Hospital costs

Objective: The fundamental role of video-assisted thoracic surgery (VATS) in the treatment of spontaneous pneumothorax is generally acknowledged today. This study intends to evaluate whether VATS is justi®ed at the onset of a ®rst spontaneous pneumothorax through analysis of parameters tested on two group of patients treated respectively with pleural drainage and VATS. Patients/methods: The study includes 70 patients affected by ®rst spontaneous pneumothorax divided into two groups of 35 patients for the purpose of therapeutic treatment. The ®rst group underwent pleural drainage while the second underwent VATS. Parameters analyzed were as follows: (1) prolonged air leaks (more than 6 days); (2) time required for pleural drainage; (3) time of hospital stay; (4) management costs; (5) recurrences (follow-up at 12 months). Results: Prolonged air leaks occurred in four patients (11.4%) in the ®rst group and two patients (5.7%) in the second; recurrences occurred in eight patients in the ®rst group (22.8%), and only one in the second group (2.8%). Mean time for drainage and hospitalization was, respectively, 9 and 12 days in patients with pleural drainage against 3.9 and 6 days of those using VATS. Average management costs per patients including hospitalization was calculated at $2,750.00 per patient for the ®rst group compared with $1,925.00 for the second group. Conclusions: The use of VATS at ®rst spontaneous pneumothorax is justi®ed in the interest of both patients and health administrations as demonstrated by the number of recurrences in patients in the ®rst group and economy savings resulting from use of VATS.

Background-There is increasing national focus on hospital initiatives to improve obstetric and neonatal outcomes. While costs of providing care may decrease with improved quality, the accompanying reduced adverse outcomes may impact hospital revenues. The purpose of this study was to estimate, from a hospital perspective, the financial impacts of implementing a perinatal quality and safety initiative. Methods-In 2008, a Minnesota-based health system (Fairview Health Services) launched the Zero Birth Injury (ZBI) initiative, which uses evidence-based care bundles to guide management of obstetric services. We conducted a pre-post analysis of financial impacts of ZBI, using hospital administrative records to measure costs and revenues associated with changes in maternal and neonatal birth injuries before (2008) and after (2009-11) the initiative. Results-After adjusting for relevant covariates, implementation of ZBI was associated with an 11% decrease in the rate of maternal and neonatal adverse outcomes between 2008 and 2011 (AOR=0.89, p=0.076). As a result of the adverse events avoided, the hospital system saved Lead Author Address and Contact Information Katy B. Kozhimannil,

This retrospective study compares the cost and quality outcomes of two matched groups of infants; one of which received neonatal care provided by neonatal nurse practitioners (NNPs), the other delivered by the medical house staff in one hospital's NICU. Parameters evaluated for both groups included LOS, days on ventilator, days on oxygen, mortality, morbidity, and costs. The infants in the study were matched by place of birth, gestational age, birth weight, sex, race, and Apgar scores. This study showed that in the 35 cases cared for by NNPs, in collaboration with neonatoologists, neonates received care equal in quality to the 35 matched cases cared for by medical house staff at lower cost with greater continuity and consistency. Cost effectiveness of the NNP group was documented as $18,240 less per infant than those managed by medical house staff. Differences were seen as chiefly attributable to the NNP's unique blend of knowledge, communication skills, and continuous presence plus early identification of service coordination needs.

This retrospective study compares the cost and quality outcomes of two matched groups of infants; one of which received neonatal care provided by neonatal nurse practitioners (NNPs), the other delivered by the medical house staff in one hospital's NICU. Parameters evaluated for both groups included LOS, days on ventilator, days on oxygen, mortality, morbidity, and costs. The infants in the study were matched by place of birth, gestational age, birth weight, sex, race, and Apgar scores. This study showed that in the 35 cases cared for by NNPs, in collaboration with neonatoologists, neonates received care equal in quality to the 35 matched cases cared for by medical house staff at lower cost with greater continuity and consistency. Cost effectiveness of the NNP group was documented as $18,240 less per infant than those managed by medical house staff. Differences were seen as chiefly attributable to the NNP's unique blend of knowledge, communication skills, and continuous prese...

This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. The present study compared ziprasidone treatment with haloperidol in sequential intramuscular/oral treatment for patients with exacerbation of schizophrenia. The study was based on the Ziprasidone Versus Haloperidol in Sequential IM/Oral Treatment (ZIMO) trial. The mean intramuscular doses were 32.1 mg/day for ziprasidone and 14.8 mg/day for haloperidol. Initial and final mean oral doses were, respectively, 113.9 and 137.2 mg/day for ziprasidone and 19 and 17 mg/day for haloperidol. Further details of the intervention strategies were described elsewhere (Perez et al. 2006, see 'Other Publications of Related Interest' below for bibliographic details). Treatment. Cost-effectiveness analysis. The population comprised patients with a schizophrenia exacerbation under conditions of standard medical practice. The patients included in this study were those who were assigned to treatment with haloperidol or ziprasidone and who took at least one dose of these drugs, and for whom information was available on both treatment effectiveness and consumption of resources whilst in hospital. The practice setting was inpatient care. The economic study was carried out in Spain. The effectiveness data came from the ZIMO study published in 2006. The resource use and cost data were derived from sources published between 2004 and 2005. The price year was 2005. The same patients represented the prospective source for both clinical and resource use data. A total of 325 patients who met the criteria (see 'Study Population') were included. Of these, 255 were treated sequentially with ziprasidone and 70 with haloperidol. The authors reported the baseline characteristics of the patients and stated that there were no statistically significant differences between the groups. The only difference in baseline score that was very close to statistical significance was the positive symptoms sub-scale. No other details of sample

