment programs that incent reduction in payments without considering value., (© 2018 American Heart Association, Inc.)

Background: The incidence of Gestational Diabetes Mellitus (GDM) is rising in all developed countries. This study aimed at assessing the short-term economic burden of GDM from the Italian healthcare system perspective., Methods: A model was built over the last pregnancy trimester (i.e., from the 28th gestational week until childbirth included). The National Hospital Discharge Database (2014) was accessed to estimate delivery outcome probabilities and inpatient costs in GDM and normal pregnancies (i.e., euglycemia). International Classification of Disease-9th Revision-Clinical Modification (ICD9-CM) diagnostic codes and Diagnosis-Related Group (DRG) codes were used to identify GDM cases and different types of delivery (i.e., vaginal or cesarean) within the database. Neonatal outcomes probabilities were estimated from the literature and included macrosomia, hypoglycemia, hyperbilirubinemia, shoulder dystocia, respiratory distress, and brachial plexus injury. Additional data sources such as regional documents, official price and tariff lists, national statistics and expert opinion were used to populate the model. The average cost per case was calculated at national level to estimate the annual economic burden of GDM. One-way sensitivity analyses and Monte Carlo simulations were performed to quantify the uncertainty around base case results., Results: The amount of pregnancies complicated by GDM in Italy was assessed at 54,783 in 2014 using a prevalence rate of 10.9%. The antenatal outpatient cost per case was estimated at €43.7 in normal pregnancies compared to €370.6 in GDM patients, which is equivalent to a weighted sum of insulin- (14%; €1034.6) and diet- (86%; €262.5) treated women's costs. Inpatient delivery costs were assessed at €1601.6 and €1150.3 for euglycemic women and their infants, and at €1835.0 and €1407.7 for GDM women and their infants, respectively. Thus, the overall cost per case difference between GDM and normal pregnancies was equal to €817.8 (+ 29.2%), resulting in an economic burden of about €44.8 million in 2014 at national level. Probabilistic sensitivity analysis yielded a cost per case difference ranging between €464.9 and €1164.8 in 80% of simulations., Conclusions: The economic burden of GDM in Italy is substantial even accounting for short-term medical costs only. Future research also addressing long-term consequences from a broader societal perspective is recommended.

Background: Same-day discharge (SDD) after elective percutaneous coronary intervention is safe, less costly, and preferred by patients, but it is usually performed in low-risk patients, if at all. To increase the appropriate use of SDD in more complex patients, we implemented a "patient-centered" protocol based on risk of complications at Barnes-Jewish Hospital., Methods and Results: Our objectives were as follows: (1) to evaluate time trends in SDD; (2) to compare (a) mortality, bleeding, and acute kidney injury, (b) patient satisfaction, and (c) hospital costs by SDD versus no SDD (NSDD); and (3) to compare SDD eligibility by our patient-centered approach versus Society for Cardiovascular Angiography and Interventions guidelines. Our patient-centered approach was based on prospectively identifying personalized bleeding, mortality, and acute kidney injury risks, with a personalized safe contrast limit and mitigating those risks. We analyzed Barnes-Jewish Hospital's National Cardiovascular Data Registry CathPCI Registry data from July 1, 2009 to September 30, 2015 (N=1752). SDD increased rapidly from 0% to 77% ( P <0.001), independent of radial access. Although SDD patients were comparable to NSDD patients, SDD was not associated with adverse outcomes (0% mortality, 0% bleeds, and 0.4% acute kidney injury). Patient satisfaction was high with SDD. Propensity score-adjusted costs were $7331 lower/SDD patient ( P <0.001), saving an estimated $1.8 million annually. Only 16 patients (6.95%) met the eligibility for SDD by Society for Cardiovascular Angiography and Interventions guidelines, implying our patient-centered approach markedly increased SDD eligibility., Conclusions: With a patient-centered approach, SDD rapidly increased and was safe in 75% of patients undergoing elective percutaneous coronary intervention, despite patient complexity. Patient satisfaction was high, and hospital costs were lower. Patient-centered decision making to facilitate SDD is an important opportunity to improve the value of percutaneous coronary intervention., (© 2018 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.)

Background: Postdischarge medication management services have been shown to reduce the incidence of medication-related problems during the transition from inpatient to outpatient care. A pharmacist-run transition of care (TOC) program has been developed to reduce the unplanned readmissions of a high-risk managed Medicaid population after hospitalization., Objective: To estimate the budget impact of adding an outpatient pharmacy-based TOC program to a medical benefit from the payer perspective., Methods: A budget impact analysis was conducted using a decision-tree model developed in Microsoft Excel. The effect on inpatient and total health care costs from the payer perspective was estimated for the 2-year period following initial hospital discharge. Inputs were based on a total plan population of 240,000 lives, with a high-risk population of 7.5%, of whom 37% were hospitalized and potentially qualified for TOC services, resulting in an eligible population of 6,660 patients. The TOC program was assumed to initially cover 30% of the eligible population, with expansion to 60% over the 2 years. We previously reported that this program reduced the risk of readmission by 32% within 6 months and saved the health plan $2,139 per patient referred to the program, inclusive of program cost, compared with patients receiving usual discharge care. Sensitivity analyses were performed to test the impact of uncertainty of model inputs on the results, with the cost of TOC services ranging from $99 to $2,000 per patient referred., Results: The model showed that the TOC program was cost saving at over $3 per member per month in the first 6 months, which translates to over $25 million in total health care cost savings over 2 years. These results were primarily driven by the estimated reduction in inpatient costs associated with the program, which were estimated at $20 million over the 2 years. Sensitivity analyses illustrated that within all the reasonable ranges of model input parameters, including the upper limit of TOC services set to $2,000 per patient referred, the TOC program resulted in cost savings to the health plan., Conclusions: The TOC program resulted in potential cost savings of over $25 million to the managed Medicaid plan over a period of 2 years, corresponding to over $4 per member per month., Disclosures: Funding for this study was contributed by the Komoto Family Foundation, which provided fellowships to Ni and McCombs during the time of this study. Colayco is employed by Synergy Pharmacy Solutions and by the Komoto Family Foundation. Hashimoto and Komoto are employed by Synergy Pharmacy Solutions. Gowda and Wearda report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article. Study concept and design were contributed by Ni, Colayco, and McCombs, along with the other authors. Hashimoto, Komoto, and Wearda took the lead in data collection, assisted by Ni, Colayco, and Gowda. Data interpretation was performed by Ni, Colayco, and McCombs, along with the other authors. The manuscript was written by Ni and Colayco and revised by Gowda and McCombs, along with the other authors.

Background: The impact of delayed discharge on patients, health-care staff and hospital costs has been incompletely characterized., Aim: To systematically review experiences of delay from the perspectives of patients, health professionals and hospitals, and its impact on patients' outcomes and costs., Methods: Four of the main biomedical databases were searched for the period 2000-2016 (February). Quantitative, qualitative and health economic studies conducted in OECD countries were included., Results: Thirty-seven papers reporting data on 35 studies were identified: 10 quantitative, 8 qualitative and 19 exploring costs. Seven of ten quantitative studies were at moderate/low methodological quality; 6 qualitative studies were deemed reliable; and the 19 studies on costs were of moderate quality. Delayed discharge was associated with mortality, infections, depression, reductions in patients' mobility and their daily activities. The qualitative studies highlighted the pressure to reduce discharge delays on staff stress and interprofessional relationships, with implications for patient care and well-being. Extra bed-days could account for up to 30.7% of total costs and cause cancellations of elective operations, treatment delay and repercussions for subsequent services, especially for elderly patients., Conclusions: The poor quality of the majority of the research means that implications for practice should be cautiously made. However, the results suggest that the adverse effects of delayed discharge are both direct (through increased opportunities for patients to acquire avoidable ill health) and indirect, secondary to the pressures placed on staff. These findings provide impetus to take a more holistic perspective to addressing delayed discharge., (© 2017 The Authors Health Expectations Published by John Wiley & Sons Ltd.)

