Incremental cost and length of stay associated with postprocedure delirium in transcatheter and surgical aortic valve replacement patients in the United States

Potter, Brian J.; Thompson, Christin; Clancy, Seth

doi:10.1002/ccd.28014

Cited by 25 publications

(33 citation statements)

References 16 publications

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“…Prior research has shown conflicting results with regard to the association of PNDs with an increased length of inpatient hospitalizations. [23][24][25] In this study, presence of a PND was associated with a more than 1-day increase in the mean length of stay. Although it is possible that the length of stay was associated with the increased costs for the acute in-hospital payments for the index hospitalization that was observed, it is noteworthy that the difference, albeit statistically significant,…”

Section: Discussionmentioning

confidence: 50%

Economic Burden of Postoperative Neurocognitive Disorders Among US Medicare Patients

et al. 2020

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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 < .001), were less likely to be discharged home (9947 patients [22.1%] vs 914 925 patients [39.2%]; P < .001), and had a higher incidence of mortality at 1 year after treatment (4580 patients [10.2%] vs 103 767 patients [4.4%]; P < .

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Section: Discussionmentioning

confidence: 50%

Economic Burden of Postoperative Neurocognitive Disorders Among US Medicare Patients

et al. 2020

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“…Previous studies have evaluated the effect of delirium on health care resources utilization among patients with TAVR, but not other geriatric syndromes (frailty and dementia or combinations of those three geriatric syndromes). 9,10 Our results showed that geriatric syndromes, especially delirium, play a substantial role in increasing health care expenditure for patients with TAVR.…”

Section: Figure 3 Predicted Average Los For Each Condition From the mentioning

confidence: 71%

“…Our findings are consistent with the results of previous studies, showing that delirium or frailty increases the hospital cost or LOS. 9,10,27 While frailty is a rather underlying condition, delirium develops during the hospitalization; considering that it poses the most substantial impact, it resonates with the importance of the effort to prevent delirium among patients who are undergoing TAVR.…”

Section: Figure 2 Predicted Average Total Hospital Cost Of Each Condmentioning

confidence: 99%

“…[3][4][5] Delirium after a cardiac procedure such as TAVR is associated with adverse clinical and economic outcomes, including higher perioperative mortality, longer hospital stay, and higher total hospital cost. [5][6][7][8][9][10] Since TAVR is less invasive than surgical aortic valve replacement, the incidence of delirium after TAVR is lower, but delirium still affects up to 44% of the patients undergoing TAVR. 5,7,11 Older adults with a high risk of delirium tend to have coexisting geriatric syndromes such as dementia, frailty, or a combination of more than one.…”

Section: Introductionmentioning

confidence: 99%

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The Association of Economic Outcome and Geriatric Syndromes among Older Adults with Transcatheter Aortic Valve Replacement (TAVR)

Kwak

Rasu

Morgan

et al. 2020

JHEOR

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Background: The association of geriatric syndromes and economic outcomes among patients who are undergoing transcatheter aortic valve replacement (TAVR) remains unknown. Methods and Results: A retrospective observational study using the National Inpatient Sample (NIS) from 2011 to 2014 was conducted with 7078 patients who were 65 years or older and underwent TAVR. The average hospital cost was US$58 703 (± SD 29 777) and length of stay (LOS) was 8.1 days (±7.20). The rates of delirium, dementia, and frailty were 8.0%, 6.1%, and 10.5%, respectively. From a multivariable generalized linear regression, delirium increased the cost by 31.5% (95% CI 25.41~37.92) and LOS by 70.3% (95% CI 60.20~83.38). Frailty increased the cost by 7.4% (95% CI 3.44~11.53) and the LOS by 22.6% (95% CI 15.15~30.55). Dementia had no significant association with either outcome. When the interactions of the geriatric syndromes were tested for association with the outcomes, delirium in the absence of dementia but presence of frailty showed the strongest association with cost (increase by 45.1%, 95% CI 26.45~66.45), and delirium in the absence of both dementia and frailty showed the strongest association with LOS (increase by 74.5%, 95% CI 62.71~87.13). When the average hospital cost and LOS were predicted using the model with interaction terms, patients with delirium and frailty (but without dementia) had the highest value (total hospital cost US$86 503 and LOS 14.9 days). Conclusion: Among TAVR patients, delirium was significantly associated with increased hospital cost and LOS, and the association was significantly higher in the absence of dementia. The results of this study will be a great asset for health care providers and administrators in planning for efficient care strategy to lower health care expenditure in the hospital for older adults who underwent TAVR.

