Brief was revised to use an updated version of a nationwide ambulatory surgery analytic file that was created from the 2014 State Ambulatory Surgery and Services Databases (SASD) and weighted for national estimates. The updates involved a change to the census region assigned to a subset of hospitals in the sample. This change affected the encounter weights used to produce national estimates, resulting in minor changes to ambulatory surgery totals and related percentages and rankings reported in this Statistical Brief.

Objective: We sought to evaluate the overall financial burden associated with traumatic injury amongst patients with private insurance and assess the effect of high deductible plans on out-of-pocket costs (OOPCs). Summary of Background Data: Traumatic injury can be a source of unexpected financial burden for households. However, the effect of increasing participation in higher cost-sharing private health insurance plans remains unknown. Methods: We conducted a retrospective cohort observational study, using the Clinformatics Data Mart Database, a nationwide single-payer administrative claims database to identify US adults who required emergency department services or hospital admission for single traumatic injury from 2008 to 2018. A 2-part model using a logistic regression and a generalized linear model with gamma distribution and log link was used to evaluate 12-month OOPCs after traumatic injury. Multivariable logistic regression was used to evaluate the likelihood of catastrophic health expenditure (CHE) after injury. Results: Of 426,945 included patients, 53% were male, 71% were white, and median age was 42 years. Patients faced monthly OOPC of $660 at the time of their injury. High deductible plan enrollment was associated with an increase of $1703 in 12-month OOPC after trauma, compared to those covered by traditional health plans. In addition to high deductible health plan enrollment, worsening injury severity and longer hospital stays were also associated with increased 12-month OOPC after trauma. Non-white minorities paid less 12month OOPC after trauma compared to non-Hispanic white patients, but also used fewer services. Overall, the incidence of CHE was 5%; however highdeductible health plan enrollees faced a 13% chance of CHE. Conclusions: Privately insured trauma patients face substantial OOPCs at the time of their injuries. High-deductible health plans are associated with increased financial vulnerability after trauma.

Key Points Question What is the association of a new cancer diagnosis and enrollment in a high-deductible health plan with out-of-pocket costs for patients? Findings In this cohort study using propensity score matching and triple difference-in-differences analysis, 134 826 patients with a new diagnosis of cancer and enrolled in a high-deductible health plan faced sharp increases in out-of-pocket costs relative to those with traditional health plans and those without cancer. Meaning This study suggests that private health insurance plans (particularly those with high cost sharing) leave patients vulnerable to considerable financial burden after receiving a diagnosis of cancer.

Postesophagectomy anastomotic leak is a common postsurgical complication. The current standard method of detecting leak is esophagram usually late in the postoperative period. Perianastomotic drain amylase level had shown promising results in early detection anastomosis leak. Previous studies have shown that postoperative day 4 amylase level is more specific and sensitive than esophagram. The purpose of this study is to determine if implementing a drain amylase-based screening method for anastomotic leak can reduce length of stay and hospital cost relative to a traditional esophagram-based pathway. The drain amylase protocol we propose uses postoperative day 4 drain amylase level to direct the initiation of PO intake and discharge. We designed a decision analysis tree using TreeAge Pro software to compare the drain amylase-based screening method to the standard of care, the esophagram. We performed a retrospective review of postesophagectomy patients from a tertiary academic medical center (University hospital Cleveland medical center) where amylase level was measured routinely postoperatively. The patients were separated into amylase-based pathway group and the standard of care group based on their postop management. The length of stay, costs, complications, and leak rate of these two groups were used to inform the decision analysis tree. In the base-case analysis, the decision analysis demonstrated that an amylase-based screening method can reduce the hospital stay by one day and reduced costs by ∼$3,000 compared to esophagram group. To take the variability of the data into consideration, we performed a Monte Carlo simulation. The result showed again a median saving of 0.71 days and ∼$2,500 per patient in hospital cost. A ballistic sensitivity analysis was performed to show that the sensitivity of postoperative day 4 amylase level in detecting a leak was the most important factor in the model. We conclude that implementing an amylase-based screening method for anastomotic leak in postesophagectomy patient can significantly reduce hospital cost and length of stay. This study demonstrates a novel protocol to improve postesophagectomy care. Based on this result, we believe a prospective multicenter study is appropriate.