Objective: To assess the impact of hospital affiliation, centralization, and managed care plan ownership on inpatient cost and quality., Data Sources: Inpatient discharges from 3,957 community hospitals in 44 states and American Hospital Association Annual Survey data from 2010 to 2012., Study Design: We conducted a retrospective longitudinal regression analysis using hierarchical modeling of discharges clustered within hospitals., Data Collection: Detailed discharge data including costs, length of stay, and patient characteristics from the Healthcare Cost and Utilization Project State Inpatient Databases were merged with hospital survey data from the American Hospital Association., Principal Findings: Hospitals affiliated with health systems had a higher cost per discharge and better quality of care compared with independent hospitals. Centralized systems in particular had the highest cost per discharge and longest stays. Independent hospitals with managed care plans had a higher cost per discharge and better quality of care compared with other independent hospitals., Conclusions: Increasing prevalence of health systems and hospital managed care ownership may lead to higher quality but are unlikely to reduce hospital discharge costs. Encouraging participation in innovative payment and delivery reform models, such as accountable care organizations, may be more powerful options., (© Health Research and Educational Trust.)

Background: Despite the importance of continuity of care after detoxification and residential treatment, many clients do not receive further treatment services after discharged. This study examined whether offering financial incentives and providing client-specific electronic reminders to treatment agencies lead to improved continuity of care after detoxification or residential treatment., Methods: Residential (N = 33) and detoxification agencies (N = 12) receiving public funding in Washington State were randomized into receiving one, both, or none (control group) of the interventions. Agencies assigned to incentives arms could earn financial rewards based on their continuity of care rates relative to a benchmark or based on improvement. Agencies assigned to electronic reminders arms received weekly information on recently discharged clients who had not yet received follow-up treatment. Difference-in-difference regressions controlling for client and agency characteristics tested the effectiveness of these interventions on continuity of care., Results: During the intervention period, 24,347 clients received detoxification services and 20,685 received residential treatment. Overall, neither financial incentives nor electronic reminders had an effect on the likelihood of continuity of care. The interventions did have an effect among residential treatment agencies which had higher continuity of care rates at baseline., Conclusions: Implementation of agency-level financial incentives and electronic reminders did not result in improvements in continuity of care, except among higher performing agencies. Alternative strategies at the facility and systems levels should be explored to identify ways to increase continuity of care rates in specialty settings, especially for low performing agencies., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Objective: Currently only 5 out of the 50 states in the United States have laws restricting the age of passengers permitted to ride on a motorcycle. This study sought to characterize the visits by patients under the age of 16 to U.S. emergency departments (EDs) for injuries sustained as a passenger on a motorcycle., Methods: In this retrospective cohort study, data were obtained from the Nationwide Emergency Department Sample (NEDS) for the years 2006 to 2011. Pediatric patients who were passengers on a motorcycle that was involved in a crash were identified using International Classification of Diseases, Ninth Revision (ICD-9) External Cause of Injury codes. We also examined gender, age, disposition, regional differences, common injuries, and charges., Results: Between 2006 and 2011 there were an estimated 9,689 visits to U.S. EDs by patients under the age of 16 who were passengers on a motorcycle involved in a crash. The overall average patient age was 9.4 years, and they were predominately male (54.5%). The majority (85%) of these patients were treated and released. The average charges for discharged patients were $2,116.50 and amounted to roughly $17,500,000 during the 6 years. The average cost for admission was $51,446 per patient and totaled over $54 million. The most common primary injuries included superficial contusions; sprains and strains; upper limb fractures; open wounds of head, neck, and trunk; and intracranial injuries., Conclusion: Although there were only about 9,700 visits to U.S. EDs for motorcycle crashes involving passengers less than 16 years old for 2006 to 2011, the total cost of visits that resulted in either ED discharge or hospital admission amounted to over $71 million.

Incisional hernia (IH) is a challenging, potentially morbid condition. This study evaluates recent trends in hospital encounters associated with IH care in the United States. Using Nationwide Inpatient Sample databases from 2007 to 2011, annual estimates of IH-related hospital discharges, charges, and serious adverse events were identified. Significance in observed trends was tested using regression modeling. From 2007 to 2011, there were 583,054 hospital discharges associated with a diagnosis of IH. 81.1 per cent had a concurrent procedure for IH repair. The average discharge included a female patient (63.2%), 59.8 years of age, with either Medicare (45.3%) or Private insurance (38.3%) as the anticipated primary payer. Comparing 2007 to 2011, significant increases in IH discharges (12%; 2007 = 109,702 vs 2011 = 123,034, P = 0.009) and IH repairs (10%; 2007 = 90,588 vs 2011 = 99,622, P < 0.001) were observed. This was accompanied by a 37 per cent increase in hospital charges (2007 = $44,587 vs 2011 = $60,968, P < 0.001), resulting in a total healthcare bill of $7.3 billion in 2011. Significant trends toward greater patient age (2007 = 59.7 years vs 2011 = 60.2 years, P < 0.001), higher comorbidity index (2007 = 3.0 vs 2011 = 3.5, P < 0.001), and increased frequency of serious adverse events (2007 = 13.5% vs 2011 = 17.7%, P < 0.001) were noted. Further work is needed to identify interventions to mitigate the risk of IH development.

Hospital readmissions are a major contributor to increased health care costs and are associated with worse patient outcomes after neurosurgery. We used the newly released Nationwide Readmissions Database (NRD) to describe the association between patient, hospital and payer factors with 30- and 90-day readmission following craniotomy for malignant brain tumor. All adult inpatients undergoing craniotomy for primary and secondary malignant brain tumors in the NRD from 2013 to 2014 were included. We identified all cause readmissions within 30- and 90-days following craniotomy for tumor, excluding scheduled chemotherapeutic procedures. We used univariate and multivariate models to identify patient, hospital and administrative factors associated with readmission. We identified 27,717 admissions for brain tumor craniotomy in 2013-2014, with 3343 (13.2%) 30-day and 5271 (25.7%) 90-day readmissions. In multivariate analysis, patients with Medicaid and Medicare were more likely to be readmitted at 30- and 90-days compared to privately insured patients. Patients with two or more comorbidities were more likely to be readmitted at 30- and 90-days, and patients discharged to skilled nursing facilities or home health care were associated with increased 90-day readmission rates. Finally, hospital procedural volume above the 75th percentile was associated with decreased 90-day readmission rates. Patients treated at high volume hospitals are less likely to be readmitted at 90-days. Insurance type, non-routine discharge and patient comorbidities are predictors of postoperative non-scheduled readmission. Further studies may elucidate potentially modifiable risk factors when attempting to improve outcomes and reduce cost associated with brain tumor surgery.

