Inpatient Costs of Treating Patients With COVID-19

Importance

With more than 6.2 million hospitalizations due to COVID-19 in the US, recognition of the average hospital costs to provide inpatient care during the pandemic is necessary to understanding the national medical resource use and improving public health readiness and related policies.

Objective

To examine the mean cost to provide inpatient care to treat COVID-19 and how it varied through the pandemic waves and by important sociodemographic patient characteristics.

Design, Setting, and Participants

This cross-sectional study used inpatient-level data from March 1, 2020, to March 31, 2022, extracted from a repository of clinical, administrative, and financial information covering 97% of academic medical centers across the US.

Main Outcomes and Measures

Cost to produce care for each stay was calculated using direct hospital costs to provide care adjusted for geographic differences in labor costs using area wage indices.

Results

The sample included 1 333 404 stays with a primary or secondary COVID-19 diagnosis from 841 hospitals. The cohort included 692 550 (52%) men, with mean (SD) age of 59.2 (17.5) years. The adjusted mean cost of an inpatient stay was $11 275 (95% CI, $11 252-$11 297) overall, increasing from $10 394 (95% CI, $10 228-$10 559) at the end of March 2020 to $13 072 (95% CI, $12 528-$13 617) by the end of March 2022. Patients with specific comorbidities had significantly higher mean costs than their counterparts: those with obesity incurred an additional $2924 in inpatient stay costs, and those with coagulation deficiency incurred an additional $3017 in inpatient stay costs. Stays during which the patient required extracorporeal membrane oxygenation (ECMO) had an adjusted mean cost of $36 484 (95% CI, $34 685-$38 284).

Conclusions and Relevance

In this cross-sectional study, an adjusted mean hospital cost to provide care for patients with COVID-19 increased more than 5 times the rate of medical inflation overall. This appeared to be explained partly by changes in the use of ECMO, which increased over time.

Surge in Incidence and COVID-19 Hospital Risk of Death, United States, September 2020 to March 2021

Background

Studies of the early months of the coronavirus disease 2019 (COVID-19) pandemic indicate that patient outcomes may be adversely affected by surges. However, the impact on in-hospital mortality during the largest surge to date, September 2020–March 2021, has not been studied. This study aimed to determine whether in-hospital mortality was impacted by the community surge of COVID-19.

Methods

This is a retrospective cohort study of 416 962 adult COVID-19 patients admitted immediately before or during the surge at 229 US academic and 432 community hospitals in the Vizient Clinical Database. The odds ratios (ORs) of death among hospitalized patients during each phase of the surge was compared with the corresponding odds before the surge and adjusted for demographic, comorbidity, hospital characteristic, length of stay, and complication variables.

Results

The unadjusted proportion of deaths among discharged patients was 9% in both the presurge and rising surge stages but rose to 12% during both the peak and declining surge intervals. With the presurge phase defined as the referent, the risk-adjusted ORs (aORs) for the surge periods were rising, 1.14 (1.10–1.19), peak 1.37 (1.32–1.43), and declining, 1.30 (1.25–1.35). The surge rise in-hospital mortality was present in 7 of 9 geographic divisions and greater for community hospitals than for academic centers.

Conclusions

These data support public policies aimed at containing pandemic surges and supporting healthcare delivery during surges.

A Structural, Cognitive, and Behavioral Model for Error Analysis of Group B Streptococcus Prophylaxis in Pregnancy

The objective of this study was to develop a structural-cognitive-behavioral model for error analysis of group B streptococcus (GBS) prophylaxis failure, classify delivery cases into this model, and examine compliance with treatment guidelines. A retrospective, cohort study was conducted of women with liveborn pregnancies greater than 24 weeks in April 2018 at a single hospital. We created a structural-cognitive-behavioral model of five assessments for adherence to GBS prophylaxis guidelines and then classified these into four distinct error stages. A descriptive analysis was performed to determine if the pregnancy had a perfect process, a GBS prophylaxis failure, or a fortuitous outcome. There were 313 women who met the study criteria. The rate of GBS positive was 12.8%, negative 37.4%, and unknown 49.8%. The most common errors were cognitive perception errors related to incorrectly documenting GBS status, 57.7% ( N  = 79). Of these errors, 15.2% ( N  = 12) led to GBS prophylaxis failure. Perfect outcomes occurred in 62.7% ( N  = 196) women, GBS prophylaxis failure occurred in 13.7% ( N  = 43), and fortuitous outcomes occurred in 23.6% ( N  = 74). In our study, we were able to identify structural, cognitive, and behavioral errors that contribute to GBS prophylaxis failures. In other cases, these errors may contribute to fortuitous outcomes.

