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Economic Burden of Postoperative Neurocognitive Disorders Among US Medicare Patients.

ABSTRACT: Importance:Postoperative neurocognitive disorders (PNDs) after surgical procedures are common and may be associated with increased health care expenditures. Objective:To quantify the economic burden associated with a PND diagnosis in 1 year following surgical treatment among older patients in the United States. Design, Setting, and Participants:This retrospective cohort study used claims data from the Bundled Payments for Care Improvement Advanced Model from 4285 hospitals that submitted Medicare Fee-for-service (FFS) claims between January 2013 and December 2016. All Medicare patients aged 65 years or older who underwent an inpatient hospital admission associated with a surgical procedure, did not experience a PND before index admission, and were not undergoing dialysis or concurrently enrolled in Medicaid were included. Data were analyzed from October 2019 and May 2020. Exposures:PND, defined as an International Classification of Diseases, Ninth or Tenth Revision, diagnosis of delirium, mild cognitive impairment, or dementia within 1 year of discharge from the index surgical admission. Main Outcomes and Measures:The primary outcome was total inflation-adjusted Medicare postacute care payments within 1 year after the index surgical procedure. Results:A total of 2?380?473 patients (mean [SD] age, 75.36 (7.31) years; 1?336?736 [56.1%] women) who underwent surgical procedures were included, of whom 44?974 patients (1.9%) were diagnosed with a PND. Among all patients, most were White (2?142?157 patients [90.0%]), presenting for orthopedic surgery (1?523?782 patients [64.0%]) in urban medical centers (2?179?893 patients [91.6%]) that were private nonprofits (1?798?749 patients [75.6%]). Patients with a PND, compared with those without a PND, experienced a significantly longer hospital length of stay (mean [SD], 5.91 [6.01] days vs 4.29 [4.18] days; P?

SUBMITTER: Boone MD

PROVIDER: S-EPMC7395237 | biostudies-literature | 2020 Jul

REPOSITORIES: biostudies-literature

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Economic Burden of Postoperative Neurocognitive Disorders Among US Medicare Patients.

Boone M Dustin MD Sites Brian B von Recklinghausen Friedrich M FM Mueller Ariel A Taenzer Andreas H AH Shaefi Shahzad S

JAMA network open 20200701 7

<h4>Importance</h4>Postoperative neurocognitive disorders (PNDs) after surgical procedures are common and may be associated with increased health care expenditures.<h4>Objective</h4>To quantify the economic burden associated with a PND diagnosis in 1 year following surgical treatment among older patients in the United States.<h4>Design, setting, and participants</h4>This retrospective cohort study used claims data from the Bundled Payments for Care Improvement Advanced Model from 4285 hospitals ...[more]

PMID: 32735336

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Project description:BackgroundPostoperative neurocognitive disorders (PNDs) is common among surgical patients, however, the effect of glucocorticoids for preventing PNDs is not clear. This review aims to evaluate the effect of glucocorticoids on the incidence of PNDs in adult patients undergoing surgery.MethodsThe databases of PubMed/Medline, Embase, the Cochrane Library, and Web of science were searched for all available randomized controlled trials (RCTs) from inception to April 30, 2022. RCTs comparing the effect of glucocorticoids with placebo on the incidence of PNDs in adult surgical patients (≥18 years old) were eligible. Subgroup analyses and meta-regressions were performed to evaluate sources of clinical heterogeneity. The level of certainty for main outcomes were assessed by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.ResultsEleven trials with a total of 10,703 patients were identified. Compared with the control group, glucocorticoids did not reduce the incidence of PNDs (RR: 0.84, 95% CI: 0.67 to 1.06, P = 0.13, GRADE = moderate). Secondary analyses for primary outcome did not change the result. In addition, the length of ICU stay was decreased in glucocorticoids group (RR: -13.58, 95% CI: -26.37 to -0.80, P = 0.04, GRADE = low). However, there were no significant differences between groups with regards to the incidence of postoperative infection (RR: 0.94, 95% CI: 0.84 to 1.06, P = 0.30, GRADE = moderate), blood glucose level (RR: 1.05, 95% CI: -0.09 to 2.19, P = 0.07, GRADE = low), duration of mechanical ventilation (RR: -2.44, 95% CI: -5.47 to 0.59, P = 0.14, GRADE = low), length of hospital stay (RR: -0.09, 95% CI: -0.27 to 0.09, P = 0.33, GRADE = moderate) and 30-day mortality (RR: 0.86, 95% CI: 0.70 to 1.06, P = 0.16, GRADE = moderate).ConclusionsThis meta-analysis suggests that perioperative administration of glucocorticoids may not reduce the incidence of PNDs after surgery. The effect of glucocorticoids on decreased length of ICU stay needs further researches. Future high-quality trials using acknowledged criteria and validated diagnostic tools are needed to determine the influence of glucocorticoids on long-term PNDs.Systematic review registrationhttps://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022302262, identifier: CRD42022302262.