Objective: To complete an economic evaluation within a randomised controlled trial (RCT) comparing the use of an electronic discharge communication tool (eDCT) compared with usual care., Setting: Patients being discharged from a single tertiary care centre's internal medicine Medical Teaching Units., Participants: Between January 2012 and December 2013, 1399 patients were randomised to a discharge mechanism. Forty-five patients were excluded from the economic evaluation as they did not have data for the index hospitalisation cost; 1354 patients contributed to the economic evaluation., Intervention: eDCT generated at discharge containing structured content on reason for admission, details of the hospital stay, treatments received and follow-up care required. The control group was discharged via traditional dictation methods., Primary and Secondary Outcome Measures: The primary economic outcome was the cost per quality-adjusted life year (QALY) gained. Secondary outcomes included the cost per death avoided and the cost per readmission avoided., Results: The average transcription cost was $C22.28 per patient, whereas the estimated cost of the eDCT was $C13.33 per patient. The cost per QALY gained was $C239 933 in the eDCT arm compared with usual care due to the very small gains in effectiveness and approximately $C800difference in resource utilisation costs. The bootstrap analyses resulted in eDCT being more effective and more costly in 29.2% of samples, less costly and more effective in 29.2% of samples, less effective and more costly in 23.9% of samples and finally, less costly and less effective in 17.7% of samples., Conclusions: The eDCT reduced per patient costs of the generation of discharge summaries. The bootstrap estimates demonstrate considerable uncertainty supporting the finding of neutrality reported in the clinical component of the RCT. The immediate transcription cost savings and previously documented provider and patient satisfaction may increase the impetus for organisations to invest in such systems, provided they have a foundation of eHealth infrastructure and readiness., Trial Registration Number: NCT01402609., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Introduction: We explore trends in U.S. inpatient costs of care over a 10-year period., Methods: We compare myasthenia gravis (MG) with multiple sclerosis (MS) and overall U.S. hospital admissions using the Agency for Healthcare Research and Quality Nationwide Inpatient Sample database for 2003-2013., Results: Total costs of MG inpatient care rose 13-fold from 2003 to 2013. This was accounted for by a greater than sixfold increase in discharges and a greater than twofold increase in cost per discharge. The < 17 and >85 years age groups experienced the greatest increases in discharges. Medicare and Medicaid use increased. Regional variations in cost were apparent. There were greater rises in the Midwestern and Southern United States, which is dissimilar to MS and all hospital admissions., Discussion: There was a dramatic and disproportionate rise in the number of MG discharges, most likely because of changes in practice patterns. Muscle Nerve 56: 1114-1118, 2017., (© 2017 Wiley Periodicals, Inc.)

Objective: To evaluate whether Medicare-style bundled payments are lower or higher for beneficiaries discharged from hospitals with postacute care (PAC) referrals concentrated among fewer PAC providers., Data Source: Medicare Part A and Part B claim (2008-2012) for all beneficiaries residing in any of 17 market areas: the Provider of Service file, the Healthcare Cost Report Information System, and the Dartmouth Atlas., Study Design: An observational study in which hospitals were distinguished according to PAC referral concentration, which is the tendency to utilize fewer rather than more PAC providers. We tested the hypothesis that higher referral concentration would be associated with total Medicare bundled payments., Data Collection/extraction Methods: The data represent a convenience sample of market areas that were defined by the locations of grantees from the ONC Beacon Community Program., Principal Findings: The four most-used PAC providers accounted for an average of 60 percent of patients discharged from hospitals in the sample. Regression analysis suggested that higher referral concentration was associated with lower Medicare costs per bundle., Conclusions: Hospitals that tend to use fewer PAC providers may lead to lower costs for payers such as Medicare. The study results reinforce the importance of limited networks for PAC services under bundling arrangements for hospital and PAC payments., (© Health Research and Educational Trust.)

Background: Rising acuity levels in inpatient settings have led to growing reliance on observers and increased the cost of care., Objectives: Minimizing use of observers, maintaining quality and safety of care, and improving bed access, without increasing cost., Design: Nursing staff on two inpatient psychiatric units at an academic medical center pilot-tested the use of a "milieu manager" to address rising patient acuity and growing reliance on observers. Nursing cost, occupancy, discharge volume, unit closures, observer expense, and incremental nursing costs were tracked. Staff satisfaction and reported patient behavioral/safety events were assessed., Results: The pilot initiatives ran for 8 months. Unit/bed closures fell to zero on both units. Occupancy, patient days, and discharges increased. Incremental nursing cost was offset by reduction in observer expense and by revenue from increases in occupancy and patient days. Staff work satisfaction improved and measures of patient safety were unchanged., Conclusions: The intervention was effective in reducing observation expense and improved occupancy and patient days while maintaining patient safety, representing a cost-effective and safe approach for management of acuity on inpatient psychiatric units.

Background: The greatest burden from stroke-related disability is borne by Low-and-Middle Income countries (LMICs) where access to rehabilitation after stroke is severely challenged. Tele-rehabilitation could be a viable avenue to address unmet rehabilitation needs in LMICs., Objectives: To assess the burden of post-stroke physical deficits, rates of utilization of physiotherapy services, and perceptions of tele-rehabilitation among recent Ghanaian stroke survivors., Methods: Using a consecutive sampling strategy, 100 stroke survivors attending an outpatient Neurology clinic in a Ghanaian tertiary medical center were enrolled into this cross-sectional study. After collecting basic demographic data, clinical history on stroke type, severity and level of disability, we administered the validated 20-item Functional Independence Measure questionnaire to evaluate functional status of study participants and an 8-item questionnaire to assess participants' attitudes towards telemedicine administered rehabilitation intervention., Results: Mean±SD age of study participants was 57.2±13.3years of which 51.0% were males with a mean duration of stroke of 1.3±2.2years. 53% had Modified Rankin scores of ≥3, 57% were fully independent and only 27% reported utilizing any physiotherapy services. Barriers to access to physiotherapy included financial constraints due to cost of physiotherapy services and transportation as well as premature discharge from physiotherapy to avoid overburdening of available physiotherapy services. These factors led to the limited provision of rehabilitative therapy. Participants held positive views of the potential for tele-rehabilitation interventions (80-93%). However, while 85% owned mobile phones, only 35% had smart phones., Conclusion: Despite, a high burden of residual disability, only about 1 out of 4 stroke patients in this Ghanaian cohort was exposed to post-stroke physiotherapy services, largely due to relatively high costs and limited health system resources. These Ghanaian stroke patients viewed the potential role of Tele-rehabilitation as positive, but this promising intervention needs to be formally tested for feasibility, efficacy and cost-effectiveness., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: Hospital evaluation of patients with chest pain is common and costly. The HEART score risk stratification tool that merges troponin testing into a clinical risk model for evaluation emergency department patients with possible acute myocardial infarction (AMI) has been shown to effectively identify a substantial low-risk subset of patients possibly safe for early discharge without stress testing, a strategy that could have tremendous healthcare savings implications., Method and Results: A total of 105 patients evaluated for AMI in the emergency departments of 2 teaching hospitals in the Henry Ford Health System (Detroit and West Bloomfield, MI), between February 2014 and May 2015, with a modified HEART score ≤3 (which includes cardiac troponin I <0.04 ng/mL at 0 and 3 hours) were randomized to immediate discharge (n=53) versus management in an observation unit with stress testing (n=52). The primary end points were 30-day total charges and length of stay. Secondary end points were all-cause death, nonfatal AMI, rehospitalization for evaluation of possible AMI, and coronary revascularization at 30 days. Patients randomized to early discharge, compared with those who were admitted for observation and cardiac testing, spent less time in the hospital (median 6.3 hours versus 25.9 hours; P <0.001) with an associated reduction in median total charges of care ($2953 versus $9616; P <0.001). There were no deaths, AMIs, or coronary revascularizations in either group. One patient in each group was lost to follow-up., Conclusions: Among patients evaluated for possible AMI in the emergency department with a modified HEART score ≤3, early discharge without stress testing as compared with transfer to an observation unit for stress testing was associated with significant reductions in length of stay and total charges, a finding that has tremendous potential national healthcare expenditure implications., Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT03058120., (© 2017 American Heart Association, Inc.)