Leveraging a health information exchange for analyses of COVID-19 outcomes including an example application using smoking history and mortality

Understanding sociodemographic, behavioral, clinical, and laboratory risk factors in patients diagnosed with COVID-19 is critically important, and requires building large and diverse COVID-19 cohorts with both retrospective information and prospective follow-up. A large Health Information Exchange (HIE) in Southeast Texas, which assembles and shares electronic health information among providers to facilitate patient care, was leveraged to identify COVID-19 patients, create a cohort, and identify risk factors for both favorable and unfavorable outcomes. The initial sample consists of 8,874 COVID-19 patients ascertained from the pandemic's onset to June 12th, 2020 and was created for the analyses shown here. We gathered demographic, lifestyle, laboratory, and clinical data from patient's encounters across the healthcare system. Tobacco use history was examined as a potential risk factor for COVID-19 fatality along with age, gender, race/ethnicity, body mass index (BMI), and number of comorbidities. Of the 8,874 patients included in the cohort, 475 died from COVID-19. Of the 5,356 patients who had information on history of tobacco use, over 26% were current or former tobacco users. Multivariable logistic regression showed that the odds of COVID-19 fatality increased among those who were older (odds ratio = 1.07, 95% CI 1.06, 1.08), male (1.91, 95% CI 1.58, 2.31), and had a history of tobacco use (2.45, 95% CI 1.93, 3.11). History of tobacco use remained significantly associated (1.65, 95% CI 1.27, 2.13) with COVID-19 fatality after adjusting for age, gender, and race/ethnicity. This effort demonstrates the impact of having an HIE to rapidly identify a cohort, aggregate sociodemographic, behavioral, clinical and laboratory data across disparate healthcare providers electronic health record (HER) systems, and follow the cohort over time. These HIE capabilities enable clinical specialists and epidemiologists to conduct outcomes analyses during the current COVID-19 pandemic and beyond. Tobacco use appears to be an important risk factor for COVID-19 related death.

Analysis, synthesis, formulation, and field testing of three major components of male mediterranean fruit fly pheromone

Three major components, ethyi-(E)-3-octenoate, geranyl acetate, and (E,E)-α-farnesene, emitted as volatiles by laboratory-reared and wild male medflies were collected and analyzed qualitatively and quantitatively. Peak emission of these compounds occurred during the third to fifth hours of the photophase and differences were observed in the ratios of the three components emitted by male laboratory-reared and wild flies. These three compounds were synthesized, and a method was developed to formulate a synthetic blend that released the compounds in a ratio similar to that emitted by wild male medflies. Attractiveness of the blend to female medflies was demonstrated under field conditions by comparing trap catches. Black spherical traps, baited with the synthetic blend to release 1.6 male equivalents, caught significantly more females than blank traps and traps from which the blend released was 0.3, 3.2 or 6.4 male equivalents.

Effectiveness of bar coded medication alerts for elevated potassium

Bar coded medication administration (BCMA), the automated electronic verification of medications by nurses at the patient bedside, provides an additional layer of safety to the process of medication administration in the hospital setting. We performed a retrospective, descriptive study of BCMA alerts for elevated potassium (>5.5 mg/dL) in place within a multihospital healthcare system. Overall, 642 BCMA alerts were analyzed with a 21.3% acceptance rate. In subgroup analysis, we found that the BCMA acceptance rate was 6.9% for patients aged less than one year, and 85.6% for patients aged greater than one year. The major contributing factor to the low overall acceptance rate was the high frequency of alerts in patients less than 1 year of age. Modifications to rules logic may be necessary for this specific population. While BCMA alerts can beneficial, they should be carefully implemented with periodic post-implementation analysis and refinement.

Therapeutic hypothermia after cardiac arrest - implementation in UK intensive care units

A telephone survey was carried out to determine how many United Kingdom intensive care units were using therapeutic hypothermia as part of their management of unconscious patients admitted after cardiac arrest. All 247 intensive care units listed in the 2008 Directory of Critical Care Services were contacted to determine how many units were using hypothermia as part of their post-cardiac arrest management and how it was implemented. We obtained information from 243 (98.4%) of the intensive care units. At the time of the study, 208 (85.6%) were using hypothermia as part of post-cardiac arrest management. There has been a steady increase annually in the number of units performing therapeutic cooling from 2003 to date, with the majority of units starting in 2007 or 2008. The International Liaison Committee on Resuscitation guidelines, which recommend the use of therapeutic hypothermia for comatose patients following successful resuscitation from cardiac arrest, have taken at least 4-5 years to achieve widespread implementation in the United Kingdom.

