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Background: Anterior cruciate ligament reconstruction (ACLR) is one of the most commonly performed orthopaedic procedures in the United States, and the number of procedures is increasing annually, as is the cost. Patients are expected to shoulder a larger out-of-pocket expenditure. Purpose: To answer the following questions: (1) How is reimbursement changing for ACLR, and how is this affecting patients’ out-of-pocket expenditures? (2) How are reimbursements from payers and patients’ out-of-pocket expenses for ACLR distributed, and how is this changing? (3) Does performing ACLR in an ambulatory surgery center (ASC) result in lower costs for payers and patients? Study Design: Economic and decision analysis study; Level of evidence, 4. Methods: A total of 37,763 patients who underwent outpatient primary arthroscopic ACLR in the United States between 2013 and 2017 were identified using the IBM MarketScan Commercial Claims and Encounters Database. Patients with concomitant procedures and revision ACLR were excluded. Recorded outcomes were total patient payments and reimbursed claim totals in US dollars. Results: Day-of-surgery reimbursement decreased 4.3% from $11,536 in 2013 to $11,044 in 2017, while patient out-of-pocket expenses increased 36% from $1085 in 2013 to $1480 in 2017. Day-of-surgery charges were the highest expense for patients, followed by physical therapy and magnetic resonance imaging (MRI) costs. Total reimbursement for MRI decreased 22.5%, while patient out-of-pocket expenses for MRI increased 166%. ACLR performed in an outpatient hospital resulted in 61% greater day-of-surgery expenditure for payers compared with ACLR performed in an ASC; however, the median total patient out-of-pocket savings for ACLRs performed in an ASC versus outpatient hospital was only $11. Conclusion: Out-of-pocket expenses for patients are increasing as they are forced to cover a larger percentage of their health care costs despite overall payer reimbursement decreasing. High-deductible health plans reimbursed the least out of all insurance types while having the highest patient out-of-pocket expenditure.

Background: Anterior cruciate ligament reconstruction (ACLR) is a commonly performed orthopaedic procedure. The volume and cost of ACLR procedures are increasing annually, but the drivers of these cost increases are not well described. Purpose: To analyze the modifiable drivers of total health care utilization (THU), immediate procedure reimbursement, and surgeon reimbursement for patients undergoing ACLR using a large national commercial insurance database from 2013 to 2017. Study Design: Descriptive epidemiology study. Methods: For this study, the cohort consisted of patients identified in the MarketScan Commercial Claims and Encounters database who underwent outpatient arthroscopic ACLR in the United States from 2013 to 2017. Patients with Current Procedural Terminology code 29888 were included. THU was defined as the sum of any payment related to the ACLR procedure from 90 days preoperatively to 180 days postoperatively. A multivariable model was utilized to describe the patient- and procedure-related drivers of THU, immediate procedure reimbursement, and surgeon reimbursement. Results: There were 34,862 patients identified. On multivariable analysis, the main driver of THU and immediate procedure reimbursement was an outpatient hospital as the surgical setting (US$6789 increase in THU). The main driver of surgeon reimbursement was an out-of-network surgeon (US$1337 increase). Health maintenance organization as the insurance plan type decreased THU, immediate procedure reimbursement, and surgeon reimbursement (US$955, US$108, and US$38 decrease, respectively, compared with preferred provider organization; P < .05 for all). Conclusion: Performing procedures in more cost-efficient ambulatory surgery centers had the largest effect on decreasing health care expenditures for ACLR. Health maintenance organizations aided in cost-optimization efforts as well, but had a minor effect on surgeon reimbursement. Overall, this study increases transparency into what drives reimbursement and serves as a foundation for how to decrease health care expenditures related to ACLR.

