Impact of Active Hemostatic Treatment on Bleeding Complications and Hospital Costs (2021) PDF

Journal of Medical Economics ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/ijme20 Impact of an active hemostatic product treatment approach on bleeding-related complications and hospital costs among inpatient surgeries in the United States David A. Iannitti, Chong...

Journal of Medical Economics ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/ijme20 Impact of an active hemostatic product treatment approach on bleeding-related complications and hospital costs among inpatient surgeries in the United States David A. Iannitti, Chong Kim, Diane Ito & Josh Epstein To cite this article: David A. Iannitti, Chong Kim, Diane Ito & Josh Epstein (2021) Impact of an active hemostatic product treatment approach on bleeding-related complications and hospital costs among inpatient surgeries in the United States, Journal of Medical Economics, 24:1, 514-523, DOI: 10.1080/13696998.2021.1916751 To link to this article: https://doi.org/10.1080/13696998.2021.1916751 © 2021 The Author(s). Published by Informa View supplementary material UK Limited, trading as Taylor & Francis Group. Published online: 29 Apr 2021. Submit your article to this journal Article views: 854 View related articles View Crossmark data Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=ijme20 JOURNAL OF MEDICAL ECONOMICS 2021, VOL. 24, NO. 1, 514–523 https://doi.org/10.1080/13696998.2021.1916751 Article 0042-FT.R1/1916751 ORIGINAL RESEARCH Impact of an active hemostatic product treatment approach on bleeding-related complications and hospital costs among inpatient surgeries in the United States David A. Iannittia, Chong Kimb, Diane Itob and Josh Epsteinb a Atrium Health – Carolinas Medical Center, Charlotte, NC, USA; bStratevi, Santa Monica, CA, USA ABSTRACT ARTICLE HISTORY Aims: To examine the impact of active only (A) vs. combined passive and active (PA) hemostatic prod- Received 3 March 2021 ucts on bleeding-related complications and costs among inpatient surgeries. Revised 2 April 2021 Materials and Methods: This retrospective analysis of the US Premier Hospital Database included Accepted 6 April 2021 patients who had an inpatient procedure within a specialty of interest (cardiac, vascular, noncardiac KEYWORDS thoracic, solid organ, general, reproductive organ, knee/hip replacement, spinal, or neurosurgery) that Surgery; active hemostatic utilized a hemostatic product from January 1, 2017 to December 31, 2018. Patients were directly products; total hospital matched 1:1 on surgery code, age categories, and Charlson Comorbidity Index score categories into A costs; bleeding-related or PA cohorts. Unadjusted and adjusted rates of bleeding-related complications, length of stay (LOS) complications; hemostatic and total hospital costs were compared between cohorts. treatment approach Results: A total of 5,934 cardiac, 7,986 vascular, 2,042 noncardiac thoracic, 8,260 solid organ, 9,502 general, 4,616 reproductive organ, 2,758 knee/hip replacement, 42,648 spinal, and 10,716 neuro sur- JEL CLASSIFICATION CODES geries were included. Higher unadjusted rates of bleeding-related complications and greater LOS and I10; I11 total hospital costs were observed in the PA cohort vs A cohort across all specialties. The adjusted odds of bleeding complications were significantly higher in solid organ, general, knee/hip replacement, reproductive organ, and spinal surgery (OR range ¼ 1.17–2.48, all p $1 million, or did not have demographics and clinical characteristics reported. For patients who had multiple procedures during generate clotting factors. Passive products are most effective the index hospitalization, it was not possible within the for minimal bleeding scenarios and are appropriate for Premier database to determine which hemostatic product patients who have an adequately functioning coagulation was used for each procedure, nor to associate the specific cascade. Active products (e.g. topical thrombin, fibrin seal- costs or bleeding complication with a specific procedure. ants, advanced patches, etc.) participate at the end of the Thus, in order to identify the association between hemostatic coagulation cascade and bypass the initial steps of the clot- product type and the aforementioned outcomes for each ting cascade. Thus, other aspects of the coagulation cascade surgery type, only surgeries with 1 ICD-10 PCS code for the can be dysfunctional without impacting product efficacy. index hospitalization were included in the analysis. Patients with coagulopathies from clotting factors, other Patients in the active hemostat cohort (A; i.e. where only than hypofibrinogenemia, platelet dysfunction, or those an active hemostat was utilized during the index hospitaliza- receiving antithrombotic medications may be ideal candi- tion) and patients in the combined passive & active hemostat dates for active hemostats15,18,19. Details on the classification cohort (PA; i.e. where both passive and active hemostats of