Straight talk--new approaches in healthcare. The road to a digital healthcare community. Panel discussion

Healthcare organizations are often criticized for skeptically deferring the purchase of information technologies that can improve the safety, quality and efficiency of patient care. But some forward-thinking healthcare organizations have broken out of the pack, leveraging leading-edge technologies to gain a competitive advantage. They integrate information technologies across the enterprise, allowing them to compress processes, adapt to market forces and generate the kind of quality data that payers, physicians and patients expect. In this installment of Straight Talk, we discuss the strategies that three organizations have deployed successfully to move themselves along the digital continuum. Modern Healthcare and PricewaterhouseCoopers present Straight Talk. The session on digital healthcare was held on May 3, 2005 at Modern Healthcare's Chicago headquarters. Fawn Lopez, publisher of Modern Healthcare, was the moderator.

Age related neural adaptation following short term resistance training in women

BACKGROUND

This study examined the influence of age on neural facilitation and neural cross-education following short term unilateral dynamic resistance training with the hypothesis that older women may have a diminished ability for adaptation.

METHODS

EXPERIMENTAL DESIGN

This was a prospective, repeated measures design. The non-dominant left arm served as a control limb and follow-up testing was performed two weeks after pretesting.

SETTING

Testing was conducted in the Neuromuscular Research Laboratory at the University of Oklahoma.

PATIENTS

20 females (n=10, young (YF) 20.8+/-0.1 yrs; n=10, older (OF) 58.1+/-0.14) were assessed.

INTERVENTIONS

14 days of training of the right elbow flexors only. On each day, subjects performed four sets of ten repetitions using 70 percent of maximal strength of the biceps brachii.

MEASURES

The following variables in both right and left elbow flexor muscle groups were evaluated; isometric strength (IMS), efficiency of electrical activity (EEA) and estimated upper arm cross-sectional area (CSA).

RESULTS

There were significant increases (p<or=0.01) in IMS of both the right (28 percent) and left (12-15 percent) muscle groups for both age groups. Strength improvements were explained by neural adaptation since there were no changes in upper arm CSA but consistent decreases in EEA (12-16 percent). While OF had consistently lower values for all variables, there were no significant age effects.

CONCLUSIONS

Short term unilateral dynamic resistance training is a sufficient stimulus to induce significant strength increases in both trained and untrained contralateral limbs and that a neural mechanism is responsible for the muscular adaptation in both young and older women. Implication exists for unilateral stroke victims, individuals with single hip or knee replacements, or single limb casts.

Anti-sense oligonucleotides, for progestin receptors in the VMH and glutamic acid decarboxylase in the VTA, attenuate progesterone-induced lordosis in hamsters and rats

Immunocytochemical (ICC) staining for progesterone (P) receptors (PRs) and glutamic acid decarboxylase (GAD), the enzyme responsible for GABA production, reveal that there are many PRs in the ventral medial hypothalamus (VMH) and many GAD containing neurons in the ventral tegmental area (VTA). To investigate P's action on lordosis in the VMH and VTA, anti-sense oligos specific to PRs and GAD(65&67) were intracerebrally infused into the VMH and VTA of 24 ovariectomized hamsters and 40 ovariectomized rats. Estradiol benzoate (2 microg) primed hamsters and rats were infused to the VMH and the VTA with either PR (250 ng/1.0 microl infusion) or GAD (500 ng/1.0 microl infusion) anti-sense oligos, their scramble controls, or saline vehicle at hour 0 and again at hour 24. At hr 44, rodents were subcutaneously injected with P (500 microg) and were tested for sexual receptivity with a male 4 h later. There were significant reductions in lordosis of hamsters and rats following PR anti-sense infusions to the VMH compared to scrambled or vehicle control infusions. Effects of PR anti-sense to the VMH were not different from combined VMH and VTA PR anti-sense infusions; however, VMH infusions reduced lordosis compared to VTA-only anti-sense infusions. GAD anti-sense infusions reduced lordosis when infused into the VTA, compared to scrambled or saline vehicle infusions. Lordosis responsiveness following VTA GAD anti-sense infusions was not different from combined VMH and VTA infusions, but VTA infusions of GAD anti-sense reduced lordosis compared to VMH-only anti-sense infusions. These data suggest that in the VMH, PRs are important for P-facilitated lordosis, whereas in the VTA, GABAergic neurons may be an important substrate for mediating P's actions on lordosis of rodents.