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“…Examining Medicare patients over the age of 80, transcatheter aortic valve replacement (TAVR) was less likely to generate a billing code for delirium (1.6%) than surgical aortic valve replacement (SAVR) at 3.6% ( p < .0001) in Potter's study . This occurred despite the TAVR patients being older with greater comorbidities, perhaps heralding another improvement in outcome with TAVR compared to SAVR.…”

mentioning

confidence: 97%

Costs of postoperative delirium with transcatheter aortic valve replacement: Improved yet still present

Ashley

Hillegass

2019

Cathet Cardio Intervent

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Transcatheter aortic valve replacement (TAVR) is associated with a lower risk of postoperative delirium (PD) than surgical aortic valve replacement (SAVR) in patients aged ≥80, based on billing codes.• Postoperative delirium remains a frequent problem after both SAVR and TAVR in clinical series and is costly.• Improved pre-procedural prediction of PD risk would improve targeting of clinical care and allow testing of preventative and management strategies.Examining Medicare patients over the age of 80, transcatheter aortic valve replacement (TAVR) was less likely to generate a billing code for delirium (1.6%) than surgical aortic valve replacement (SAVR) at 3.6% (p < .0001) in Potter's study. 1 This occurred despite the TAVR patients being older with greater comorbidities, perhaps heralding another improvement in outcome with TAVR compared to SAVR. Yet postoperative delirium (PD) remains an important and difficult clinical problem for both approaches. In patients over 65 years of age undergoing cardiac surgery, postoperative delirium has a reported incidence of 26 to 52%.The estimated incremental cost of PD after cardiac surgery is 150 billion dollars annually in the United States. 2 TAVR patients had 29% incidence of PD in the best study to date. 2 PD is associated with significantly longer hospitalizations, costs, and mortality. While yielding some comparative insight, billing code ascertainment of PD undoubtedly significantly underestimates its incidence. Prospective studies suggest only one in four patients with delirium (particularly hypoactive or "quiet" delirium) were clinically recognized and/or addressed. The causes of PD are multiple with predisposing baseline factors and acute precipitants. 3 These include generalized frailty, preoperative cognitive impairment, and cerebrovascular disease with severe white matter hyperintensities on preoperative MRI. Precipitants include anesthetic technique, pain control medicines, and perhaps inflammation. Particularly with increasing application of TAVR to older patients with greater frailty, a renewed and concerted effort to improve preprocedural TAVR (and SAVR) PD prediction is warranted. 4 Preoperative prediction would permit targeting resources for both clinical care and further research. Minimalist TAVR without general anesthesia may be an effective strategy to reduce PD. Other promising strategies such as better-tolerated pain control regimens(as recently demonstrated with IV acetaminophen after cardiac surgery) should be tested surrounding TAVR. 5 While this study seems to be another "win" for TAVR versus SAVR in some immaterial scorecard, postoperative/post-procedural delirium remains a significant, seemingly intractable problem as we address ever-frailer and sicker patients with structural heart diseases. ORCIDWilliam B. Hillegass https://orcid.org/0000-0001-6428-0564 REFERENCES 1. Potter BJ, Thompson C, Green P, Clancy S. Incremental cost and length of stay associated with post-procedure delirium in transcatheter and surgical aortic valve replacement patien...

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Incremental cost and length of stay associated with postprocedure delirium in transcatheter and surgical aortic valve replacement patients in the United States

Cited by 25 publications

References 16 publications

Economic Burden of Postoperative Neurocognitive Disorders Among US Medicare Patients

Economic Burden of Postoperative Neurocognitive Disorders Among US Medicare Patients

The Association of Economic Outcome and Geriatric Syndromes among Older Adults with Transcatheter Aortic Valve Replacement (TAVR)

Costs of postoperative delirium with transcatheter aortic valve replacement: Improved yet still present

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