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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 2  |  Issue : 3  |  Page : 6-9

Republication: Examination of financial charges associated with intentional foreign body ingestions by prisoners: A pattern of escalation


1 Department of Anesthesiology, The Ohio State University College of Medicine, Columbus, OH, USA
2 Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA
3 Department of Neurology, The Ohio State University College of Medicine, Columbus, OH, USA
4 Department of Surgery, Wright State University Boonshoft School of Medicine, Dayton, OH, USA
5 Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, PA, USA

Date of Submission13-Mar-2016
Date of Acceptance21-Mar-2016
Date of Web Publication19-Aug-2016

Correspondence Address:
Stanislaw P Stawicki
Department of Research and Innovation, St Luke's University Health Network, 801 Ostrum Street, Bethlehem, PA 18015
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2455-5568.188730

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  Abstract 

Introduction: Intentional ingestions of foreign objects (IIFO) continue to be prevalent among prisoners. Our previous research examined determinants of hospital admission, endoscopy, and surgery among prisoners who ingest foreign objects. However, little is known about the financial impact of these events on healthcare facilities that service the prisoner population. This study aims to fill this gap by examining hospital charges attributable to 435 prisoner episodes of IIFO.
Methods: A retrospective review of all prisoners who presented to our medical center with the complaint of IIFO was conducted. Both Institutional Review Board and Bureau of Prisons approvals were obtained before data collection. All prisoners ages 18–75 were included between the dates of January 2004 and December 2011. Episodes were divided into three categories: (a) Unverified IIFO wherein ingested object was claimed by the patient but never identified; (b) verified IIFO wherein ingested object was clearly identified; (c) secondary events due to direct complications of previous IIFO episode (s). The temporal occurrence of IIFO was organized by increasing the number of episodes and grouped accordingly. Detailed list of hospital charges was obtained for every IIFO episode including: (a) emergency services, (b) procedures, (c) laboratory, (d) surgical supplies, (e) allied health services, (f) radiology studies, (g) anesthesiology charges, (h) pharmacy, and (h) intensive care costs. Descriptive statistics were used to analyze basic data. Kruskal–Wallis test was used to examine differences among nonnormally distributed variables and sub-groups. Statistical significance set at alpha = 0.05.
Results: A total of 435 IIFO episodes occurred during the study period in a population of 125 patients (mean age 33.8 ± 11.7 years, median age 34 [range 19–75] years, 92.8% male). Hospital charges associated with these episodes totaled $6,209,557. There were 94 unverified IIFOs, 332 verified IIFOs, and 9 secondary events. Verified IIFOs were associated with significantly greater median charges ($5,860) than unverified IIFOs ($3,997) and secondary events carried lower cost ($3,501) than the former two (P < 0.01). We also observed a pattern of escalating costs associated with increasing number of sequential IIFO episodes, with the 1st episode carrying median charges of $4,683 and episodes numbered 11+ carrying median charges of $7,698 (P < 0.01).
Conclusions: Hospital charges associated with the care of prisoners who ingest foreign objects tend to escalate over time. Although charges in most of the categories demonstrated increases with greater numbers of ingestions, the largest contributors to this pattern of escalating charges included radiology, pharmacy, hospital room charges, and surgical services. These findings suggest that early intervention in the destructive cycle of IIFO may not only improve patient outcomes but also result in savings to the healthcare system.
The following core competencies are addressed in this article: Medical knowledge, Patient care, Practice based learning and improvement, Systems based practice.
Republished with permission from: Otey AJ, Houser JS, Jones C, Evans DC, Dalal P, Whitmill ML, Levine E, McKimmie R, Papadimos TJ, Steinberg SM, Bergese SD, Stawicki SP. Examination of financial charges associated with intentional foreign body ingestion by prisoners: A pattern of escalation. OPUS 12 Scientist 2014;8(1):6-8.

Keywords: Correctional healthcare, Correctional medicine, Healthcare costs, Intentional ingestion of foreign objects, Preventive care, Prison inmates


How to cite this article:
Otey AJ, Houser JS, Jones C, Evans DC, Dalal PP, Whitmill ML, Levine EJ, McKimmie RL, Papadimos TJ, Steinberg SM, Bergese SD, Stawicki SP. Republication: Examination of financial charges associated with intentional foreign body ingestions by prisoners: A pattern of escalation. Int J Acad Med 2016;2, Suppl S1:6-9

How to cite this URL:
Otey AJ, Houser JS, Jones C, Evans DC, Dalal PP, Whitmill ML, Levine EJ, McKimmie RL, Papadimos TJ, Steinberg SM, Bergese SD, Stawicki SP. Republication: Examination of financial charges associated with intentional foreign body ingestions by prisoners: A pattern of escalation. Int J Acad Med [serial online] 2016 [cited 2019 Jul 16];2, Suppl S1:6-9. Available from: http://www.ijam-web.org/text.asp?2016/2/3/6/188730


