1
|
Gattini D, Yan H, Belza C, Avitzur Y, Wales PW. Cost-utility analysis of 4% tetrasodium ethylenediaminetetraacetic acid, taurolidine, and heparin lock to prevent central line-associated bloodstream infections in children with intestinal failure. JPEN J Parenter Enteral Nutr 2024; 48:47-56. [PMID: 37465871 DOI: 10.1002/jpen.2551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 07/17/2023] [Accepted: 07/17/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND Central line-associated bloodstream infections (CLABSI) are a serious complication in children with intestinal failure. This study assessed the incremental costs of 4% tetrasodium ethylenediaminetetraacetic acid (EDTA) compared with taurolidine lock and heparin lock per quality-adjusted life-year (QALY) gained in children with intestinal failure from the healthcare payer and societal perspective. METHODS A Markov cohort model of a 1-year-old child with intestinal failure was simulated until the age of 17 years (time horizon), with a cycle length of 1 month. The health outcome measure was QALYs, with results expressed in terms of incremental costs and QALYs. Model parameters were obtained from published literature and institutional data. Deterministic, probabilistic, and scenario sensitivity analyses were performed. RESULTS 4% Tetrasodium EDTA was dominant (more effective and less expensive) compared with taurolidine and heparin, yielding an additional 0.17 QALYs with savings of CAD$88,277 compared with heparin, and an additional 0.06 QALYs with savings of CAD$52,120 compared with taurolidine lock from the healthcare payer perspective. From the societal perspective, 4% tetrasodium EDTA resulted in savings of CAD$90,696 compared with heparin and savings of CAD$36,973 compared with taurolidine lock. CONCLUSIONS This model-based analysis indicates that 4% tetrasodium EDTA can be considered the optimal strategy compared with taurolidine and heparin in terms of cost-effectiveness. The decision uncertainty can be reduced by conducting further research on the model input parameters. An expected value of perfect information analysis can identify what model input parameters would be most valuable to focus on.
Collapse
Affiliation(s)
- Daniela Gattini
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Division of Gastroenterology, Hepatology & Nutrition, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Group for Improvement of Intestinal Function and Treatment, Transplant and Regenerative Medicine Centre, Toronto, Ontario, Canada
| | - Han Yan
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Christina Belza
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Group for Improvement of Intestinal Function and Treatment, Transplant and Regenerative Medicine Centre, Toronto, Ontario, Canada
| | - Yaron Avitzur
- Division of Gastroenterology, Hepatology & Nutrition, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Group for Improvement of Intestinal Function and Treatment, Transplant and Regenerative Medicine Centre, Toronto, Ontario, Canada
| | - Paul W Wales
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, University of Toronto, Cincinnati, Ohio, United States
- Cincinnati Center of Excellence for Intestinal Rehabilitation, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
| |
Collapse
|
2
|
Gattini D, Belza C, Kraus R, Avitzur Y, Ungar WJ, Wales PW. Cost-utility analysis of teduglutide compared to standard care in weaning parenteral nutrition support in children with short bowel syndrome. Clin Nutr 2023; 42:2363-2371. [PMID: 37862822 DOI: 10.1016/j.clnu.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 09/29/2023] [Accepted: 10/02/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND & AIMS A growing proportion of children with short bowel syndrome (SBS) remain dependent on long-term parenteral nutrition (PN). Teduglutide offers the potential for more children to decrease PN support and achieve enteral autonomy (EA), but at a significant expense. This study aims to assess the incremental costs of teduglutide plus standard of care compared to standard of care alone in weaning PN support per quality-adjusted life year (QALY) gained in children with SBS. METHODS This is a cost-utility analysis comparing teduglutide with standard of care alone in children with SBS. A microsimulation model of children with SBS on PN aged 1-17 years was constructed over a time horizon of six years, with a cycle length of one month. The study adopted the healthcare system and societal payer perspectives in Ontario, Canada. The health outcome measure was QALYs, with results expressed in terms of incremental costs and QALYs. Scenario analyses were performed to examine the effects of different time horizons, timing of teduglutide initiation, and