Clinical benefits of endoscopic vein harvesting in patients with risk factors for saphenectomy wound infections undergoing coronary artery bypass grafting

OBJECTIVE

The influence of endoscopic harvesting techniques on the prevalence of leg-wound complications after coronary artery bypass grafting remains to be defined for patients at high risk for the development of wound infections.

METHODS

Among 1473 patients undergoing coronary artery bypass grafting who had the saphenous vein harvested by either a continuous incision or skip incisions leaving intact skin bridges, we determined the prevalence of wound infections to be 9.6%. The following variables were entered into logistic regression analysis to identify significant risk factors that might be predictive of wound infection: diabetes, peripheral vascular disease, obesity, renal failure, steroid use, age, sex, and type of closure. We then prospectively randomized 132 patients found to be at high risk of wound infection to either endoscopic vein harvesting or a continuous open incision.

RESULTS

Univariate analysis showed female sex (P =.04), diabetes (P <.001), and obesity (P <.001) to be predictors of wound infection. In a multivariate model diabetes (P =.02) and obesity (P =.001) were independent predictors. In patients at high risk, the prevalence of wound infection was 4.5% for the endoscopic group versus 20% for the open group (P =.01). Vein procurement time was greater in the endoscopic group (65 minutes vs 32 minutes, P <.001), as was the number of vein repairs required (2.5 vs 0.6, P <.001).

CONCLUSION

The use of endoscopic vein harvesting decreases the prevalence of postoperative leg-wound infections in high-risk patients with diabetes and obesity. Whether this translates into an economic benefit that justifies the additional cost of that technology requires further analysis.

A Low Protein, High Carbohydrate Diet Attenuates Alcohol Intake in Rats

To test whether a tryptophan-enhancing diet will reduce alcohol intake as serotonergic drugs do, two studies were conducted. In Experiment 1, 32 male, alcohol-drinking rats were randomly assigned to one of four isocaloric diets containing 25%-protein/65%-carbohydrate, 25%-protein/4%-carbohydrate, 4%-protein/65%-carbohydrate, or 4%-protein/4%-carbohydrate. Following a baseline week during which they ate standard lab chow, rats were offered their assigned experimental diet, water, and 5%-alcohol solution ad lib for three weeks. Alcohol and diet intakes were measured daily. In Experiment 2, 32 naive male, alcohol-drinking rats were assigned to one of the experimental diets used in Experiment 1. Following a one-week baseline, rats were offered their assigned diet, water, and 5%-alcohol/1%-sucrose solution ad lib for two weeks and then were switched back to standard lab chow for one week, with alcohol intake measured daily. Rats consuming the low protein, high carbohydrate diet drank 60-80% less alcohol than did rats offered other diets. This reduction in alcohol intake is most likely due to increased brain serotonin levels produced by the dietary manipulation.

Carotid occlusive disease and stroke risk in coronary artery bypass graft surgery

To clarify the perioperative stroke risk in patients with carotid stenosis or occlusion having coronary artery bypass graft (CABG) surgery, we retrospectively reviewed the records of 1,022 patients who had CABG during a 2-year period (1992, 1993). Of these, 224 had preoperative carotid duplex studies, usually for bruit or remote symptoms. We analyzed clinical and neuroimaging findings for all patients who had strokes to determine infarct topography and presumed mechanism, either low perfusion or embolism. Perioperative stroke was always ipsilateral to severe (> or = 70%) carotid disease, and occurred in 2 (8.0%) of 25 patients with carotid occlusion, 3 (50.0%) of 6 patients with 70 to 99% stenosis, and 9 (4.7%) of 193 patients with less than 70% stenosis. Borderzone infarcts occurred with all degrees of carotid stenosis. Stroke frequency had a positive correlation with the degree of carotid stenosis. Eight (1.0%) of the 798 patients not studied by carotid duplex had stroke in various vascular distributions. Overall, stroke occurred in 22 (2.2%) of the 1,022 patients having CABG surgery. Our results suggest that while the overall risk of perioperative stroke in CABG surgery is low, the risk is increased in patients with severe extracranial carotid stenosis or occlusion. The role of carotid disease and the mechanism of borderzone infarction in CABG surgery remain unsettled.

Surgical treatment of systemic atheroembolism from the thoracic aorta

BACKGROUND

Surgical procedures performed exclusively for atheroembolic events arising from the thoracic aorta rarely have been reported. Presented here are 2 patients who underwent successful operation for these problems.