Objective: To compare tension-free open mesh hernioplasty under local anaesthetic with transabdominal preperitoneal laparoscopic hernia repair under general anaesthetic. Design: A randomised controlled trial of 403 patients with inguinal hernias. Setting: Two acute general hospitals in London between May 1995 and December 1996. Subjects: 400 patients with a diagnosis of groin hernia, 200 in each group. Main outcome measures: Time until discharge, postoperative pain, and complications; patients' perceived health (SF-36), duration of convalescence, and patients' satisfaction with surgery; and health service costs. Results: More patients in the open group (96%) than in the laparoscopic group (89%) were discharged on the same day as the operation ( 2 = 6.7; 1 df; P = 0.01). Although pain scores were lower in the open group while the effect of the local anaesthetic persisted (proportional odds ratio at 2 hours 3.5 (2.3 to 5.1)), scores after open repair were significantly higher for each day of the first week (0.5 (0.3 to 0.7) on day 7) and during the second week (0.7 (0.5 to 0.9)). At 1 month there was a greater improvement (or less deterioration) in mean SF-36 scores over baseline in the laparoscopic group compared with the open group on seven of eight dimensions, reaching significance on five. For every activity considered the median time until return to normal was significantly shorter for the laparoscopic group. Patients randomised to laparoscopic repair were more satisfied with surgery at 1 month and 3 months after surgery. The mean cost per patient of laparoscopic repair was £335 (95% confidence interval £228 to £441) more than the cost of open repair. This study confirms that laparoscopic hernia repair has considerable short term clinical advantages after discharge compared with open mesh hernioplasty, although it was more expensive.

Current clinical and economic consequences of cancer after kidney transplantation are incompletely defined. We examined United States Renal Data System records of Medicare-insured kidney transplant recipients in 2000-2011 to determine clinical and economic impacts of cancer diagnosed within the first 3 years posttransplantation. Cancer diagnoses were identified using Medicare billing codes and categorized as nonmelanoma skin cancer (NMSC), viral-linked and "other" cancers. Associations of cancers with mortality and graft loss were estimated by time-varying Cox regression. Impacts of cancer diagnoses on inpatient and outpatient costs within each year were quantified by multivariate linear regression modeling. Among 67,157 recipients, by 3 years posttransplant, NMSC was diagnosed in 5.7%, viral-linked in 1.9%, and "other" cancers in 6.3%. Viral-linked cancer was associated with more than 3-fold increased risk in subsequent mortality until the third transplant anniv...

Our objective was to determine if the All-Patient Refined Diagnosis-Related Groups (APR-DRGs) and other comorbidity scores correlate with pain level, functional abilities, and hospital cost after primary total joint arthroplasty (TJA). Three hundred three patients having TJA were evaluated with average follow-up of 21 months. Western Ontario and McMaster Universities osteoarthritis index, Short-Form 36, and Quality of Well-Being index were administered before and after surgery. The APR-DRG subclassification including severity of illness (SOI) subclass scores and risk of mortality (ROM), Charlson index, American Society of Anesthesiologist (ASA), Charnley score, length of stay, and hospital costs were reported. Patients in a higher SOI and ROM subclasses had a statistically significant decrease in functional outcomes scores, longer length of stay, and greater hospitals costs than those in lower subclasses. However, correlations of comorbidity categories with outcome scores were poor. The APR-DRG classification helps identify those individuals with worse function and is specially suited in identifying those patients who incur a higher hospital cost.

With the aim of reducing restenosis after percutaneous coronary intervention with bare-metal stents (BMSs) for the treatment of ischemic heart disease, drug-eluting stents (DESs) were introduced in the field of percutaneous coronary intervention in 2002. However, the higher cost of DES in comparison with BMS made it necessary to determine whether their use brings a real economic advantage. In order to verify the clinical and economic benefit of DES in comparison with BMS and surgical treatment with coronary artery bypass graft (CABG), the Sicily Regional Government arranged for the creation of a directory where patients receiving at least one DES (with sirolimus or with paclitaxel) were enrolled from June 2004 to February 2005. The cost-effectiveness analysis for DES was carried out by means of two decisional models: one referring to patients treated with DES who, without such a device, would have undergone CABG, and the second one referring to patients treated with DES who, without...

Children with multiple chronic conditions (CMCC) are increasingly using hospital care. We assessed how much of US pediatric inpatient care is used by CMCC and which chronic conditions are the key drivers of hospital use. A retrospective analysis of all 2.3 million US acute-care hospital discharges in 2012 for children age 0 to 18 years in the Kids' Inpatient Database. The ∼4.5 million US hospitalizations for pregnancy, childbirth, and newborn and neonatal care were not assessed. We adapted the Agency for Healthcare Research and Quality's Chronic Condition Indicators to classify hospitalizations for children with no, 1, or multiple chronic conditions, and to determine which specific chronic conditions of CMCC are associated with high hospital resource use. Of all pediatric acute-care hospitalizations, 34.3% were of children with no chronic conditions, 36.5% were of those with 1 condition, and 29.3% were of CMCC. Of the $23.6 billion in total hospital costs, 19.7%, 27.4%, and ...

This quantitative case study aimed to learn and analyze the personnel cost in nursing direct care in the intensive care unit. We opted to use a therapeutic intervention score index, TISS-28, for the analysis of the indirect gravity of patients and the dimension of the nursing staff working time. Evaluating the cost by a gravity score presented to be a logical and relatively simple method to allocate costs per patient in the intensive care unit. In this exploratory and descriptive study, the average TISS-28 per patient was 31 points, requiring a daily expenditure of care hours of R$ 298.69. It was evidenced in this study that personnel costs are variable since there are patients with different complexities. Therefore is possible to estimate the nursing staff cost by assessing its work load.