modeling cost of teduglutide based on pediatric weight-dosing. RESULTS Incremental healthcare system costs for teduglutide compared to standard of care were CAD$441,314 (95% CI, 414,006 to 441,314) and incremental QALYs were 1.80 (95% CI, 1.70 to 1.89) resulting in an incremental cost-effectiveness ratio (ICER) of CAD$285,334 (95% CI, 178,209 to 392,459) per QALY gained. Incremental societal costs were CAD$418,504 (95% CI, 409,487 to 427,522) and incremental societal QALYs were 1.91 (95% CI, 1.85 to 1.98) resulting in an ICER of CAD$261,880 (95% CI, 136,887 to 386,874) per QALY gained. Scenario analysis showed that teduglutide was cost-effective when it was started two years after intestinal resection (ICER CAD$48,741, 95% CI, 17,317 to 80,165) and when its monthly cost was adjusted using weight-based dosing, avoiding wastage of the remaining 5 mg dose vial (Teduglutide dominated over SOC as the less costly and most effective strategy). CONCLUSIONS Although teduglutide was not cost-effective in weaning PN support in children with SBS, starting teduglutide once natural intestinal adaptation is reduced and adjusting its monthly cost to reflect cost by volume as dictated by weight-based dosing rendered the intervention cost-effective relative to standard of care. These results indicate the potential for clinicians to re-assess optimal time for initiation of teduglutide after intestinal resection, drug manufacturers to consider the use of multi-dose or paediatric-dose vials, and the opportunity for decision-makers to re-evaluate teduglutide funding.
Collapse
Affiliation(s)
- Daniela Gattini
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Gastroenterology, Hepatology & Nutrition, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant and Regenerative Medicine Centre, Toronto, Ontario, Canada
| | - Christina Belza
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant and Regenerative Medicine Centre, Toronto, Ontario, Canada
| | - Raphael Kraus
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Pediatric Rheumatologist, Centre Hospitalier Sainte-Justine (CHUSJ), Montreal, Quebec, Canada
| | - Yaron Avitzur
- Division of Gastroenterology, Hepatology & Nutrition, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; Group for Improvement of Intestinal Function and Treatment (GIFT), Transplant and Regenerative Medicine Centre, Toronto, Ontario, Canada
| | - Wendy J Ungar
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Child Health Evaluative Sciences Program, Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Paul W Wales
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, United States; Cincinnati Center of Excellence for Intestinal Rehabilitation (CinCEIR), Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.
| |
Collapse
|
3
|
Sierra CM, Rodriquez C, Bahjri K. Ethanol Lock for Prevention of CVC-Related Bloodstream Infection in Pediatric Patients: A Systematic Review and Meta-Analysis. J Pediatr Pharmacol Ther 2023; 28:386-396. [PMID: 38130502 PMCID: PMC10731934 DOI: 10.5863/1551-6776-28.5.386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 08/11/2022] [Indexed: 12/23/2023]
Abstract
Ethanol lock therapy (ELT) can be used in patients with an indwelling central line to assist in the prevention of central venous catheter (CVC)-associated infections. However, its efficacy has not been consistently demonstrated in the pediatric population. The primary objective of this review and meta-analysis was to determine the efficacy and safety of ELT in prevention of central line-associated bloodstream infection (CLABSI) in the pediatric population. A search was conducted with the PubMed, CINAHL, PSCYInfo, Cochrane Library, and Academic Search Premier databases from inception through January 21, 2022. Studies were included if they reported incidence of CVC-related infections with ELT in pediatric patients. Meta-analyses used random-effects models according to the heterogeneity of all included studies. Of 736 studies, 25 met inclusion criteria for review and 10 for inclusion in the meta-analysis. Meta-analysis with pre- and post-ELT treatment showed that use of ELT significantly decreased mean CVC-related infections when compared with pre-treatment with no ELT with a mean difference of -5.79 (95% CI, -9.08 to -2.51; p < 0.001). The number of CVC infections also significantly decreased (OR, 0.42; 95% CI, 0.23-0.75; p = 0.004). Increased risk of thrombosis and increased frequency of catheter breakage, repair, and replacement were noted in several studies. Ethanol lock therapy is effective in preventing infection related to central venous catheter use in pediatric patients. Further study is warranted to determine the optimal protocol for, and incidence of, adverse events related to use of ELT.