hemostatic products assessed in this study are listed in were utilized during the index hospitalization) were extracted Table 1. via a 1:1 direct matching procedure. The passive and active Despite the growing evidence of the significant clinical hemostatic products used during surgery are defined in and economic outcome benefits of active products13,20–22, Table 1. The final study sample (Figure 1) included patients most surgeons typically employ an approach where a passive that were matched on ICD-10-PCS code of the index hospi- product is universally utilized as the first choice. This pattern talization, age categories (0–17, 18–45, 46–64, and 65þ) and of passive first use is often repeated multiple times at the Charlson Comorbidity Index (CCI) score categories (0–2, same bleeding site regardless of the ineffectiveness of the 3–4, 5þ). hemostat. Thus, the objective of this analysis was to identify the most beneficial clinical and economic treatment approach to treat intraoperative bleeding during surgery Study variables through the comparison of active product use only vs com- Patient and hospital characteristics bination passive then active product use approach. Patient demographics (age, gender, race, geographic location of provider, and primary payer), hospital characteristics (hos- Methods and materials pital bed size, teaching hospital status, hospital location [urban or rural], and hospital length of stay) and pre-/peri- Data source operative use of antiplatelet/anticoagulant products were This retrospective observational analysis utilized the Premier evaluated during the index hospitalization while clinical char- US Perspective Hospital Database (PHD), a nationally repre- acteristics (CCI score, any-cause hospitalization within sentative hospital administrative database that has captured 6 months prior to index hospitalization, and prior surgery) >8 million inpatient admissions per year from >600 hospi- and comorbidities were evaluated during pre-index period (i.e. period starting from 12 months prior to index hospitaliza- tals (>25% of annual US inpatient admissions) since 2012. All tion to index hospitalization unless otherwise noted). CCI data analyzed were de-identified and in compliance with the scores were calculated for each patient by identifying diag- patient requirements of the Health Insurance Portability and noses using ICD-10-CM codes that were associated with hos- Accountability Act (HIPAA).This analysis using the Premier US pitalizations occurring within the 12-month pre-index period. PHD did not meet the criteria for human subject research Higher CCI scores indicated a greater likelihood of mortality and was not subject to Institutional Review Board approval. or resource use, whereas a CCI score of zero signified no comorbidity23. Study population Patients undergoing an inpatient surgery of interest (i.e. car- Key study outcomes diac, vascular, noncardiac thoracic, solid organ, general, Occurrence of any bleeding-related complications and/or knee/hip replacement, reproductive organ, spinal and neuro blood product transfusions and total hospital costs (i.e. total 516 D. A. IANNITTI ET AL. cost to treat the patient during the hospitalization, including geographic region, year of surgery, hospital size, teaching both fixed and variable costs) were evaluated during the hospital status, admission type, and any-cause hospitalization index hospitalization (see Supplemental Appendix 3). Total within 6 months prior to index hospitalization), and presence hospital costs were standardized to 2019 US Dollars using of comorbidities including diabetes, obesity, COPD, cancer, the medical care component of the Consumer Price Index25. liver cirrhosis, thrombocytopenia, non-MI coronary disease, deep vein thrombosis, congestive heart failure, hypertension, renal disease, and peripheral vascular disease; all comorbid- Statistical analysis ities modeled as separate covariates) within a generalized Statistical analyses were conducted using R version 3.6.024. estimating equations model with logit link function. Adjusted Patient demographics, clinical characteristics, hospital charac- total hospital costs and the ratio of average total hospital teristics and study outcomes were summarized descriptively costs between A (reference) and PA cohorts were calculated using the mean (standard deviation [SD]) and median (range for all surgeries as well as by surgery type within a general- or minimum and maximum) for continuous variables, and ‘N’ ized estimating equations model with gamma log link func- and proportion (%) for categorical variables across study tion, adjusting for the same variables as the bleeding-related cohorts. Comparisons of patient demographics, clinical char- complications regression model. For (adjusted and acteristics, and hospital characteristics were conducted with unadjusted) total hospital costs, patients with $0 total hos- a t-test for continuous variables and chi-squared test for cat- pital costs were excluded from the analysis. A p