Increasing health care expenditures, a rapid introduction of new medical technologies and a need for cost containment policies in most countries during the last decades have led to a growing interest in information from economic evaluations for decision making about resource allocation in health care. Economic evaluations can provide valuable information in many types of decision making, e.g. related to the use of drugs, other health care interventions/programs and investments in new technologies or research. These are, however, currently most widely used in pricing and reimbursement decisions for new drugs, in health technology assessment and for development of guidelines for prevention and treatment. This thesis discusses the role of economic evaluations in different types of health care decision making concerning resource allocation. Two of the studies analyse the available cost-effectiveness evidence for new drugs. The other four studies discuss and provide cost-effectiveness information to be used in the following important types of decision making situations in Sweden: reimbursement of new drugs, investments in new technology, implementation of screening programs and choices between therapies. The publication of economic evaluations increased dramatically during the 1980's and 1990's. This thesis demonstrates that economic evaluations during the 1990's were more likely to be conducted for drugs with improved effectiveness or safety as compared to those of the competitors and for drugs with high sales. Although requirements for economic evaluations for reimbursement decisions may lead to a more cost-effective use of the resources, it is important to recognise that regulations also involve a cost. Increasing requirements for cost-effectiveness in Sweden and Finland may have been associated with a delayed introduction of new drugs on the market, at least the first year after the changed regulations. However, it cannot be ruled out that the observed data might be due to chance or adaptations in the timing of new drug introductions. This thesis discusses four types of decision making where cost-effectiveness information can be of value for the decisions. The four economic evaluations identified patient populations and indications where teriparatide treatment for osteoporosis, proton radiation for breast cancer, screening for abdominal aortic aneurysm in men and use of iodixanol in angiography may be considered cost-effective in Sweden.

This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn.

A incidência do parto pré-termo tem aumentado em todo o mundo, desafios de sobrevivência dos recémnascidos prematuros de muito baixo peso têm colocado a inovação e a evolução tecnológica acima de outros fatores críticos a eles inerentes: a hipersensibilidade sensorial e a imaturidade neurológica para a manifestar. Estudos realizados em diferentes países e Unidades de Cuidados Intensivos Neonatais têm revelado o elevado número de procedimentos dolorosos a que diariamente estes recém-nascidos são submetidos e confirmado o seu insuficiente tratamento. A dor continuada e prolongada tem reflexos imediatos (alterações cardiovasculares, hormonais e metabólicas) no prematuro, e posteriormente na infância e idade adulta (hiperatividade, deficit de atenção, transtornos de ansiedade e stress. Apesar de ser possível avaliar e tratar a dor no recém nascido, existe um hiato entre o conhecimento cientifico e a pratica clinica. Conquistou-se nas últimas décadas a valorização e o reconhecimento pelo...

The purpose of this paper is to describe the process of cross-mapping and validating the Finnish Care Classification, FinCC and the Oulu Patient Classification, OPC measurement tool for patient care intensity. The process will be carried out with two expert panels. This will result a cross-mapped classification system to use be used in every electronic patient record systems in Finland.

Objective: Cost-effectiveness of heart surgery for elderly patients is still poorly defined. We evaluated outcome, quality of life (QoL), cost, and cost-effectiveness of octogenarians undergoing cardiac surgery. Methods: One thousand six hundred forty octogenarians undergoing various cardiac surgical procedures were prospectively studied between January 1998 and January 2009 and compared with similar patients aged 70 to 79 years. Several questionnaires were used to assess QoL. Six hundred age-and sex-matched healthy octogenarians and three hundred forty patients older than 80 years with medically treated valvular or coronary artery disease were healthy and unoperated control groups, respectively. In-hospital costs were obtained from the hospital's financial accounting department and cost-effectiveness was estimated and expressed as cost/QoL-adjusted life year (QALY) and cost-effectiveness ratio. Results: Significant improvements occurred in elderly patients in Role Physical (P < .001), Bodily Pain (P<.001), General Health (P ¼ .004), Social Functioning (P<.001), and Role Emotional (P<.001), whereas Physical Functioning, Vitality, and Mental Health did not change (difference not signficant).

Capitalizing on price regulation of health care services in Maryland, this paper investigates if uninsured individuals receive less care, if such a reduction in care is related to income constraints, and how these reductions in care translate into a differential likelihood of readmission or of mortality. Using propensity score matching to address selection effects, uninsured individuals receive about 5% fewer services on an illnessadjusted basis than their insured counterparts. A Blinder-Oaxaca decomposition estimates 8.3% fewer services for uninsured individuals. The uninsured are less likely to be readmitted than their insured counterparts and are more likely to die.

The purpose of this study was to establish a method by which independent predictors of survival could be determined and used to select CDH patients who may benefit from rescue therapy. Data from our 10-year, single institutional experience of 62 infants with CDH were analyzed. Fifteen preoperative and seven intraoperative variables were analyzed. Stepwise logistic regression analysis yielded a prediction equation with four independent, statistically significant (P<0.05) predictors of survival: lower VI, higher BW, higher 5-minute APGAR, and lower PaCO 2 . Using a survival probability of <20%, this equation yielded a sensitivity of 94% and specificity of 82% in selecting those patients with CDH who failed conventional management. We conclude that the preoperative values for VI, BW, 5-minute APGAR, and PaCO 2 of neonates with CDH in our institution can be used to select those patients with predicted high mortality who may benefit from salvage therapy.

The aim of the present study is to estimate the procedure (implantation) cost, the total hospitalization cost and annual follow-up cost, in patients subjected to pacemaker (PM) and implantable cardioverter-defibrillator (ICD) implantation. A single-center, prospective, cost-of-illness study was conducted between August 2008 and July 2009. In total, 464 consecutive patients were recruited (370 were subjected to PM implantation and 94 to ICD implantation). Resource data were assessed at patients' enrolment in the study and at 6th and 12th months of patients' follow-up. Then, the procedure cost, the total hospitalization cost as well as the annual patients' follow up costs were calculated using a bottom-up approach. The mean (95% confidence interval) procedure cost of PM and ICD implantation (including the costs of devices, electrodes, other supplies, and personnel's time) was calculated to be E1803 (E1758-E1858) and E13 521 (E13 153-E13 892), respectively. The mean total hospitalization cost (including procedure cost, hospitalization cost, cost of laboratory and imaging diagnostic examinations and the indirect cost attributed to productivity lost due to patient's hospitalization) was E3926 (E3711 -E4167) for PM and E17 764 (E16 852-E18 692) for ICD. The mean annual cost (direct and indirect) was E1816 (E1433-E2421) for PM and E2819 (E2115-E3703) for ICD. No difference was detected in the annual cost between patients with initial implantation and replacement. These data revealed that although these devices are associated with a relatively high upfront cost, the annual societal cost following the implantation is low. Therefore, implantation of such devices should be encouraged since these devices reduce the morbidity and mortality without a high economic burden to society.