Background: Total joint arthroplasty (TJA) accounts for more Medicare expenditure than any other inpatient procedure. The Comprehensive Care for Joint Replacement model was introduced to decrease cost and improve quality in TJA. The largest portion of episode-of-care costs occurs after discharge. This study sought to quantify the cost variation of primary total hip arthroplasty (THA) according to discharge disposition., Methods: The Medicare and Humana claims databases were used to extract charges and reimbursements to compare day-of-surgery and 91-day postoperative costs simulating episode-of-care reimbursements. Of the patients who underwent primary THA, 257,120 were identified (204,912 from Medicare and 52,208 from Humana). Patients were stratified by discharge disposition: home with home health, skilled nursing facility, or inpatient rehabilitation facility., Results: There is a significant difference in the episode-of-care costs according to discharge disposition, with discharge to an inpatient rehabilitation facility the most costly and discharge to home the least costly., Conclusion: Postdischarge costs represent a sizeable portion of the overall expense in THA, and optimizing patients to allow safe discharge to home may help reduce the cost of THA., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: The 72-hour Medicare mandate (3-night stay rule) requires a 3-day inpatient stay for patients discharging to skilled nursing facilities (SNFs). Studies show that 48%-64% of Medicare total joint arthroplasty (TJA) patients are safe for discharge to SNFs on postoperative day (POD) #2. The purpose of this study was to extrapolate the financial impact of the 3-night stay rule., Methods: The American College of Surgeons National Surgical Quality Improvement Program database was queried for all primary TJAs performed in 2015. Discharge destination was recorded. Institutional cost accounting examined costs for patients discharging on POD #2 vs POD #3., Results: A total of 42,423 TJAs (14,395 total hip arthroplasties [THAs] and 28,028 total knee arthroplasties [TKAs]) were performed in patients over the age of 65 years. Of these patients, 5252 THAs (36.5%) and 12,022 TKAs (42.9%) were discharged from the hospital on POD #3, with 2404 THAs (16.7%) and 5083 TKAs (18.1%) being discharged to SNFs. Institutional cost accounting revealed hospital costs for THA were $2014 more, whereas hospital costs for TKA were $1814 more for a 3-day length of stay when compared with a 2-day length of stay (P < .001). The mean charge per day for an SNF was $486., Conclusion: The National Surgical Quality Improvement Program database is a representative sample of all surgeries performed in the United States. Extrapolating our findings to all Medicare TJAs nationally gives an estimated $63 million in annual savings. Medicare mandated, but potentially medically unnecessary inpatient days at a higher level of care increase the total cost for TJAs. Policies regarding minimum stay requirements before discharge should be re-evaluated., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Re-hospitalization after discharge for acute decompensated heart failure is a common problem. Low-socioeconomic urban patients suffer high rates of re-hospitalization and often over-utilize the emergency department (ED) for their care. We hypothesized that early consultation with a cardiologist in the ED can reduce re-hospitalization and health care costs for low-socioeconomic urban patients with acute decompensated heart failure., Methods: There were 392 patients treated at our center for acute decompensated heart failure who received standardized education and follow-up. Patients who returned to the ED received early consultation with a cardiologist; 392 patients who received usual care served as controls. Thirty- and 90-day re-hospitalization, ED re-visits, heart failure symptoms, mortality, and health care costs were recorded., Results: Despite guideline-based education and follow-up, the rate of ED re-visits was not different between the groups. However, the rate of re-hospitalization was significantly lower in patients receiving the intervention compared with controls (odds ratio 0.592), driven by a reduction in the risk of readmission from the ED (0.56 vs 0.79, respectively). Patients receiving the intervention accumulated 14% fewer re-hospitalized days than controls and 57% lower 30-day total health care cost. Despite the reduction in health care resource consumption, mortality was unchanged. After accounting for the total cost of intervention delivery, the health care cost savings was substantially greater than the cost of intervention delivery., Conclusion: Early consultation with a cardiologist in the ED as an adjunct to guideline-based follow-up is associated with reduced re-hospitalization and health care cost for low-socioeconomic urban patients with acute decompensated heart failure., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objectives: The high cost of critical care has engendered research into identifying influential factors. However, existing studies have not considered patient vital status at ICU discharge. This study sought to determine the effect of mortality upon the total cost of an ICU stay., Design: Retrospective cohort study., Setting: Twenty-six ICUs at 13 hospitals in the United States., Patients: 58,344 admissions from January 1, 2012, to June 30, 2016, obtained from a commercial ICU database., Interventions: None., Measurements and Main Results: The median observed cost of a unit stay was $9,619 (mean = $16,353). A multivariable regression model was developed on the log of total costs for a unit stay, using severity of illness, unit admitting diagnosis, mortality in the unit, daily unit occupancy (occupying a bed at midnight), and length of mechanical ventilation. This model had an r of 0.67 and a median difference between observed and expected costs of $437. The first few days of care and the first day receiving mechanical ventilation had the largest effect on total costs. Patients dying before unit discharge had 12.4% greater costs than survivors (p < 0.01; 99% CI = 9.3-15.5%) after multivariable adjustment. This effect was most pronounced for patients with an extended ICU stay who were receiving mechanical ventilation., Conclusions: While the largest drivers of ICU costs at the patient level are day 1 room occupancy and day 1 mechanical ventilation, mortality before unit discharge is associated with substantially higher costs. The increase was most evident for patients with an extended ICU stay who were receiving mechanical ventilation. Studies evaluating costs among ICUs need to take mortality into account.

Study Objective: Most surgical discharges (54%) at the average hospital are for procedures performed no more often than once per month at that hospital. We hypothesized that such uncommon procedures would be associated with an even greater percentage of the total cost of performing all surgical procedures at that hospital., Design: Observational study., Setting: State of Texas hospital discharge abstract data: 4th quarter of 2015 and 1st quarter of 2016., Patients: Inpatients discharged with a major therapeutic ("operative") procedure., Measurements: For each of N=343 hospitals, counts of discharges, sums of lengths of stay (LOS), sums of diagnosis related group (DRG) case-mix weights, and sums of charges were obtained for each procedure or combination of procedures, classified by International Classification of Diseases version 10 Procedure Coding System (ICD-10-PCS). Each discharge was classified into 2 categories, uncommon versus not, defined as a procedure performed at most once per month versus those performed more often than once per month., Main Results: Major procedures performed at most once per month per hospital accounted for an average among hospitals of 68% of the total inpatient costs associated with all major therapeutic procedures. On average, the percentage of total costs associated with uncommon procedures was 26% greater than expected based on their share of total discharges (P<0.00001). Average percentage differences were insensitive to the endpoint, with similar results for the percentage of patient days and percentage of DRG case-mix weights., Conclusions: Approximately 2/3rd (mean 68%) of inpatient costs among surgical patients can be attributed to procedures performed at most once per month per hospital. The finding that such uncommon procedures account for a large percentage of costs is important because methods of cost accounting by procedure are generally unsuitable for them., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: To assess the health care burden of septic arthritis in the U.S. and examine the associated factors., Methods: We used the U.S. Nationwide Emergency Department Sample (NEDS) data of patients hospitalized with septic arthritis as the primary diagnosis from 2009-12 to assess time-trends. Multivariable-adjusted models assessed demographics, comorbidity and hospital characteristics as potential predictors of duration of hospitalization, total hospital (inpatient and ED) charges and discharge to home., Results: In 2009, 2010 and 2012 in the U.S., respectively, there were 13,087, 13,662 and 13,714 hospitalizations with septic arthritis as the primary diagnosis. Respective average hospital stay was 7.4 vs. 7.4 vs. 7.2 days; total hospital charges were $601 vs. $674 vs. $759 million; and proportion discharged home were 43% vs. 43% vs. 44%. Almost 25% each were discharged to a skilled facility or with home health. Age >50 years, Medicaid and self-pay as primary payer, Northeast U.S. hospital location, teaching hospital status, heart failure and diabetes were associated with longer hospitalization; hyperlipidemia, hypertension or gout were associated with a shorter hospital stay. Similar associations were noted for higher hospital charges. Age >50 years, higher income, Medicare insurance, heart failure, diabetes and longer hospital stay were associated with lower odds, and Western U.S. hospital location and gout with higher odds, of discharge to home., Conclusions: We noted an increase in hospital charges from 2009-12, but no time trends in duration or outcomes of hospitalization for septic arthritis. Comorbidity associations with outcomes indicate the potential for developing interventions to improve outcomes.