METHODS

The clinical presentation, diagnostic evaluation and surgical approach to 2 patients with different embolic sources in the thoracic aorta are presented. One patient had experienced three strokes and was noted by multiplane transesophageal echocardiography to have protruding atheromas with ulcerations in the transverse arch and origin of the brachiocephalic vessels. The transverse arch was replaced using hypothermic circulatory arrest with individual reimplantation of the brachiocephalic vessels. The second patient presented with "blue toe" syndrome from mobile atheromas in the mid-descending thoracic aorta defined by transesophageal echocardiography. A localized debridement was performed using simple aortic cross-clamping.

RESULTS

Both patients had uneventful postoperative courses and had no further atheroembolic events.

CONCLUSIONS

When standard diagnostic modalities do not delineate an embolic source for either stroke or peripheral embolization, transesophageal echocardiography is recommended as an excellent means of identifying atheromas in the thoracic aorta that could be the source for emboli. Once these lesions are identified, a surgical procedure should be performed to prevent further embolization.

Viscous effects in capillary electrophoresis: theory and experiment

Simple theory which relates the viscous effects of additives used in capillary electrophoresis (CE) to resolution and resolution per unit time are developed for small molecule separations in the absence of sieving effects. The resolution theory shows that there is no advantage to using viscous additives for resolution improvement unless either a binding energy difference exists between the solutes and additive, or viscous effects cause a reduction in the vector sum of electrophoretic and electroosmotic velocities when these are of opposite sign. In general, increasing the viscosity is shown to result in a loss of resolution per unit time. Theory demonstrates that in cases where only binding is considered to be present, the maximum resolution increase is found to be at relatively small amounts of additive. In addition, specific regions of the elecctrophoreogram may demonstrate resolution enhancement at a specific concentration while other regions exhibit a resolution decrease, as compared to no additive present. CE separations of the components in a Triton surfactant, conducted using a polyethylene glycol (PEG) additive, demonstrate that improved resolution for some of the peaks exists at a specific PEG concentration. These results are mostly explained through the reduction in electroosmotic flow velocity that takes place through additive adsorption to the capillary wall, although some binding is present.

A protocol for pediatric trauma receiving units

Management of the child with multiple injuries is among the most challenging problems in pediatric surgery. The first 20 minutes are crucial in determining the outcome. Our conceptual model of accomplishing 60 minutes' work in 20 minutes by the additive efforts of three teams working together is a simple, practical, and proven method for a pediatric trauma receiving unit. The checklist approach is recommended as the surest way to organize treatment and accomplish a thorough evaluation while effectively stabilizing pediatric trauma patients.

Pediatric trauma. Part II: Development of an emergency care system

Treatment of pediatric trauma begins at the moment of injury (with the arrival of the first person who assists the victim), continues through transport of the patient to the hospital and administration of definitive medical care, and concludes with a rehabilitation program that is aimed at returning the child to a pre-accident life-style. Community hospitals can reduce morbidity and mortality associated with pediatric trauma by implementing specific organizational concepts and procedures used at established pediatric trauma centers. These include swift and accurate assessment at the scene of the accident, pre-arrival coordination between rescue team and emergency room personnel, a preestablished contact network for essential hospital staff, emergency equipment in a broad range of sizes, and charts specifying pediatric dosages of necessary medications. Morbidity and mortality could be further reduced with a national system of comprehensive regional treatment centers designed specifically for children. PAs who are familiar with the specific needs of seriously injured children can significantly influence community and professional responses to this growing area of medicine.

Virilizing malignant lipid cell tumor producing erythropoietin

Paraneoplastic erythrocytosis associated with production of erythropoietin and testosterone by a malignant lipid cell tumor is demonstrated in this case report. Several chemotherapeutic regimens failed to halt the progression of this aggressive metastatic lipid cell tumor. The scant literature on malignant lipid cell tumors is reviewed. Possible mechanisms for paraneoplastic erythrocytosis are presented. Adequate control of polycythemia preoperatively will reduce thromboembolic and hemorrhagic complications.

Off-axis effects in a mosaic Michelson interferometer

The interferogram equations for a Michelson interferometer operated with a mosaic array of detectors are derived. The effects on the instrumental line shape function (ILF) due to an individual detector field subtense and its displacement from the optical axis of the interferometer have been numerically computed from the interferogram equations. Theoretical predictions of the dependence of the ILF on various system parameters are presented as well as comparisons of the theoretical ILF with those measured in the laboratory.

Improvements in time resolved Fourier spectroscopy

The technique of Fourier spectroscopy, the full realization of its advantage, has been applied to a time-dependent study. The principle of the technique, the SNR expected, and the instrumentation involved are discussed together with some recent results.