Background: There is no more effective intervention for secondary prevention of coronary heart disease than smoking cessation. Yet, evidence about the (cost-)effectiveness of smoking cessation treatment methods for cardiac inpatients that also suit nursing practice is scarce. This protocol describes the design of a study on the (cost-) effectiveness of two intensive smoking cessation interventions for hospitalised cardiac patients as well as first results on the inclusion rates and the characteristics of the study population. Methods/design: An experimental study design is used in eight cardiac wards of hospitals throughout the Netherlands to assess the (cost-)effectiveness of two intensive smoking cessation counselling methods both combined with nicotine replacement therapy. Randomization is conducted at the ward level (cross-over). Baseline and follow-up measurements after six and 12 months are obtained. Upon admission to the cardiac ward, nurses assess patients' smoking behaviour, ensure a quit advice and subsequently refer patients for either telephone counselling or face-to-face counselling. The counselling interventions have a comparable structure and content but differ in provider and delivery method, and in duration. Both counselling interventions are compared with a control group receiving no additional treatment beyond the usual care. Between December 2009 and June 2011, 245 cardiac patients who smoked prior to hospitalisation were included in the usual care group, 223 in the telephone counselling group and 157 in the face-to-face counselling group. Patients are predominantly male and have a mean age of 57 years. Acute coronary syndrome is the most frequently reported admission diagnosis. The ultimate goal of the study is to assess the effects of the interventions on smoking abstinence and their cost-effectiveness. Telephone counselling is expected to be more (cost-)effective in highly motivated patients and patients with high SES, whereas face-to-face counselling is expected to be more (cost-)effective in less motivated patients and patients with low SES. Discussion: This study examines two intensive smoking cessation interventions for cardiac patients using a multicentre trial with eight cardiac wards. Although not all eligible patients could be included and the distribution of patients is skewed in the different groups, the results will be able to provide valuable insight into effects and costs of counselling interventions varying in delivery mode and intensity, also concerning subgroups.

To investigate whether screening for gallstone disease was economically feasible and clinically effective. This clinical study was initially conducted in 2002 in Taipei, Taiwan. The study cohort total included 2386 healthy adults who were voluntarily admitted to a regional teaching hospital for a physical check-up. Annual follow-up screening with ultrasound sonography for gallstone disease continued until December 31, 2007. A decision analysis using the Markov Decision Model was constructed to compare different screening regimes for gallstone disease. The economic evaluation included estimates of both the cost-effectiveness and cost-utility of screening for gallstone disease. Direct costs included the cost of screening, regular clinical fees, laparoscopic cholecystectomy, and hospitalization. Indirect costs represent the loss of productivity attributable to the patient&#39;s disease state, and were estimated using the gross domestic product for 2011 in Taiwan. Longer time intervals ...

Background: The gold standard treatment for calculus cholecystitis is laparoscopic cholecystectomy (LC). In the conventional laparoscopic cholecystectomy (CLC), three instruments are most useful in ensuring the critical view of safety. The two ports plus one puncture laparoscopic cholecystectomy (TPPOP LC) assisted needle grasper approach upholds the laparoscopic triangulation principles and allows an accessible critical view of safety. This technique successfully reduces port numbers while maintaining equivalent surgical outcomes.
Method: The main objective is to compare clinical outcomes of conventional and two ports plus one puncture laparoscopic cholecystectomy. This is a single-center hospital based interventional double-blinded randomized controlled trial that included 98 patients undergoing laparoscopic cholecystectomy at No. (1) Military Hospital (700 bedded) from 01/12/2019 to 31/07/2021. The patients were randomized into group A (CLC) (n = 49) and group B (TPPOP LC) (n = 49). This trial was registered in the ISRCTN registry with the registration number ISRCTN50339464.
Results: Among total of 98 patients, 46.9% were male patients and 53.1% were female patients. Mean age in group A was 49.86 ± 7.77 years and in group B was 49.33 ± 7.69 years. Mean operation time in group A was 57.9 ± 6.7 minutes and in group B was 58.5 ± 7.1 minutes, with no significant difference (p = 0.66). Although 4.1% of patients in CLC group and 12.2% in TPPOP LC group experienced bile spillage, no other major intraoperative complications were noted. A significant difference was observed at 36 and 48 hours postoperatively (VAS: 2.69 ± 1.16 in group A and 1.94 ± 0.83 in group B at 36 hours; p = 0.005 and VAS: 1.69 ± 0.92 in group A and 1.33 ± 0.63 in group B at 48 hours; p = 0.002). Postoperative minor wound infection was detected 6.1% in group A and 4.1% in group B (p = 0.64). The mean duration of the postoperative hospital stay was 5.24 ± 1.01 days in group A and 4.98 ± 0.92 days in group B (p = 0.17).
Conclusion: This clinical trial concludes that two ports plus one puncture laparoscopic cholecystectomy is as effective and safe as conventional four-port laparoscopic cholecystectomy.