  Introduction Top


Intentional ingestions of foreign objects (IIFO) continue to be a major problem among the US prison population. In addition to the serious medical consequences associated with IIFO [Figure 1], the financial impact of this phenomenon is also substantial. Previous research performed by our group as well as other investigators examined determinants of hospital admission, endoscopy, and surgery among prisoners who ingest foreign objects.[1],[2] However, little is known about the financial impact of these events on healthcare systems that service the prisoner population. This study aims to fill this gap by examining and quantifying hospital charges attributable to 435 episodes of IIFO in a sample of 125 patients.
Figure 1: An example of computed tomographic scan demonstrating innumerable ingested foreign objects in the patient's stomach. Surgical removal was required in this case

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  Methods Top


After medical record screening for suspected IIFO cases, a retrospective review of all prisoners who presented to a tertiary university medical center with the complaint of IIFO was conducted. Both Institutional Review Board and Bureau of Prisons permissions were obtained before data collection. All inmates ages 18–75 were included between the dates of January 01, 2004, and December 30, 2011.

Detailed list of hospital charges was obtained for every IIFO episode including (a) emergency services, (b) procedures, (c) laboratory, (d) surgical supplies, (e) allied health services, (f) radiology studies, (g) anesthesiology charges, (h) pharmacy, and (h) intensive care costs. These charges were then grouped according to the occurrence number [Table 1] and tabulated before performing statistical comparisons.
Table 1: Hospital charges associated with escalating number of intentional ingestions of foreign objects. A pattern of escalation is seen in most of the categories listed

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Descriptive statistics were used to present basic demographic data. The Kruskal–Wallis test was used to examine differences among nonnormally distributed variables and sub-groups. Analysis of variance was utilized for comparisons of groups characterized by normally distributed variables. Statistical significance set at alpha = 0.05. We utilized Minitab ® 16 Statistical Software (Minitab Inc., State College, Pennsylvania, USA) to perform statistical analyses.


  Results Top


A total of 435 IIFO episodes occurred during the study period in a population of 125 patients. Mean patient age was 33.8 ± 11.7 years (median age 34 years, age range 19–75 years). The majority of patients (116/125, or 92.8%) were male. There were 94 unverified IIFOs, 332 verified IIFOs, and 9 secondary events.

The overall hospital charges associated with all recorded episodes totaled $6,209,557. This translates to approximately $49,676.50 per patient, or $14,274.80 per episode. Verified IIFOs were associated with significantly greater median charges ($5,860) than unverified IIFOs ($3,997), and secondary events involved lower charges ($3,501) than the former two event subtypes (P < 0.01).

Furthermore, we also observed a pattern of escalation associated with increasing number of sequential IIFO episodes. More specifically the “average” 1st episode was associated with median charges of $4,683 per episode while the “average” late episode (11th episode and beyond) was associated with median total charges of $7,698 per episode (P < 0.01). Mean (or median) hospital charges, grouped by charge category and episode range (episode 1, episodes 2–5, and 6+ episodes) are listed in [Table 1]. Some degree of escalation was seen in all of the charge categories; however, the largest contributors to this pattern included radiology, pharmacy, hospital room, and combined surgery-anesthesiology service charges.


  Discussion Top


IIFO continue to be major problem among the prison population.[1],[2] In addition to the serious medical consequences associated with IIFO,[1],[3] the financial impact of this phenomenon is also substantial. Previous research performed by our group as well as other investigators examined determinants of hospital admission, endoscopy, and surgery among prisoners who ingest foreign objects.[1],[2],[4] However, other than a perceived high level of expenditures associated with IIFO, little is known about the actual financial impact of these events on healthcare systems that service the prisoner population. The current study aims to fill this important knowledge gap by examining and quantifying hospital charges attributable to a large number of patients, many of whom experienced multiple episodes of IIFO.

One of the major difficulties faced by healthcare professionals who care for high-frequency IIFO groups, including psychiatric and prison populations, is the constant readiness and vigilance required to rapidly deploy necessary resources required to effectively treat foreign object ingestions before they turn into surgical emergencies.[1],[3] Such resources include, but are not limited to, 24-h emergency medicine coverage, around-the-clock availability of endoscopy, and the standby capacity in the operating rooms. Due to the complexity of endoscopic foreign object removal, patient noncompliance, and high rates of psychiatric medication use, a larger than expected number of these endoscopic cases necessitate general anesthesia. Consequently, the real costs associated with the care of high-frequency IIFO groups are likely much higher than the charges provided in this report.