Objective: To determine if hospitals that routinely discharge patients early after lobectomy have increased readmissions., Background: Hospitals are increasingly motivated to reduce length of stay (LOS) after lung cancer surgery, yet it is unclear if a routine of early discharge is associated with increased readmissions. The relationship between hospital discharge practices and readmission rates is therefore of tremendous clinical and financial importance., Methods: The National Cancer Database was queried for patients undergoing lobectomy for lung cancer from 2004 to 2013 at Commission on Cancer-accredited hospitals, which performed at least 25 lobectomies in a 2-year period. Facility discharge practices were characterized by a facility's median LOS relative to the median LOS for all patients in that same time period., Results: In all, 59,734 patients met inclusion criteria; 2687 (4.5%) experienced an unplanned readmission. In a hierarchical logistic regression model, a routine of early discharge (defined as a facility's tendency to discharge patients faster than the population median in the same time period) was not associated with increased risk of readmission (odds ratio 1.12, 95% confidence interval 0.97-1.28, P = 0.12). In a risk-adjusted hospital readmission rate analysis, hospitals that discharged patients early did not experience more readmissions (P = 0.39). The lack of effect of early discharge practices on readmission rates was observed for both minimally invasive and thoracotomy approaches., Conclusions: It is possible for hospitals to develop early discharge practices without increasing readmissions. Further study is needed to identify the critical practice elements that have enabled hospitals to aggressively discharge patients without increasing readmission risk.

Background: The surgical treatment of urinary incontinence and erectile dysfunction by prosthetic devices has become part of urologic practice, although sparse data exist at a national level on readmissions and hospital costs., Aim: To assess causes and costs of early (≤30 days) and late (31-90 days) readmissions after implantation of penile prostheses (PPs), artificial urinary sphincters (AUSs), or PP + AUS., Methods: Using the 2013 and 2014 US Nationwide Readmission Databases, sociodemographic characteristics, hospital costs, and causes of readmission were compared among PP, AUS and AUS + PP surgeries. Multivariable logistic regression models tested possible predictors of hospital readmission (early, late, and 90 days), increased hospital costs, and prolonged length of stay at initial hospitalization and readmission., Outcome: Outcomes were rates, causes, hospital costs, and predictive factors of early, late, and any 90-day readmissions., Results: Of 3,620 patients, 2,626 (73%) had PP implantation, 920 (25%) had AUS implantation, and 74 (2%) underwent PP + AUS placement. In patients undergoing PP, AUS, or PP + AUS placement, 30-day (6.3% vs 7.9% vs <15.0%, P = .5) and 90-day (11.6% vs 12.8% vs <15.0%, P = .8) readmission rates were comparable. Early readmissions were more frequently caused by wound complications compared with late readmissions (10.9% vs <4%, P = .03). Multivariable models identified longer length of stay, Charlson Comorbidity Index score higher than 0, complicated diabetes, and discharge not to home as predictors of 90-day readmissions. Notably, hospital volume was not a predictor of early, late, or any 90-day readmissions. However, within the subset of high-volume hospitals, each additional procedure was associated with increased risk of late (odds ratio = 1.06, 95% CI = 1.03-1.09, P < .001) and 90-day (odds ratio = 1.03 95% CI = 1.02-1.05, P < .001) readmissions. AUS and PP + AUS surgeries had higher initial hospitalization costs (P < .001). A high hospital prosthetic volume decreased costs at initial hospitalization. Mechanical complications led to readmission of all patients receiving PP + AUS., Clinical Implications: High-volume hospitals showed a weaker association with increased initial hospitalization costs. Charlson Comorbidity Index, diabetes, and length of stay were predictors of 90-day readmission, showing that comorbidity status is important for surgical candidacy., Strengths and Limitations: This is the first study focusing on readmissions and costs after PP, AUS, and PP + AUS surgeries using a national database, which allows ascertainment of readmissions to hospitals that did not perform the initial surgery. Limitations are related to the limited geographic coverage of the database and lack of surgery- and surgeon-specific variables., Conclusions: Analysis of readmissions can provide better care for urologic prosthetic surgeries through better preoperative optimization, counseling, and resource allocation. Pederzoli F, Chappidi MR, Collica S, et al. Analysis of Hospital Readmissions After Prosthetic Urologic Surgery in the United States: Nationally Representative Estimates of Causes, Costs, and Predictive Factors. J Sex Med 2017;14:1059-1065., (Copyright © 2017 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Competing Interests: The authors have declared no potential conflicts of interest.

Background: People with stroke conventionally receive a substantial part of their rehabilitation in hospital. Services have now been developed that offer people in hospital an early discharge with rehabilitation at home (early supported discharge: ESD)., Objectives: To establish if, in comparison with conventional care, services that offer people in hospital with stroke a policy of early discharge with rehabilitation provided in the community (ESD) can: 1) accelerate return home, 2) provide equivalent or better patient and carer outcomes, 3) be acceptable satisfactory to patients and carers, and 4) have justifiable resource implications use., Search Methods: We searched the Cochrane Stroke Group Trials Register (January 2017), Cochrane Central Register of Controlled Trials (CENTRAL 2017, Issue 1) in the Cochrane Library (searched January 2017), MEDLINE in Ovid (searched January 2017), Embase in Ovid (searched January 2017), CINAHL in EBSCO (Cumulative Index to Nursing and Allied Health Literature; 1937 to December 2016), and Web of Science (to January 2017). In an effort to identify further published, unpublished, and ongoing trials we searched six trial registries (March 2017). We also performed citation tracking of included studies, checked reference lists of relevant articles, and contacted trialists., Selection Criteria: Randomised controlled trials (RCTs) recruiting stroke patients in hospital to receive either conventional care or any service intervention that has provided rehabilitation and support in a community setting with an aim of reducing the duration of hospital care., Data Collection and Analysis: The primary patient outcome was the composite end-point of death or long-term dependency recorded at the end of scheduled follow-up. Two review authors scrutinised trials, categorised them on their eligibility and extracted data. Where possible we sought standardised data from the primary trialists. We analysed the results for all trials and for subgroups of patients and services, in particular whether the intervention was provided by a co-ordinated multidisciplinary team (co-ordinated ESD team) or not. We assessed risk of bias for the included trials and used GRADE to assess the quality of the body of evidence., Main Results: We included 17 trials, recruiting 2422 participants, for which outcome data are currently available. Participants tended to be a selected elderly group of stroke survivors with moderate disability. The ESD group showed reductions in the length of hospital stay equivalent to approximately six days (mean difference (MD) -5.5; 95% confidence interval (CI) -3 to -8 days; P < 0.0001; moderate-grade evidence). The primary outcome was available for 16 trials (2359 participants). Overall, the odds ratios (OR) for the outcome of death or dependency at the end of scheduled follow-up (median 6 months; range 3 to 12) was OR 0.80 (95% CI 0.67 to 0.95, P = 0.01, moderate-grade evidence) which equates to five fewer adverse outcomes per 100 patients receiving ESD. The results for death (16 trials; 2116 participants) and death or requiring institutional care (12 trials; 1664 participants) were OR 1.04 (95% CI 0.77 to 1.40, P = 0.81, moderate-grade evidence) and OR 0.75 (95% CI 0.59 to 0.96, P = 0.02, moderate-grade evidence), respectively. Small improvements were also seen in participants' extended activities of daily living scores (standardised mean difference (SMD) 0.14, 95% CI 0.03 to 0.25, P = 0.01, low-grade evidence) and satisfaction with services (OR 1.60, 95% CI 1.08 to 2.38, P = 0.02, low-grade evidence). We saw no clear differences in participants' activities of daily living scores, patients subjective health status or mood, or the subjective health status, mood or satisfaction with services of carers. We found low-quality evidence that the risk of readmission to hospital was similar in the ESD and conventional care group (OR 1.09, 95% CI 0.79 to 1.51, P = 0.59, low-grade evidence). The evidence for the apparent benefits were weaker at one- and five-year follow-up. Estimated costs from six individual trials ranged from 23% lower to 15% greater for the ESD group in comparison to usual care.In a series of pre-planned analyses, the greatest reductions in death or dependency were seen in the trials evaluating a co-ordinated ESD team with a suggestion of poorer results in those services without a co-ordinated team (subgroup interaction at P = 0.06). Stroke patients with mild to moderate disability at baseline showed greater reductions in death or dependency than those with more severe stroke (subgroup interaction at P = 0.04)., Authors' Conclusions: Appropriately resourced ESD services with co-ordinated multidisciplinary team input provided for a selected group of stroke patients can reduce long-term dependency and admission to institutional care as well as reducing the length of hospital stay. Results are inconclusive for services without co-ordinated multidisciplinary team input. We observed no adverse impact on the mood or subjective health status of patients or carers, nor on readmission to hospital.

