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Hospitalizations and
Preventable Conditions
in
Adult Spina Bifida
Brad Dicianno, MD
Assistant Professor,
Univ. of Pittsburgh Medical Center (UPMC)
Dept. of PM&R
Director, Adult Spina Bifida Clinic
University of Pittsburgh Medical Center
Director, UPMC Center for Wellness
For Individuals with Spina Bifida
and Spinal Cord Injury
Objectives
• Learn potentially preventable
reasons for:
– Hospitalization
– Death
• Make a plan to be
– more proactive
– less reactive
Previous studies
•
1996 - 1 acute care U.S. hospital.
– Admitted an ave of 3.6 x per yr
– LOS 11.2 days
– 47% due to potentially preventable secondary conditions:
• UTI, kidney stones, skin breakdown, osteomyelitis
– LOS 12.5 days
•
1999 - 1 site in UK – mortality study
– in many instances, the cause could not be identified
– renal failure, cardiac complications and respiratory complications
•
2001 to 2003 – U.S. claims database
–
–
–
–
–
paid medical and prescription drug claims
employer-sponsored insurance
Medical expenses 3 to 6 x greater
$13,000/yr at ages 18 to 44 yrs
$10,000/yr at ages 45 to 64 yrs
Paper 1: Methods
• Retrospective data analysis
• Nationwide Inpatient Sample (NIS)
• AHRQ Healthcare Cost & Utilization
Project
• 2004 and 2005
• Records from U.S. inpatient hospital
admissions
• SB, age 18 + yrs
• Units are hospitalization, not individual
Preventable or
Iatrogenic
conditions
• UTI
• Indwelling urinary catheter infection
• Iatrogenic surgical or medical
complications
• Pneumonia
• Pressure ulcers
• Infective arthritis/osteomyelitis
• Septicemia
Paper 1: Results
• 7670 hospitalizations
• ~37,464 hospitalizations nationally
• Average LOS 7 days
• Each stay $28,918
Paper 1: Results
• Potentially preventable or iatrogenic
conditions
– 33.8% of hospitalizations
– $364 million nationally
– death in 35.7%
– occurred most often under age 51 yrs
Paper 1: Results
Hospitalizations
• 10% UTI
• 9% Complications from devices/grafts/implants
– 53% shunt malfunctions and infections
– Rest Bladder Catheters, AV fistulas, joint replacements
• 6% Wounds
Deaths
• 19% sepsis
• 9% pneumonia
• 7% respiratory failure
• 2.5% renal failure –only the 7th most common diagnosis
Paper 1: Results
Top 3 reasons for hospitalization
18-35
yrs
36-50
yrs
51-64
yrs
65+
yrs
UTI
spondylosis
pneumonia
device
complications
disc disease
anemia
wounds
back pain
CHF
Stroke
• 65+ yrs
– 3% of admissions
– 6.5% of deaths
– (1% admissions in general pop)
Paper 2: Methods
• California State Inpatient Database
• AHRQ Healthcare Cost & Utilization
Project
• 2004
• all nonfederal hospital inpatient
discharges
• unique patient identifiers
Paper 2: Methods
• AHRQ Ambulatory care sensitive conditions
–
–
–
–
–
–
–
–
–
–
–
Short and term complication of diabetes
Perforated appendix
COPD
Hypertension
CHF
Dehydration
Bacterial pneumonia
UTI
Angina
Adult asthma
Leg amputation
Paper 2: Results
• 995 unique people
• 1952 admissions
Paper 2: Results
SB
General
population
IRR (95% CI)
Incidence rate
ratio
Ave. #
admissions
2.0
1.4
1.5 (1.5-1.6)*
30 day
readmisison
0.5
0.2
3.0 (2.5-3.5)*
Paper 2: Results
% of hospitalizations
18-39 40-64
UTI
7.2%
5.2%
Bacterial
pneumonia
1.7%
65-74 75+
Gen
pop
OR
0.6%
18.5*
0.9%
5.3*
3.3% 2.6%
2.4*
0.5%
2.9*
Paper 2: Results
• 75 yrs+
– 42% had 30 day readmission
Paper 3:
Lymphedema
• Retrospective chart review of 240 patients
• 2005 to 2008
• 22 (9.2%) had lymphedema
– 100 times the rate in general population
• Mean age was 35
• Lymphedema was sig associated with:
–
–
–
–
–
–
–
–
trauma
cellulitis
cancer
obesity
wounds
hypertension
higher lesion level
wheelchair use
Stay tuned…