Project description:BackgroundHyperkalemia (serum potassium >5.0 mEq/L) may be caused by reduced kidney function and drugs affecting the renin-angiotensin-aldosterone system and is often present in patients with chronic kidney disease (CKD).ObjectiveTo quantify the burden of hyperkalemia in US Medicare fee-for-service and commercially insured populations using real-world claims data, focusing on prevalence, comorbidities, mortality, medical utilization, and cost.MethodsA descriptive, retrospective claims data analysis was performed on patients with hyperkalemia using the 2014 Medicare 5% sample and the 2014 Truven Health Analytics MarketScan Commercial Claims and Encounter databases. The starting study samples required patient insurance eligibility during ?1 months in 2014. The identification of hyperkalemia and other comorbidities required having ?1 qualifying claims in 2014 with an appropriate International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code in any position. To address the differences between patients with and without hyperkalemia, CKD subsamples were analyzed separately. Mortality rates were calculated in the Medicare sample population only. The claims were grouped into major service categories; the allowed costs reflected all costs incurred by each cohort divided by the total number of member months for that cohort.ResultsThe prevalence of hyperkalemia in the Medicare and commercially insured samples was 2.3% and 0.09%, respectively. Hyperkalemia was associated with multiple comorbidities, most notably CKD. The prevalence of CKD in the Medicare and the commercially insured members with hyperkalemia was 64.8% and 31.8%, respectively. After adjusting for CKD severity, the annual mortality rate for Medicare patients with CKD and hyperkalemia was 24.9% versus 10.4% in patients with CKD without hyperkalemia. The allowed costs in patients with CKD and hyperkalemia in the Medicare and commercially insured cohorts were more than twice those in patients with CKD without hyperkalemia. Inpatient care accounted for >50% of costs in patients with CKD and hyperkalemia.ConclusionHyperkalemia is associated with substantial clinical and economic burden among US commercially insured and Medicare populations.

Project description:BackgroundIt remains unknown whether there is a causal relationship between intraoperative hypotension and postoperative neurocognitive disorders. We tested the hypothesis that personalised-compared to routine-intraoperative blood pressure management reduces the incidence of postoperative neurocognitive disorders in patients having major noncardiac surgery.MethodsIn this single-centre trial, 328 elective major noncardiac surgery patients were randomly allocated to receive personalised blood pressure management (i.e. maintaining intraoperative mean arterial pressure [MAP] above preoperative baseline MAP from automated 24-h blood pressure monitoring) or routine blood pressure management (i.e. maintaining MAP above 65 mm Hg). The primary outcome was the incidence of neurocognitive disorders (composite of delayed neurocognitive recovery and delirium) between postoperative days 3 and 7.ResultsThe primary outcome, neurocognitive disorders, occurred in 18 of 147 patients (12%) assigned to personalised and 21 of 148 patients (14%) assigned to routine blood pressure management (odds ratio [OR]=0.84, 95% confidence interval [CI]: 0.40-1.75, P=0.622). Delayed neurocognitive recovery occurred in 17 of 146 patients (12%) assigned to personalised and 17 of 145 patients (12%) assigned to routine blood pressure management (OR=0.99, 95% CI: 0.45-2.17, P=0.983). Delirium occurred in 2 of 157 patients (1%) assigned to personalised and 4 of 158 patients (3%) assigned to routine blood pressure management (OR=0.50, 95% CI: 0.04-3.53, P=0.684).ConclusionsPersonalised intraoperative blood pressure management maintaining preoperative baseline MAP neither reduced the incidence of the composite primary outcome neurocognitive disorders between postoperative days 3 and 7 nor the incidences of the components of the composite primary outcome-delayed neurocognitive recovery and delirium-compared to routine blood pressure management in patients having major noncardiac surgery.Clinical trial registrationClinicalTrials.gov (NCT03442907).

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Economic Burden of Postoperative Neurocognitive Disorders Among US Medicare Patients.

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Economic Burden of Postoperative Neurocognitive Disorders Among US Medicare Patients.

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