1. 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 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
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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: 1 1
For more information contact 1
p < 0.001
LOS measured in days 1
p < 0.001 2
p < 0.01 3
p < 0.05