•
•
•
•
•
Payer-Provider initiative
Full time CRNP/Mobile RN
Targeted Preventative Care
Wellness Visit (CMS)
Evidence Based
– Validated Screening tools
– Clinical practice guidelines
• Prevention
• Treatment algorithms/principles
Stay tuned…
• Clinical outcomes
– Multiple medical outcomes (see table)
– WHO-QOL-BREF
– CHART-SF
• Knowledge surveys
• Compliance with Wellness goals
• Satisfaction with Care
– PACIC
• Cost
– Utilization of unplanned care
– Cost of preventable conditions
Module
Quantitative
Outcome Measure
or screening tool
Clinical Outcome
Measure
Preventable Diagnoses
(Utilization and cost)
Bladder
Management
•Bowel logs
•Incontinent
episodes
•GFR
Bowel Management
•Bladder logs
•Incontinent
episodes
Skin Integrity
•Salzberg tool
•Wounds
•Sepsis - wounds
•Infective arthritis or osteo
Behavioral Health
•BDI-II
•CAGE
•DAST
•Depression
Quality of Life and
Functional
Independence
•CHART-SF
•WHOQOL-BREF
•UTI
•bladder catheter
infections
•sepsis - bladder
infections
•Knowledge
Survey
•Hours performing self
care
•Time lost from
work/school
•BMI
Body Mass Index
Patient
Education
Medications and
supplies
•Medication log
•Medication
possession ratio
General Health
Maintenance
•PACIC
•Routine PCP visits
Nutrition
•Nutrition contract
Exercise
•Exercise contract
•Time spent
exercising/wk
•Obesity
•Pneumonia/Flu
•Surgical/Medical
complications
UPMC Health Plan Medical Expenses* For SB and SCI
$3,000
$2,647
$2,388
$2,500
$2,365
$2,256
$ per
Member
per
Month
$2,000
$1,753
$1,606
FY 2010
$1,500
$1,161
FY 2011
$1,180
$1,000
$500
$0
Commercial
Medicaid
Medicare
Special Needs Plan
*Allegheny, Armstrong, Beaver, Butler, Westmoreland, and Washington counties only.
FY 2010 (n = 1,579); FY 2011 (n = 1,636)
Medical Expenses* for 7 preventable conditions in SB and SCI
$70
$60
$ per
Member
per
Month
$50
$40
FY 2010
$30
FY 2011
$20
$10
$0
UTI
Ulcer of skin
Skin subq inf
Septicemia
Complic of
surg/med care
Pneumonia
Inf arthritis and
osteomyelitis
*Allegheny, Armstrong, Beaver, Butler, Westmoreland, and Washington counties only.
FY 2010 (n = 1,579); FY 2011 (n = 1,636)
Takehome points
Preventable or iatrogenic conditions
• 1/3 of hospitalizations
• > 1/3 deaths
• Biggest problem in younger adults
• We can and should change the way
we practice
References
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Dicianno BE, Wilson R. Hospitalizations of adults with spina bifida and
congenital spinal cord anomalies. Arch Phys Med Rehabil. 2010
Apr;91(4):529-35.
Wilson R, Lewis SA, Dicianno BE. Targeted preventive care may be
needed for adults with congenital spine anomalies. PMR. 2011
Aug;3(8):730-8.
Singhal B, Mathew KM. Factors affecting mortality and morbidity in
adult spina bifida. Eur J Pediatr Surg 1999;9(Suppl 1):31-2.
Kinsman SL, Doehring MC. The cost of preventable conditions in adults
with spina bifida. Eur J Pediatr Surg 1996;6(Suppl 1):17-20.
Ouyang L, Grosse SD, Armour BS, Waitzman NJ. Health care
expenditures of children and adults with spina bifida in a privately
insured U.S. population. Birth Defects Res A Clin Mol Teratol
2007;79:552-8.
Garcia AM, Dicianno BE. The frequency of lymphedema in an adult
spina bifida population. Am J Phys Med Rehabil. 2011 Feb;90(2):89-96.
[email protected]
Send reprint requests to Michael Lane at [email protected]
About the NIS
•
•
•
•
•
•
stratified sample of hospital inpatient stays
20% of community hospitals in the United States
all payer discharge data
over 1000 hospitals
37 states
nonfederal, short-term general, and specialty
hospitals
• excludes short-term rehabilitation, long-term
acute care, substance abuse centers, and
psychiatric hospitals