Background: Congestion in the postanesthesia care unit (PACU) leads to the formation of waiting queues for patients being transferred after surgery, negatively affecting hospital resources. As patients recover in the operating room, incoming surgeries are delayed. The purpose of this study was to establish the impact of this phenomenon in multiple settings. Methods: An operational mathematical study based on the queuing theory was performed. Average queue length, average queue waiting time, and daily queue waiting time were evaluated. Calculations were based on the mean patient daily flow, PACU length of stay, occupation, and current number of beds. Data was prospectively collected during a period of 2 months, and the entry and exit time was recorded for each patient taken to the PACU. Data was imputed in a computational model made with MS Excel. To account for data uncertainty, deterministic and probabilistic sensitivity analyses for all dependent variables were performed. Results: With a mean patient daily flow of 40.3 and an average PACU length of stay of 4 hours, average total lost surgical opportunity time was estimated at 2.36 hours (95% CI: 0.36-4.74 hours). Cost of opportunity was calculated at $1592 per lost hour. Sensitivity analysis showed that an increase of two beds is required to solve the queue formation. Conclusions: When congestion has a negative impact on cost of opportunity in the surgical setting, queuing analysis grants definitive actions to solve the problem, improving quality of service and resource utilization.

This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn.

Abdominal aortic aneurysm (AAA) represents a critical vascular pathology defined by a permanent, localized dilation of the abdominal aorta exceeding 150% of its normal diameter. This condition carries a high risk of rupture, which is associated with catastrophic mortality rates exceeding 80% in untreated cases. This review provides a professor-level exploration of AAA, encompassing its etiology, epidemiology, pathophysiology, histopathology, clinical presentation, diagnostic modalities, and evidence-based management strategies. The discussion integrates recent guidelines from the European Society for Vascular Surgery (2024) and the Society for Vascular Surgery (2018), emphasizing the roles of advanced imaging, individualized treatment planning, and postoperative surveillance. Special attention is directed to differential diagnosis, prognosis, potential complications, patient education, and interprofessional care models. Emerging endovascular technologies, including fenestrated and branched grafts, are evaluated in the context of complex aneurysm repair. The review concludes by highlighting strategies to optimize patient outcomes through early detection, risk factor modification, surgical innovation, and coordinated multidisciplinary management.

This paper estimates the total cost to women and their families associated with a spontaneous vaginal delivery and five types of 'near-miss' obstetric complication in Benin and Ghana, and assesses affordability in relation to household cash expenditure. A retrospective evaluation of costs was carried out among 121 mothers in three hospitals in Ghana. A prospective evaluation of costs was undertaken among 420 pregnant women in two hospitals in Benin. Information was collected on the cost of travel to the facilities and of direct medical and non-medical costs incurred during their stay in hospital. In Benin, costs ranged from an average of US$15 for a spontaneous delivery to US$256 for a near-miss complication caused by dystocia. In Ghana, average costs ranged from US$18 for a spontaneous vaginal delivery to US$115 for a near-miss complication caused by haemorrhage. Medical costs accounted for the largest share of total costs, mainly drugs and medical supplies in Ghana and costs of the delivery and any surgical intervention in Benin. Payments associated with a spontaneous vaginal delivery amounted to at least 2% of annual household cash expenditure in both countries. In the case of severe obstetric complications, costs incurred reached a high of 34% of annual household cash expenditure in Benin. The economic burden of hospital-based delivery care in Ghana and Benin is likely to deter or delay women's use of health services. Should a woman develop severe obstetric complications while in labour, the relatively high costs of hospital care could have a potentially catastrophic impact on the household budget.

Osteoarthritis (OA) and rheumatoid arthritis (RA) are the most common joint diseases in the elderly population. In Brazil, the prevalence of RA in adults varies between 0.2 and 1%, affecting more women, between 30 and 50 years old. Symptomatic OA mainly affects people over 60 and is considered a major cause of joint pain and disability principally in females. In Brazil, there are no accurate estimates of the prevalence of OA in the elderly, and the percentage of people with RA and advanced OA who require arthroplasty is unknown. Our objectives were to determine the prevalence of RA and OA cases requiring total joint arthroplasty (TJA) and, from these values, to estimate the prevalence of OA and RA in our population.

Background: Total joint arthroplasty (TJA) benefit patients with osteoarthritis (OA) and rheumatoid arthritis (RA). However, a specific approach to detect patients at higher risk of prosthetic joint infection (PJI) and mechanical complications is absent. The aim of this study is to identify groups at higher risk for infections and mechanical complications after TJA in patients with RA and OA based on their most significant predictors. Methods: This is a hospital-based cohort study with 1150 recipients of TJA. Risk factors and comorbidities were assessed prior to the index surgery. Multivariate logistic and hazard regression were used to determine the relationship between risk factors and occurrence of complications after TJA. Odds ratios (OR), hazard ratios (HR), 95% confidence intervals (CI), and comparison between areas under the curve (AUC) using DeLong's method are presented. Results: Complications were more frequent in subjects with RA, use of corticosteroids, and previous comorbidities: respiratory disease, infections, diabetes, anemia, mental and musculoskeletal comorbidities than in subjects without these risk factors, and these factors were predictors of infections and mechanical complications (P < 0.05). A model including these factors was superior to a model with only type of joint disease (OA/RA) or age and gender to detect infections or mechanical complications after TJA (P < 0.05 for difference between models). Complication risk proportionally increased with the presence of two or more comorbidities (P < 0.001). Conclusions: There are two groups at higher risk for infections after TJA: patients with OA with at least two risk factors and patients with RA, who usually present at least one of the risk factors for infection.

, in 2000, many changes have been implemented and an increasing number of cases led to the development of expertise. The aim of this article was to summarise 12-years out of liver transplantation experience. Data was obtained retrospectively from inpatient medical records at the Hospital of LUHS, Kaunas Clinic. All cases of liver transplantations from November 2009 to September 2021 were included (n = 96). The median age of transplant recipients was 50 years . Two-thirds of recipients were male (n = 66, 69%). The mean Model for End-Stage Liver Disease (MELD) score was 23 (SD 6). The most common indication for liver transplantation was hepatitis C virus-related end-stage liver disease (n = 24, 25%). Immediate extubation was performed with a median of 63% of cases . We further compared data between the early (November 2009 -December 2015) and late phases (January 2016 -September 2021) of experience: the number of liver transplantation cases increased by 66% from 36 to 60), MELD scores stayed similar (an average of 22 vs 24, p = 0.282), and mean intraoperative time did not change significantly (543 minutes vs 496 minutes, p = 0.078). Liver transplantation has been gaining momentum in Lithuania. Increasing experience enables our centre to meet an increasing demand for liver transplantations.