Our previous research demonstrated a pattern of escalating psychiatric history among prisoners, with a noticeable increase in documented psychiatric disorders with increasing number of consecutive IIFO episodes.[5] In a way, these findings constitute a “call to arms” for early psychiatric preventive intervention to reduce the chances for recurrent IIFO events. The current study adds further urgency to our previous findings, especially given the fact that the total ($6,209,557), per-patient ($49,676.50), and per episode ($14,274.80) charges associated with IIFO in this study could be easily translated into a substantial preventive effort and would likely result in overall savings to the system. The need for cost containment as well as preventive, rather than reactive care, has been noted by other authors as well.[6],[7],[8] Furthermore, in many cases IIFO constitutes a chronic, recurring condition, and should be approached as such.

There are important limitations to this study. First, this study is retrospective and thus does not enable the authors to draw any causative inferences. Second, financial data presented are limited to hospital charges, which correlate but do not directly translate to, direct and indirect costs of patient care associated with IIFO ingestions. Physician professional service charges, transportation costs, and the security costs of transporting patients for health services are not captured in this study but are presumably significant. Third, the size of patient sub-groups decreased with increasing number of IIFOs, thus further limiting the generalizability of our observations and likely introducing additional bias as fewer patients accounted for many of the late episodes. Finally, due to the complexity of the current financial dataset, a reliable/meaningful adjustment for effects of inflation was not possible. This study has a number of distinct advantages as well. First, it describes one of the largest patient samples and IIFO episodes to date.[9] Second, it focuses on the financial aspect of this negative phenomenon. Finally, it provides a strong impetus for early intervention within the prison healthcare system as both a health measure and cost reduction strategy. Such effort is certainly warranted given the high per-episode and per-patient costs, especially in the context of escalating charges observed in this series.


  Conclusions Top


Hospital charges associated with the care of prisoners who ingest foreign objects tend to escalate over time. Although most of the charge categories demonstrated an increase with the greater number of ingestions, the largest contributors to this pattern of escalation included radiology, pharmacy, hospital room charges, and surgical services. These findings suggest that preventive interventions early in the destructive cycle of IIFO may result not only in improved patient outcomes but also substantial savings to the healthcare system.

Acknowledgement

Justifications for re-publishing this scholarly content include: (a) The phasing out of the original publication after a formal merger of OPUS 12 Scientist with the International Journal of Academic Medicine and (b) Wider dissemination of the research outcome(s) and the associated scientific knowledge.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Dalal PP, Otey AJ, McGonagle EA, Whitmill ML, Levine EJ, McKimmie RL, et al. Intentional foreign object ingestions: Need for endoscopy and surgery. J Surg Res 2013;184:145-9.  Back to cited text no. 1
    
2.
O'Sullivan ST, Reardon CM, McGreal GT, Hehir DJ, Kirwan WO, Brady MP. Deliberate ingestion of foreign bodies by institutionalised psychiatric hospital patients and prison inmates. Ir J Med Sci 1996;165:294-6.  Back to cited text no. 2
    
3.
Selivanov V, Sheldon GF, Cello JP, Crass RA. Management of foreign body ingestion. Ann Surg 1984;199:187-91.  Back to cited text no. 3
    
4.
Lai AT, Chow TL, Lee DT, Kwok SP. Risk factors predicting the development of complications after foreign body ingestion. Br J Surg 2003;90:1531-5.  Back to cited text no. 4
    
5.
Jones C, McGonagle EA, Stawicki SP, Otey AJ, Dalal PP, Whitmill ML, et al. Intentional ingestion of foreign bodies and psychiatric disease among prisoners. J Surg Res 2014;186:687.  Back to cited text no. 5
    
6.
Awofeso N. Making prison health care more efficient – Inmates need more organised and more preventive health care in emptier prisons. Br Med J 2005;331:248-9.  Back to cited text no. 6
    
7.
Awofeso N. Prisoner healthcare co-payment policy: A cost-cutting measure that might threaten inmates' health. Appl Health Econ Health Policy 2005;4:159-64.  Back to cited text no. 7
    
8.
Marquart JW, Merianos DE, Hebert JL, Carroll L. Health condition and prisoners: A review of research and emerging areas of inquiry. Prison J 1997;77:184-208.  Back to cited text no. 8
    
9.
Velitchkov NG, Grigorov GI, Losanoff JE, Kjossev KT. Ingested foreign bodies of the gastrointestinal tract: Retrospective analysis of 542 cases. World J Surg 1996;20:1001-5.  Back to cited text no. 9
    


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