Few studies have examined rates and causes of short-term readmissions among adults across age and insurance types. We compared rates, characteristics, and costs of 30-day readmission after all-cause hospitalizations across insurance types in the US. We retrospectively evaluated alive patients ≥18 years old, discharged for any cause, 1/1/13-11/31/13, 2006 non-federal hospitals in 21 states in the Nationwide Readmissions Database. The primary stratification variable of interest was primary insurance. Comorbid conditions were assessed based on Elixhauser comorbidities, as defined by administrative billing codes. Additional measures included diagnoses for index hospitalizations leading to rehospitalization. Hierarchical multivariable logistic regression models, with hospital site as a random effect, were used to calculate the adjusted odds of 30-day readmissions by age group and insurance categories. Cost and discharge estimates were weighted per NRD procedures to reflect a nationally representative sample. Diagnoses for index hospitalizations leading to rehospitalization were determined. Among 12,533,551 discharges, 1,818,093 (14.5%) resulted in readmission within 30 days. Medicaid insurance was associated with the highest adjusted odds ratio (AOR) for readmission both in those ≥65 years old (AOR 1.12, 95%CI 1.10-1.14; p <0.001), and 45-64 (AOR 1.67, 95% CI 1.66-1.69; p < 0.001), and Medicare in the 18-44 group (Medicare vs. private insurance: AOR 1.99, 95% CI 1.96-2.01; p <0.001). Discharges for psychiatric or substance abuse disorders, septicemia, and heart failure accounted for the largest numbers of readmissions, with readmission rates of 24.0%, 17.9%, 22.9% respectively. Total costs for readmissions were 50.7 billion USD, highest for Medicare (29.6 billion USD), with non-Medicare costs exceeding 21 billion USD. While Medicare readmissions account for more than half of the total burden of readmissions, costs of non-Medicare readmissions are nonetheless substantial. Medicaid patients have the highest odds of readmission in individuals older than age 44, commonly due to hospitalizations for psychiatric illness and substance abuse disorders. Medicaid patients represent a population at uniquely high risk for readmission.

Hospice care is designed to support patients and families through the final phase of illness and death. Yet for more than a decade, hospices have steadily increased the rate at which they discharge patients before death-a practice known as "live discharge." Although certain live discharges are consistent with high-quality care, regulators have expressed concern that some hospices' desire to maximize profits drives them to inappropriately discharge patients. We used Medicare claims data for 2012-13 and cost reports for 2011-13 to explore relationships between hospice-level financial margins and live discharge rates among freestanding hospices. Adjusted analyses showed positive and significant associations between both operating and total margins and hospice-level rates of live discharge: One-unit increases in operating and total margin were associated with increases of 3 percent and 4 percent in expected hospice-level live discharge rates, respectively. These findings suggest that additional research is needed to explore links between profitability and patient-centeredness in the Medicare hospice program., (Project HOPE—The People-to-People Health Foundation, Inc.)

Background: Bundled Payments for Care Improvement (BPCI) initiatives were developed by Medicare in an effort to reduce expenditures while preserving quality of care. Payment model 2 reimburses based on a target price for 90-day episode of care postprocedure. The challenge for valve patients is the historically high (>35%) 90-day readmission rate. We analyzed our institutional cardiac surgical service line adaptation to this initiative., Methods: On May 1, 2015, we instituted a readmission reduction initiative (RRI) that included presurgical risk stratification, comprehensive predischarge planning, and standardized postdischarge management led by cardiac nurse practitioners (CNPs) who attempt to guide any postdischarge encounters (PDEs). A prospective database also was developed, accruing data on all cardiac surgery patients discharged after RRI initiation. We analyzed detailed PDEs for all valve patients with complete 30-day follow-up through November 2015., Results: Patients included 219 surgical patients and 126 transcatheter patients. Sixty-four patients had 79 PDEs. Of these 79 PDEs, 46 (58.2%) were guided by CNPs. PDEs were due to fluid overload/effusion (21, 27%), arrhythmia (17, 22%), bleeding/thromboembolic events (13, 16%), and falls/somatic complaints (12, 15%). Thirty-day readmission rate was 10.1% (35/345). Patients with transcatheter aortic valve replacement had a higher rate of readmission than surgical patients (15.0% vs 6.9%), but were older with more comorbidities. The median readmission length of stay was 2.0 days (interquartile range 1.0-5.0 days). Compared with 2014, the 30-day readmission rate for BPCI decreased from 18% (44/248) to 11% (20/175), P = .05., Conclusions: Our reengineering of pre/postdischarge management of BPCI valve patients under tight CNP control has significantly reduced costly 30-day readmissions in this high-risk population., (Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Uninsured patients may not have access to postacute care facilities that play an important role in clinical recovery, and functional outcomes after vascular surgery. We sought to determine whether discharge disposition is associated with insurance status., Methods: We retrospectively reviewed data from the Vascular Quality Initiative ® for patients who underwent open abdominal aortic repair, infrainguinal bypass, or suprainguinal bypass (SB) between January 2012 and July 2015. Mixed-effects logistic regression analysis with clustering at the surgeon and facility level was used to calculate 95% confidence intervals for discharge disposition to home, skilled nursing facility (SNF) or rehabilitation (Rehab) facility by payer status (Medicare, Medicaid, Commercial, Military/Veterans Affairs, Non-US Insurance, or Self-pay), with adjustment for patient, operative, and postoperative characteristics., Results: The study cohort comprised 18,478 procedures (open abdominal aortic repair = 2,817; infrainguinal bypass = 11,572; suprainguinal bypass = 4,089) after we excluded procedures with missing data and in-hospital deaths. Twenty-four percent of the cohort was discharged to an SNF or Rehab site. On univariate analysis, the odds ratio (OR) of discharge home was 4.38 (95% CI: 3.33-5.77) for self-pay as compared to Medicare. On mixed-effects analysis, the adjusted odds of discharge home for self-pay as compared to Medicare remained high (OR = 3.09; 95% CI: 2.23-4.26), after adjustment for age, gender, race/ethnicity, preoperative ambulatory status, number of comorbidities, case urgency, total operative time, presence of a postoperative complication, procedure type, and length of stay. Adjusted odds for discharge to SNF (OR = 0.26; 95% CI: 0.15-0.46) and Rehab (OR = 0.50; 95% CI: 0.35-0.72) were lowest for self-pay status., Conclusions: Access to postacute care facilities is associated with insurance status. Self-pay (uninsured) patients are less likely to have access to discharge services that may aid clinical recovery, and functional outcomes after major vascular surgery., (Published by Elsevier Inc.)