The comparators were justified on the grounds that CABG represented existing practice. The consideration of MT was justified because existing practice may not be cost-effective by itself, and the interpretation of the results of comparisons between PET and CABG may be misleading.

Cost-effectiveness acceptability curves (CEACs) describe the probability that a new treatment or intervention is cost-effective. The net benefit regression framework (NBRF) allows cost-effectiveness analysis to be done in a simple regression framework. The objective of the paper is to illustrate how net benefit regression can be used to construct a CEAC. One hundred patients referred for ambulatory monitoring with syncope or presyncope were randomized to a one-month external loop recorder (n = 49) or 48-hour Holter monitor (n = 51). The primary endpoint was symptom-rhythm correlation during monitoring. Direct costs were calculated based on the 2003 Ontario Health Insurance Plan (OHIP) fee schedule combined with hospital case costing of labour, materials, service and overhead costs for diagnostic testing and related equipment. In the loop recorder group, 63.27% of patients (31/49) had symptom recurrence and successful activation, compared to 23.53% in the Holter group (12/51). The co...

Objectives: To know the sensitivity and specificity of ultrasound with plain abdominal film (X-ray KUB) compared to IVU inevaluation of renal colic. To develop a protocol for investigations of renal colic. Design of study: Experimental. Setting: Department of Urologyand Renal Transplantation, Quaid-I-Azam Medical College /Bahawal Victoria Hospital, Bahawalpur. Period: From July 2010 to December2011. Materials & Methods: The number of cases for the study were one hundred and fifty. Patients of either sex of age range from 10 to 50years with suspected urinary tract stone disease, PUJ obstruction and stricture ureterovesical junction were included in this study. Whilepatients of age &lt;10years, renal failure and with history of hypersensitivity to contrast media were excluded from the study. After routineinvestigations, ultrasonography, plain X-ray KUB and IVU were performed in every patient at radiology department, Bahawal Victoria hospital,Bahawalpur. Results: The mean age of patien...

Objectives: Lower extremity percutaneous transluminal angioplasty (LE PTA) is currently performed by a variety of endovascular specialists. We hypothesized that cardiologists (CRD) and vascular surgeons (VAS) may have different practice patterns, indications for intervention, and hospital resource utilization. Methods: Using the State Inpatient Databases for New Jersey (2003-2007), patients with elective admission undergoing PTA procedures with indications of claudication, rest pain, and gangrene/ulceration were examined. Physician specialty was determined based on all procedures performed. We contrasted by specialty, the indication for LE PTA for the procedure, volume, and hospital resource utilization. Results: Of the 1887 cases of LE PTA, VAS performed 866 (45.9%) and CRD 1021 (54.1%) procedures. The mean patient age was 68.0 years (CRD) vs 70.7 years (VAS), P ‫؍‬ .0163. Indications for intervention were compared for CRD vs VAS: claudication 80.7% vs 60.7%, (P < .002); rest pain 6.2% vs 16.0%, (P < .002); gangrene/ulceration 13.1% vs 23.3%, (P < .002). Stents (64.8% of cases) were utilized similarly among physicians (P ‫؍‬ .18), and mean hospital length of stay were similar (2.38 days vs 2.41 days, P ‫؍‬ .85). Hospital charges by indication varied between CRD vs VAS (all procedures: $49,748 vs $42,158 [P < .0001]). Revenue center charges were different between CRD vs VAS: medical surgical supply $19,128 vs $12,737, (P < .0001); pharmacy $1,959 vs $1,115, (P < .0001). Only 10.7% of CRD were high volume practitioners, compared with 36.8% among VAS (P < .05). High volume practitioners had significantly lower hospital charges ($41,730 vs $51,014, P < .001). Conclusions: Cardiologists performing lower extremity angioplasty were more likely to treat patients with claudication than those with rest pain or gangrene/ulceration. Despite treating younger patients with less severe peripheral vascular disease, cardiologists used significantly greater hospital resources. High practitioner volume, regardless of specialty, was associated with lower hospital resource utilization. Reducing variations in indication and practitioner volume may offer substantial cost savings for lower extremity endovascular interventions. (

Objectives: A variety of endovascular specialists perform carotid artery stenting (CAS), but little data exist on outcomes and resource utilization among these specialists. We analyzed differences in outcomes after CAS was performed by radiologists (RAD), cardiologists (CRD), and vascular surgeons (VAS). Methods: Secondary data analysis of the 2005-2006 State Inpatient Databases for New Jersey were analyzed. Patients with elective admission to the hospital who had CAS procedure <2 days after admission were identified. CAS outcomes were analyzed with respect to practitioner specialty and volume, associated complications, and hospital resource utilization. Results: We identified 625 CAS cases. CRD performed 378 (60.5%), VAS, 199 (31.8%); and RAD, 48 (7.7%). The overall stroke rate was 2.72% and by specialty was CRD, 3.17%; VAS, 2.01%, and RAD, 2.08% (P ‫؍‬ .6880). The overall cardiac complication rate was 2.40% (CRD, 2.12%; VAS, 3.02%; RAD, 2.08%; P ‫؍‬ .7899). Renal and pulmonary complications were low (0.64% and 0.32%, respectively). Mean hospital length of stay (LOS) in days was significantly shorter for VAS (1.64 ؎ 1.40) compared with RAD (2.83 ؎ 5.15; P ‫؍‬ .0167) and had the same trend compared with CRD (2.14 ؎ 3.37; P ‫؍‬ .0649). Intensive care unit (ICU) LOS was shorter for VAS (0.52 ؎ 0.97) and CRD (0.30 ؎ 0.71) than for RAD (2.12 ؎ 4.48; P < .0001). The mean total hospital cost was significantly greater for RAD

