The impact of the healthcare facility on cost and utilization in diabetic foot complications Zachary Gustin and Jonathan Labovitz, DPM, CHCQM Western University of Health Sciences, College of Podiatric Medicine INTRODUCTION PURPOSE CONCLUSIONS Characteristics of the healthcare facility can influence the cost of care delivery and the consumption of healthcare resources. The type of ownership, urban vs. rural location, and teaching hospital status all influence the cost of care and utilization, such as length of stay (LOS). Diabetes mellitus is one of the most costly chronic illnesses, yet the value of diabetes care delivery remains focused on process and clinical outcome measures. Structural outcome assessment has been neglected despite the downstream impact structural measures have on process and outcome measures. 1 Structural factors are needed to understand cost variation for informed decision-making regarding efficiency and patient outcomes. More importantly, the cost variation and the impact of structural characteristics can be used to optimize the cost to quality ratio for value based care programs. 2 Investigate the impact of hospital structural outcomes on cost and length of stay (LOS) in inpatient diabetic foot complications. For all structural outcomes Greatest cost = Peripheral arterial disease Longest LOS = ≥ 2 complications Teaching hospitals had significantly higher costs and shorter LOS than non-teaching hospitals Factors associated with significantly higher cost: Government-owned and non-profit facilities Urban location High bed count Teaching hospitals Factors associated with significantly longer LOS: Government-owned Non-teaching hospitals Hospital structural outcomes significantly impact cost of healthcare more than LOS in lower extremity complications of diabetes mellitus managed in the acute care setting. These structural outcomes should be considered when planning facilities and when establishing payment reform models since the impact healthcare providers have based on processes and direct clinical care is limited by structural outcomes. COST & LENGTH OF STAY FOR ALL COMPLICATIONS RESULTS: TYPE OF OWNERSHIP Cost (x1,000) Length of Stay Structural outcomes Cohorts n Mean-adjusted cost Mean-adjusted LOS Ownership For-profit 44,482 $8,556 4.2 Non-profit 158,149 $11,135 3.6 Government 39,376 $13,976 6.3 Bed size Small 182,382 $11,923 4.1 Medium 23,567 $9,502 Large 21,425 $8,315 4.3 City population Urban 203,558 $11,258 Urban Center 39,080 $10,270 4.0 Rural 177 $7,931 23.2 MSSA location 216,512 $11,395 24,692 $8,567 Frontier 518 $7,842 15.8 1 1 1 1 1 2 1 1 1 2 1 1 1 1 1 1 1 1 LOS measured in days LOS measured in days 1 p < 0.001 2 p < 0.01 RESULTS: TEACHING HOSPITALS RESULTS: GEOGRAPHICAL AND FACILTY SIZE METHODS Cost of lower extremity complications based on facility geography & bed size Patients with diabetes and a lower extremity complication were identified by ICD-9 codes in the California Office of Statewide Health Planning and Development 2010-2013 public discharge files using CUPID 2.0 software (SpeedTrack, Inc., Placentia, CA) Diabetes and complication were primary discharge diagnosis or one of first five subsequent diagnoses Lower extremity complications were divided into peripheral neuropathy (DPN), peripheral arterial disease (PAD), foot ulcer (DFU), foot infection (DFI), and ≥ 2 complications. Cost and LOS were adjusted using Elixhauser co-morbidity measures Cost was adjusted for inflation using 2013 US dollar Hospital characteristic categories (independent variable): Ownership type, City population, MSSA location, Bed size, Teaching hospital Welch’s ANOVA was used to determine significance of hospital characteristics impact on Inpatient cost and LOS post-hoc Games-Howell used for subcategory significance Teaching hospitals all cohorts Higher costs Shorter LOS Cost (x1,000) 1 Location MSSA location Bed Size   Urban Urban Center Rural Frontier Small Medium Large Neuropathy $8,879 1 $8,378 $7,569 $5,995 $6,704 $9,554 1  PAD $14,365 2 $13,479 $10,768 $14,449 $10,950 $8,274 $11,863 $11,552 $14,893 Foot Ulcer $10,821 $8,319 $3,100 3 $7,521 $7,299 $11,382 Infection $10,071 $9,495 $8,729 $10,156 $8,106 $6,635 $8,507 $7,971 $10,539 ≥ 2 complications $13,301 $11,881 $7,669 $13,352 $8,718 $8,442 $9,928 $10,447 $13,886 1 1 1 Length of Stay of lower extremity complications based on facility geography & bed size Length of Stay REFERENCES   Location MSSA location Bed Size Urban Urban Center Rural Frontier Small Medium Large Neuropathy 3.1 3.3 5.9 3.7 1 2.8 3.0 PAD 3.2 151.6 44.2 3.5 Foot Ulcer 4.4 3.9 0.5 1  5.0 4.0 4.5 Infection 4.7 34.8 4.6 4.3 3 ≥ 2 complications 5.4 6.5 17.5 5.5 5.1 Donabedian, A. The quality of care: How can it be assessed?. JAMA 1988; 121(11): 1145-1150. Xu X, Gariepy A, Lundsberg LS, et al. Wide Variation Found in Hospital Facility Costs for Maternity Stays Involving Low-Risk Childbirth. Health Affairs 2015; 7: 1212-1219. 1 1 For more information contact jlabovitz@westernu.edu 1 p < 0.001 LOS measured in days 1 p < 0.001 2 p < 0.01 3 p < 0.05