Background: In April 2016, the U.S. Centers for Medicare & Medicaid Services initiated mandatory 90-day bundled payments for total hip and knee arthroplasty for much of the country. Our goal was to determine duration of care, 90-day charges, and readmission rates by discharge disposition and U.S. region after hip or knee arthroplasty., Methods: Using the 2008 Medicare Provider Analysis and Review database 100% sample, we identified patients who had undergone elective primary total hip or knee arthroplasty. We collected data on patient age, sex, comorbidities, U.S. Census region, discharge disposition, duration of care, 90-day charges, and readmission. Multivariate regression was used to assess factors associated with readmission (logistic) and charges (linear). Significance was set at p < 0.01., Results: Patients undergoing 138,842 total hip arthroplasties were discharged to home (18%), home health care (34%), extended-care facilities (35%), and inpatient rehabilitation (13%); patients undergoing 329,233 total knee arthroplasties were discharged to home (21%), home health care (38%), extended-care facilities (31%), and inpatient rehabilitation (10%). Patients in the Northeast were more likely to be discharged to extended-care facilities or inpatient rehabilitation than patients in other regions. Patients in the West had the highest 90-day charges. Approximately 70% of patients were discharged home from extended-care facilities, whereas after inpatient rehabilitation, >50% of patients received home health care. Among those discharged to home, 90-day readmission rates were highest in the South (9.6%) for patients undergoing total hip arthroplasty and in the Midwest (8.7%) and the South (8.5%) for patients undergoing total knee arthroplasty. Having ≥4 comorbidities, followed by discharge to inpatient rehabilitation or an extended-care facility, had the strongest associations with readmission, whereas the region of the West and the discharge disposition to inpatient rehabilitation had the strongest association with higher charges., Conclusions: Among Medicare patients, discharge disposition and number of comorbidities were most strongly associated with readmission. Inpatient rehabilitation and the West region had the strongest associations with higher charges., Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Exacerbations of COPD carry a huge burden of morbidity and a significant economic impact. It has been shown that home care may be useful for exacerbations of COPD. This article presents a review of an integrated COPD service in east London. Hospital Episode Statistics, Public Health Mortality Files and clinical data were used to analyze differences in health care usage and COPD patient outcomes, including COPD assessment test (CAT) scores for a subsample, before and after the introduction of the integrated service. There was a significant (30%) reduction in the number of hospital bed days for COPD patients ( P <0.05), alongside a significant increase in patients with only a short stay (0-1 days) in hospital ( P <0.0001). There was a significant increase in the number of patients dying outside of hospital (a proxy for quality of end-of-life care) following introduction of the service ( P =0.00015). Patients also reported a clinically significant improvement in CAT scores. A locally developed economic model shows that the economic benefits of the service (via impact on place of death and reduction in length of hospital stay) were almost equal to the cost of the service. The increase in proportion of short-stay admissions and the reduction in bed days suggest an impact of the service on early supported discharge and that this along with an improvement in patient clinical outcomes and in quality of end-of-life care shows that an exemplar integrated COPD service can provide benefits that equate to a nearly cost-neutral service., Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Context: The proportion of patients disenrolling from hospice before death has increased over the decade with significant variations across hospice types and regions. Such trends have raised concerns about live disenrollment's effect on care quality. Live disenrollment may be driven by factors other than patient preference and may create discontinuities in care, disrupting ongoing patient-provider relationships. Researchers have not explored when and how providers make this decision with patients., Objective: The objective of this study was to ascertain provider perspectives on key drivers of live discharge from the Medicare hospice program., Methods: We conducted semistructured telephone interviews with 18 individuals representing 14 hospice providers across the country. Transcriptions were coded and analyzed using a template analysis approach., Results: Analysis generated four themes: 1) difficulty estimating patient prognosis, 2) fear of Centers for Medicare & Medicaid Services audits, 3) rising market competition, and 4) challenges with inpatient contracting. Participants emphasized challenges underlying each decision to discharge patients alive, stressing that there often exists a gray line between appropriate and inappropriate discharges. Discussions also focused on scenarios in which financial motivations drive enrollment and disenrollment practices., Conclusion: This study provides significant contributions to existing knowledge about hospice enrollment and disenrollment patterns. Results suggest that live discharge patterns are often susceptible to market and regulatory forces, which may have contributed to the rising national rate., (Copyright © 2017 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Trauma patients represent a high-volume and high-acuity population. This makes discharge planning difficult. Discharged by noon is a metric shown to correlate with hospital throughput. Improvements in efficiency will be needed to improve resource utilization and increase discharge by noon rate. This study aimed to evaluate the impact of a standardized discharge team on length of stay and discharge by noon., Materials and Methods: A university level I trauma center implemented a discharge team composed of a trauma attending and an advanced practice provider. This team is tasked with evaluating patients on the discharge list daily. This allowed patients ready for discharge to be evaluated and discharged before noon. A retrospective review was performed to analyze discharge by noon rates before and after implementation of the discharge team., Results: A total of 3053 patients were discharged before the implementation of the discharge team and 3801 after. Discharges by noon increased from 25.5% to 51.2% in the post. For patients with an injury severity score >15, this same improvement was seen, 22.5% to 51.9%. Similar improvements were seen when controlling for final discharge disposition and primary payer status., Conclusions: By establishing a separate discharge team, large improvements can be seen in the discharge by noon rate. These improvements were maintained when controlling for injury severity score, final discharge disposition, and insurance status. Significant savings are possible in both charges to the patient and direct costs to the facility. The utilization of a discharge team should be considered at similar facilities., (Copyright © 2017 Elsevier Inc. All rights reserved.)

The Centers for Medicare & Medicaid Services requires hospitals to give patients an array of documents to explain their rights, their status, and any financial obligations they may incur — and it’s usually up to case managers to see that the hospital complies. •The Medicare Outpatient Observation Notice (MOON) is the latest requirement, but the Important Message (IM) from Medicare also is required under the Medicare Conditions of Participation. In order to bill patients for services that are incurred but not covered, hospitals also must give patients a Hospital Issued Notice of Noncoverage (HINN). •If the documents are delivered at the proper time, they could affect the hospital’s reimbursement, increase the risk of audit, and affect patients’ understanding of their rights and responsibilities. •The entire treatment team should be aware of the documents and intentions. Education on delivering these documents should be part of case management orientation and regular education. •Hospitals should develop a process for delivering HINNs if the need arises. Before that happens, case managers should communicate frequently with the patient and family about the next level of care. •Patients may demand that their status be changed from observation to inpatient, but they can’t be admitted unless they meet inpatient criteria.

Background: Pediatric interhospital transfers are an economic burden to the health care, especially when deemed unnecessary. Physicians may be unaware of the cost implications of pediatric emergency transfers. A cost analysis may be relevant to reduce cost., Objective: To characterize children transferred from outlying emergency departments (EDs) to pediatric ED (PED) with a specific focus on transfers who were discharged home in 12 hours or less after transfer without intervention in PED and analyze charges associated with them., Methods: Charts of 352 patients (age, 0-18 years) transferred from 31 outlying EDs to PED during July 2009 to June 2010 were reviewed. Data were collected on the range, unit charge and volume of services provided in PED, length of stay, and final disposition. The average charge per patient transfer is calculated based on unit charge times total service units per 1000 patients per year and divided by 1000. Hospital charges were divided into fixed and variable., Results: Of 352 patients transferred, 108 (30.7%) were admitted to pediatric inpatient service, 42 (11.9%) to intensive care; 36 (10.2%) went to the operating room, and 166 (47.2%) were discharged home. The average hospital charge per transfer was US $4843. Most (89%) of the charges were fixed, and 11% were variable. One hundred one (28.7%) patients were discharged home from PED in 12 hours or less without intervention. The hospital charges for these transfers were US $489,143., Conclusions: Significant number of transfers was discharged 12 hours or less without any additional intervention in PED. Fixed charges contribute to majority of total charges. Cost saving can be achieved by preventing unnecessary transfer.