Objective: Tracheostomy is one of the most frequent interventions for ICU patients. The current trend in performing a tracheostomy is a percutaneous approach because of its popularity and significant advantages. In this study, certain indications of surgical tracheostomy (ST) are suggested and furthermore, ST is compared with percutaneous tracheostomy (PT). Patient and Methods: We performed a U-shaped ST in 121 patients and PT in 85 patients between March 2003 and December 2006. All of the STs were opened U-shaped in the operating room. In this technique; instead of removing the tracheal ring, it was used to create a flap. The tracheal flap was hung with a suture from middle of the 2nd or the 3rd cartilage rings, as a guide. Also, the PT procedure " Griggs dilatation technique" was performed in the ICU. Results: PT and ST had similar complication rates: 4.1% for ST [bleeding in 2 patients, stenosis in 2, and stomal infection in 1] versus 3.6% for PT [bleeding in 2 patients, and pneomothorax in 1] ( p = 0.08). No significant difference was found regarding mean operation time between ST [12 min (9-18)] and PT [8 min (6-16)] ( p = 0.09) Conclusions: Staff utilization and cost seem like the major advantages of PT. However, our surgical technique has similar complication rates with PT and moreover, using ST still remains favorable for select patients with thyroid hyperplasia, short neck, tracheaomalacia, obesity, neck operation history and for children.

Limited information is available on the contemporary and potentially changing trends in the incidence, management, and outcomes of cardiogenic shock complicating ST-elevation myocardial infarction (STEMI). We queried the 2003-2010 Nationwide Inpatient Sample databases to identify all patients ≥ 40 years of age with STEMI and cardiogenic shock. Overall and age-, sex-, and race/ethnicity-specific trends in incidence of cardiogenic shock, early mechanical revascularization, and intra-aortic balloon pump use, and inhospital mortality were analyzed. From 2003 to 2010, among 1 990 486 patients aged ≥ 40 years with STEMI, 157 892 (7.9%) had cardiogenic shock. The overall incidence rate of cardiogenic shock in patients with STEMI increased from 6.5% in 2003 to 10.1% in 2010 (P(trend)&lt;0.001). There was an increase in early mechanical revascularization (30.4% to 50.7%,…

Cost-benefit analyses, run before the commencement of a programme to control a parasitic disease, should include estimates of the economic losses attributable to the disease. Uruguay, a middle-income, developing country, has a recent history of persistent problems with cystic echinococcosis, in both its human population and livestock. The economic effects in Uruguay of this disease, caused by the larval stage of the canine tapeworm Echinococcus granulosus, have now been evaluated. Data on the incidence of the disease, in humans and livestock, were used to construct cost estimates. The estimated minimum cost (U.S.$2.9 million/year) was based on the condemnation costs of infected offal together with the actual costs of the hospital treatment of the human cases. The estimate of the maximum cost (U.S.$22.1 million/year) also included the production losses resulting from lower livestock efficiency and the reduced income of individuals with morbidity attributable to the disease.

Background: Given the risk of surgical site infection (SSI), the use of mesh in contaminated ventral hernia repair (VHR) is not standardized and still a clinical dilemma. This meta-analysis aimed to assess whether mesh use increased the risk of SSI in patients following VHR in contaminated field. Methods: We performed a systematic review of published literature. Studies comparing the mesh repair and anatomic repair, the use of mesh in different Center for Disease Control and Prevention (CDC) wound classes and mesh repair with synthetic mesh or other type of meshes to treat complicated and contaminated VHR were considered for analysis. The main outcome was SSI incidence. Results: Six studies compared mesh and suture repairs. No significant difference in SSI incidence was observed between patients with complicated VHR in the mesh and suture repair groups. Five studies analyzed mesh repair in patients by field contamination level. There was no significant difference between the use of mesh in clean-contaminated, contaminated and dirty field versus clean wound class. Moreover, there was no significant difference between the use of mesh in clean-contaminated and contaminated cases. Four studies compared mesh repair technique with synthetic mesh or other type of meshes were included. The incidence of SSI was significantly lower in the synthetic mesh group. Conclusions: The use of mesh repair in the management of complicated VHR compared to suture repair is not associated with an increased incidence of SSI even in potentially contaminated fields.

We evaluated the safety and efficacy of protamine administration, guided by activated clotting time, for the immediate femoral arterial sheath removal in patients undergoing percutaneous coronary intervention with unfractionated heparin in order to propose an algorithm for clinical practice. Methods: Prospective study with consecutive patients with stable angina or low-to-moderate risk acute coronary syndrome. We compared patients with an early removal of the arterial sheath to those whose sheath removal was based on a standard protocol. Results: The early removal group (n = 149) had lower access manipulation time than the conventional group (58.3 ± 21.4 minutes vs. 355.0 ± 62.9 minutes; p < 0.01), mainly due to a reduced time to sheath removal (42.3 ± 21.1 minutes vs. 338.6 ± 61.5 minutes; p < 0.01), with no impact on the duration of femoral compression (16.0 ± 3.6 minutes vs. 16.4 ± 5.1 minutes; p = 0.49). There was no stent thrombosis during hospitalization and no significant differences in the incidence of major vascular or bleeding events. The incidence of other bleeding events leading to a prolonged in-hospital length of stay was lower in the early removal group (1.3% vs. 5.1%; p = 0.05). Conclusions: The selective use of an approach for immediate femoral sheath removal, based on activated clotting time guidance and protamine administration, is a safe and effective option in patients undergoing percutaneous coronary intervention by femoral access.