Objectives: Anterior cruciate ligament reconstruction (ACLR) is one of the most performed orthopedic procedures in the United States and the volume and cost are increasing annually. Patients are increasingly expected to share a larger economic burden with out-of-pocket expenditures. Recently, there has been a shift to perform more ACLR surgeries outside of the hospital setting to reduce costs. The purpose of this project is to understand the differences in costs between ACLR performed in ambulatory surgery center (ASC) versus outpatient hospital settings and if or how this affects the patient’s out-of-pocket expenditure. Methods: We identified patients who had undergone outpatient arthroscopic ACLR in the United States (U.S.) using the IBM MarketScan Commercial Claims and Encounters Database. The database was chosen for its large, national sample of privately insured patients. Patients who had Current Procedural Terminology (CPT) code 29888 between April 1, 2013 and June 30, 2017 were included. Revision ACL procedures and procedures with a concomitant microfracture, medial collateral ligament, lateral collateral ligament, or posterior cruciate ligament repair or reconstruction (CPT: 29879, 27405, 27409, 27427, 29889) were excluded. Day-of-surgery expenditure was identified by summing all claims billed with an “immediate-procedure-related code” in a 3-day window surrounding the date of the procedure (Procedure Date ± 1 Day). The day-of-surgery expenditure was broken down into implant, anesthesia services, regional anesthesia, operating room facility, surgical team, and other expenditures. Regional anesthesia is not included in anesthesia services expenditure. Median and interquartile range were calculated for each variable. The breakdown of day-of-surgery expenditure and patient out-of-pocket expenditure between the outpatient hospital and ASC settings were compared using two-tailed Mann Whitney U Tests. Spearman Rank Order Correlation was done for all variables to test for association between expenditure and year to determine trends over time. All values were inflation adjusted to 2017 dollars. Results: A total of 34,862 patients were identified. Our results indicated that ACLR performed in the outpatient hospital setting result in 60% greater day-of-surgery expenditure (p < 0.001) than in the ASC setting. In the outpatient hospital setting, operating room facility cost was 36% greater (p Conclusions: ACLR performed in an ASC setting results in significant cost savings for payers with no change in surgeon reimbursement. Most of the cost savings came from operating room facility expenditure. For patients, there is almost no financial difference regarding where the ACLR was performed, with the difference in patient out-of-pocket expenditure being less than $10. For the surgeon, surgical team reimbursements are essentially neutral between the ASC and outpatient hospital settings. However, the overall trend in surgical team reimbursement is downwards in both the ASC and outpatient hospital settings. For the two biggest stakeholders in the surgery (surgeon and patient), there are no financial incentives to do an ACLR at an outpatient hospital over an ASC. For a healthcare system, especially under a population health perspective, the incentive to perform ACLRs at an ASC is significant. The cost savings come from every breakdown category, with implant and operating room facility costs being significantly decreased in the ASC setting. Decreased implant costs were likely due to preferred vendor contracts for ASCs. The cost savings achieved per ACLR in an ASC vs. an outpatient hospital equals almost $6000. With nearly 100,000 ACLRs performed per year, the U.S. healthcare system could save a projected $600 million per year on ACLRs alone when the surgery is performed in an ASC. Thus, our study shows that there is a clear financial advantage to the healthcare system for ACLRs being done at ASCs, although the patient does not realize these cost savings. [Figure: see text][Table: see text][Table: see text][Table: see text]

Sepsis, a life-threatening organ dysfunction caused by a dysregulated host response, leads the U.S in both mortality rate and cost of treatment. Sepsis treatment protocols currently rely on broad and non-specific parameters like heart and respiration rate, and temperature; however, studies show that biomarkers Interlukin-6 (IL-6) and Procalcitonin (PCT) correlate to sepsis progression and response to treatment. Prior work also suggests that using multi-parameter predictive analytics with biomarkers and clinical information can inform treatment to improve outcome. A point-of-care (POC) platform that provides information for multiple biomarkers can aid in the diagnosis and prognosis of potentially septic patients. Using impedance cytometry, microbead immunoassays, and biotin-streptavidin binding, we report a microfluidic POC system that correlates microbead capture to IL-6 and PCT concentrations. A multiplexed microbead immunoassay is developed and validated for simultaneous detection of both IL-6 and PCT from human plasma samples. Using the POC platform, we quantified plasma samples containing healthy, medium (~103pg/ml) and high (~105pg/ml) IL-6 and PCT concentrations with various levels of significance (P

Sepsis, a life-threatening syndrome that contributes to millions of deaths annually worldwide, represents a moral and economic burden to the healthcare system. Although no single, or even a combination of biomarkers has been validated for the diagnosis of sepsis, multiple studies have shown the high specificity of CD64 expression on neutrophils (nCD64) to sepsis. The analysis of elevated nCD64 in the first 2-6 hours after infection during the pro-inflammatory stage could significantly contribute to early sepsis diagnosis. Therefore, a rapid and automated device to periodically measure nCD64 expression at the point-of-care (POC) could lead to timely medical intervention and reduced mortality rates. Current accepted technologies for measuring nCD64 expression, such as flow cytometry, require manual sample preparation and long incubation times. For POC applications, however, the technology should be able to measure nCD64 expression with little to no sample preparation. In this paper, we demonstrate a smartphone-imaged microfluidic biochip for detecting nCD64 expression in under 50 min. In our assay, first unprocessed whole blood is injected into a capture chamber to immunologically capture nCD64 along a staggered array of pillars, which were previously functionalized with an antibody against CD64. Then, an image of the capture channel is taken using a smartphone-based microscope. This image is used to measure the cumulative fraction of captured cells (γ) as a function of length in the channel. During the image analysis, a statistical model is fitted to γ in order to extract the probability of capture of neutrophils per collision with a pillar (e). The fitting shows a strong correlation with nCD64 expression measured using flow cytometry (R2 = 0.82). Finally, the applicability of the device to sepsis was demonstrated by analyzing nCD64 from 8 patients (37 blood samples analyzed) along the time they were admitted to the hospital. Results from this analysis, obtained using the smartphone-imaged microfluidic biochip were compared with flow cytometry. Again, a correlation coefficient R2 = 0.82 (slope = 0.99) was obtained demonstrating a good linear correlation between the two techniques. Deployment of this technology in ICU could significantly enhance patient care worldwide.