Objectives: The aims of this study were to assess for changes in uninsured rates among trauma patients at age 64 versus 65 years and whether there are associated changes in post-discharge rehabilitation; determine whether changes are driven by rehabilitation provided at home, skilled nursing facilities (SNFs), or acute inpatient facilities; and determine whether changes vary among stratified subgroups of trauma-related "best-practice" factors., Summary Background Data: Rehabilitation is an important component of high-quality trauma systems with access heavily influenced by insurance status. In the wake of policy changes affecting insurance coverage, it remains unknown the extent to which insurance changes associate with variations in rehabilitation access/use among otherwise similar patients., Methods: Regression discontinuity models were used to assess for changes in insurance status and rehabilitation at age 64 versus 65 years among adults ages 54 to 75 years (±10 years age-related Medicare eligibility). Data were extracted from the 2007-2012 National Trauma Data Bank., Results: A total of 305,198 patients were included; 40.1% were discharged to rehabilitation. Medicare eligibility was associated with an abrupt 6.4 (95% confidence interval: 5.8-7.0) percentage-point decline in uninsured and a 9.6 (95% confidence interval: 6.5-12.6) percentage-point increase in rehabilitation at age 64 versus 65 years, enabling an additional 1-in-10 patients to access rehabilitation. Differences were driven by SNF use and were greatest among patients with less-severe clinical presentations. Restriction based on Medicare-payment eligibility to patients with length of stay ≥3days (SNF requirement) and ≥1 "presumptive diagnosis codes" (inpatient facilities' 60% rule) demonstrated abrupt gains in both SNF and inpatient care., Conclusions: The results reveal the magnitude of changes in access to rehabilitation associated with changes in insurance coverage at age 65 years. Use of quasiexperimental models enabled meaningful consideration of health-policy change.

Background: As payment shifts toward bundled reimbursement, decreasing unnecessary inpatient care may provide cost savings. This study examines the association between discharge status, hospital duration of stay, and cost for colorectal operation patients without complications and uses risk factors to predict the need for post-acute care., Methods: We used the New York Statewide Planning and Research Cooperative System and the California Healthcare Cost and Utilization Project State Inpatient Databases to identify all patients who underwent operative resection for colorectal cancer in 2009-2010 and were discharged to home or post-acute care. Patients with complications were excluded. Duration of stay and inpatient costs were calculated. Risk factors associated with discharge to post-acute care were identified using multivariable logistic regression and were incorporated into a model to predict discharge status., Results: A total of 5.4% of 23,942 patients were discharged to a post-acute care facility. Duration of sty was 2 days greater and $3,823 more costly for patients discharged to post-acute care. Significant risk factors included age, number of comorbidities, emergency admission, open operation, admission in the previous year, and a new ostomy. A scoring system using these factors accurately predicted discharge to post-acute care., Conclusion: Admissions after colorectal operations were greater and more costly for patients discharged to post-acute care even without operative complications. Risk factors can predict the need for post-acute care early in the postoperative course, thereby potentially facilitating early discharge planning., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Chronic obstructive pulmonary disease (COPD) is a leading cause of hospital admission, the fifth leading cause of death in North America, and is estimated to cost $49 billion annually in North America by 2020. The majority of COPD care costs are attributed to hospitalizations; yet, there are limited data to understand the drivers of high costs among hospitalized patients with COPD. In this study, we aimed to determine the patient and hospital-level factors associated with high-cost hospital care, in order to identify potential targets for the reorganization and planning of health services. We conducted a retrospective cohort study at a Canadian academic hospital between September 2010 and 2014, including adult patients with a first-time admission for COPD exacerbation. We calculated total costs, ranked patients by cost quintiles, and collected data on patient characteristics and health service utilization. We used multivariable regression to determine factors associated with highest hospital costs. Among 1,894 patients included in the study, the mean age was 73±12.6 years, median length of stay was 5 (interquartile range 3-9) days, mortality rate was 7.8% (n=147), and 9% (n=170) required intensive care. Hospital spending totaled $19.8 million, with 63% ($12.5 million) spent on 20% of patients. Factors associated with highest costs for COPD care included intensive care unit admission (odds ratio [OR] 32.4; 95% confidence interval [CI] 20.3, 51.7), death in hospital (OR 2.6; 95% CI 1.3, 5.2), discharge to long-term care facility (OR 5.7; 95% CI 3.5, 9.2), and use of the alternate level of care designation during hospitalization (OR 23.5; 95% CI 14.1, 39.2). High hospital costs are driven by two distinct groups: patients who require acute medical treatment for severe illness and patients with functional limitation who require assisted living facilities upon discharge. Improving quality of care and reducing cost in this high-needs population require a strong focus on early recognition and management of functional impairment for patients living with chronic disease., Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Aim: We aimed to summarize the pooled effect of early discharge compared with ordinary discharge after percutaneous coronary intervention (PCI) on the composite endpoint of re-infarction, revascularization, stroke, death, and incidence of rehospitalization. We also aimed to compare costs for the two strategies., Methods: The study was a systematic review and a meta-analysis of 12 randomized controlled trials including 2962 patients, followed by trial sequential analysis. An estimation of cost was considered. Follow-up time was 30 days., Results: For early discharge, pooled effect for the composite endpoint was relative risk of efficacy (RRe)=0.65, 95% confidence interval (CI) (0.52-0.81). Rehospitalization had a pooled effect of RRe=1.10, 95% CI (0.88-1.38). Early discharge had an increasing risk of rehospitalization with increasing frequency of hypertension for all populations, except those with stable angina, where a decreasing risk was noted. Advancing age gave increased risk of revascularization. Early discharge had a cost reduction of 655 Euros per patient compared with ordinary discharge., Conclusion: The pooled effect supports the safe use of early discharge after PCI in the treatment of a heterogeneous population of patients with coronary artery disease. There was an increased risk of rehospitalization for all subpopulations, except patients with stable angina. Clinical trials with homogeneous populations of acute coronary syndrome are needed to be conclusive on this issue., Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Objective: Acute pancreatitis is a common inpatient diagnosis among gastrointestinal disorders. The aim of this study was to evaluate the incidence of inpatient admissions, costs, and mortality rates associated with acute pancreatitis in the United States., Methods: We analyzed the National Inpatient Sample for all patients in which acute pancreatitis (International Classification of Diseases, Ninth Revision code: 577.0) was the principal discharge diagnosis during the period 1997-2012. The statistical significance of the difference in the hospital discharges, length of stay, and costs over the study period was determined by utilization of regression analysis., Results: In 1997, there were 164,776 admissions with a principal discharge diagnosis of acute pancreatitis as compared with 275,170 in 2012 (P < 0.001). The mean length of stay for acute pancreatitis decreased from 6.4 days in 1997 to 4.7 days in 2012 (P < 0.001). However, during this period, the mean hospital charges increased by 118.6% from $15,433 in 1997 to $33,744 in 2012 (P < 0.001). The in-hospital mortality rate decreased significantly from 1.9% in 1997 to 0.78% in 2012 (P < 0.001)., Conclusions: Inpatient admissions for acute pancreatitis and associated costs have increased markedly over the last 16 years in the United States. However, the lengths of stay and mortality rates have decreased significantly.