Women with gestational diabetes are at increased risk of non-insulin dependent diabetes and their babies are at increased risk of adverse perinatal outcomes. These risks can be reduced by better detection and control of diabetes. Identifying risk factors for gestational diabetes may improve screening programmes. As low birth weight has been related to non-insulin dependent diabetes in elderly populations, 3 we decided to investigate whether women's characteristics at birth could predict their subsequent risk of gestational diabetes. We used linked generation data from the medical birth registry of Norway to study all women born in 1967-84 who had given birth between 1988 and 1998. The registry is a compulsory reporting system and files used for analysis are anonymised. Although there were 141 107 women in the cohort, we excluded 2393 who were not singletons. We compared the birth characteristics of women with and without self reported gestational diabetes in one or more pregnancies. Data were analysed in relation to categories of birth weight; the ponderal index at birth (m/g 3 ×100); gestational age (excluding women who were considered misclassified) 4 ; weight for gestational age; and whether the woman had a mother whose pregnancy had been complicated by diabetes (any type), pre-eclampsia, eclampsia, placental abruption, or hypertension. We also considered diabetes in relation to the women's age and parity and their mothers' age and parity when they were born. We calculated odds ratios obtained from logistic regression analyses in which we adjusted for the women's age and parity and their mothers' diabetes. Altogether 498 of these women aged less than 32 reported gestational diabetes. Prevalence increased with age, from 1.5 per 1000 deliveries for women aged <20 to 4.2 for women aged >30 (odds ratio 2.8; 95% confidence interval 1.9 to 4.3). Parity increased the risk of gestational diabetes; age adjusted odds ratios (95% confidence intervals) for women with two, three, and four or more deliveries compared with one delivery were 1.5 (1.2 to 1.9), 1.9 (1.4 to 2.5), and 3.3 (2.1 to 5.1) respectively. Women whose mothers had had diabetes during pregnancy were at increased risk of gestational diabetes (table). The table also shows that there were significant inverse trends in diabetes in relation to birth weight and weight for gestational age (P < 0.001). The increased risks of gestational diabetes were 80%, 60%, and 40% in women whose birth weights were <2500 g, 2500-2999 g, and 3000-3499 g respectively compared with women in the 4000-4500 g group. We observed similar findings in relation to categories of weight for gestational age. Birth weight and weight for gestational age are strongly related; the three highest birthweight Papers Locus for Registry-based Epidemiology,

BACKGROUND. The strong association between birth weight and perinatal mortality is due both to gestational age and to factors unrelated to gestational age. Conventional analysis obscures these separate contributions to perinatal mortality, and overemphasizes the role of birth weight. An alternative approach is used here to separate gestational age from other factors. METHODS. Data are from 400,000 singleton births in the Norwegian Medical Birth Registry. The method of Wilcox and Russell is used to distinguish the contributions to perinatal mortality made by gestational age and by relative birth weight at each gestational age. RESULTS. Gestational age is a powerful predictor of birth weight and perinatal survival. After these effects of gestational age are controlled for, relative birth weight retains a strong association with survival. CONCLUSIONS. Current public health policies in the United States emphasize the prevention of low birth weight. The present analysis suggests that the...

Objective: Cardiovascular diseases are the main cause of death in both men and women around the world. Considering the heavy economic and social burden of readmission of cardiovascular patients on the patients and their families as well as the health care system, this study aimed at determining the factors associated with hospital readmission of cardiovascular patients in four public hospitals affiliated with Shiraz University of Medical Sciences, Iran. Methods: This cross-sectional study was conducted on cardiovascular patients hospitalized in public hospitals affiliated with Shiraz University of Medical Sciences, Iran. A total of 264 patients were studied, 132 of whom had been readmitted and were selected through the census method. The other 132 patients had not been readmitted and were randomly selected through stratified sampling proportional to the size and simple random sampling method. The patients were examined using a questionnaire developed according to previous studies an...

A recent Cochrane review compared laparoscopic versus open distal pancreatectomy for people with for cancers of the body and tail of the pancreas and found that laparoscopic distal pancreatectomy may reduce the length of hospital stay. We compared the cost-effectiveness of laparoscopic distal pancreatectomy versus open distal pancreatectomy for pancreatic cancer. Model based cost-utility analysis estimating mean costs and quality-adjusted life years (QALYs) per patient from the perspective of the UK National Health Service. A decision tree model was constructed using probabilities, outcomes and cost data from published sources. A time horizon of 5 years was used. One-way and probabilistic sensitivity analyses were undertaken. The probabilistic sensitivity analysis showed that the incremental net monetary benefit was positive (£3,708.58 (95% confidence intervals (CI) -£9,473.62 to £16,115.69) but the 95% CI includes zero, indicating that there is significant uncertainty about the cost-effectiveness of laparoscopic distal pancreatectomy versus open distal pancreatectomy. The probability laparoscopic distal pancreatectomy was cost-effective compared to open distal pancreatectomy for pancreatic cancer was between 70% and 80% at the willingness-to-pay thresholds generally used in England (£20,000 to £30,000 per QALY gained). Results were sensitive to the survival proportions and the operating time. There is considerable uncertainty about whether laparoscopic distal pancreatectomy is costeffective compared to open distal pancreatectomy for pancreatic cancer in the NHS setting.

This paper describes and analyses, in the French context, the effects of the diagnosis related groups (DRGs) on surgical procedures in public and private health care establishments through an analysis of annual data extracted from the PMSI medico-administrative computerised database programme for the years 2005 and 2008. A statistical analysis conducted at a national level on surgical GHMs (homogeneous groups of patients) shows that there is no such effect in the choice of the type of group (with or without CAM complications and associated morbidities) by health care establishments. However, the study reveals an increase in coding, irrespective of the sector (private or public), since the implementation of the DRGs for the same homogeneous groups of patients. This research presents the originality of measuring the effects of the DRGs on the surgical activity of health care establishments within the French context by using a significant quantitative database. To our knowledge, this is the first research in this field of comparison between the public and private establishments financing since the implementation of the DRGs in 2005. Keywords: DRGs (diagnosis related groups), Incentives, GHM (homogeneous groups of patients), CAM (complications and associated morbidities), activity development, coding www.ccsenet.org/ibr