Collapse
Affiliation(s)
- Caroline M. Sierra
- Department of Pharmacy Practice (CMS), Loma Linda University School of Pharmacy, Loma Linda University, Loma Linda, CA
| | - Cristian Rodriquez
- Loma Linda University School of Pharmacy (CR), Loma Linda University, Loma Linda, CA
| | - Khaled Bahjri
- Department of Pharmaceutical and Administrative Sciences (KB), Loma Linda University School of Pharmacy, Loma Linda, CA
| |
Collapse
|
4
|
Zhou Y, Xu Y, Cai Y. Analysis of nutritional status and influencing factors in patients with thoracoabdominal aortic dissection receiving 3D printing-assisted stent graft fenestration. J Cardiothorac Surg 2023; 18:91. [PMID: 36945041 PMCID: PMC10029305 DOI: 10.1186/s13019-023-02185-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 03/12/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND To investigate the nutritional status of patients with aortic dissection (AD) treated with using 3D printing-assisted stent graft fenestration and explore the important factors affecting the nutrition status of patients with different numbers of fenestrations (holes). METHODS Ninety-nine hospitalized patients with AD in a grade A tertiary hospital in Nanjing from January 2020 to December 2020 were selected as the study subjects. According to the different number of fenestrations, the patients were divided into four groups: one fenestration (group A), two fenestrations (group B), three fenestrations (group C) and four fenestrations (group D); and the nutrition status of patients in the four groups was analyzed. Then, according to whether the calories provided via infusion reached the 80% goal calories (25 kcal/kg/day) on postoperative day 5, the patients were assigned to the Reached group and Not reached group, and their inflammatory parameters, including white blood cell (WBC) and C-reactive protein (CRP), on postoperative days 1 and 5 were analyzed. RESULTS Compared with patients in group B (18.8%), C (19.4%) and D (6.7%), patients in group A (48.6%) had the highest rate of reaching the nutrition requirement (80% goal calories). Further, in the Reached group, WBC count and CRP concentration were significantly reduced on postoperative day 5 compared with postoperative day 1, and the proportion of patients with abnormal WBC count was significantly decreased. In contrast, although the CRP concentration on postoperative day 5 in the Not reached group was significantly lower than that on postoperative day 1, no significant changes in WBC count were observed. CONCLUSION In 3D printing-assisted stent graft fenestration for AD, multiple fenestrations (holes) were associated with a low rate of reaching nutrition requirements, which might be related to imflammation. Therefore, effective nutritional support should be given to patients with multiple fenestrations after operation to improve their nutritional status and prognosis.
Collapse
Affiliation(s)
- Yan Zhou
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, China
| | - Ying Xu
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, China
| | - Ying Cai
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, China.
| |
Collapse
|
5
|
Surveillance and attribution of ambulatory central line-associated bloodstream infections in a pediatric healthcare system. Am J Infect Control 2023; 51:220-224. [PMID: 35718060 DOI: 10.1016/j.ajic.2022.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 06/09/2022] [Accepted: 06/10/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Central line-associated bloodstream infections (CLABSI) in ambulatory pediatric populations are difficult to track at an institutional level, especially for complex patients seen by multiple divisions and home health infusion agencies. METHODS A multidisciplinary team comprised of key stakeholders from divisions with the most patients discharged with a central line utilized Lean Six Sigma methodology of Define-Measure-Analyze-Design-Verify (DMADV) to create a standardized data collection process for all ambulatory CLABSIs and infection event reviews. RESULTS A surveillance workflow was created to track, identify, and confirm ambulatory CLABSIs in all patients with an indwelling central line. Defined surveillance criteria included scope of patients eligible for ambulatory CLABSI surveillance, numerator definitions, and denominator calculations. Additionally, a novel attribution method was created for ambulatory CLABSIs in complex patient populations shared among multiple divisions and home care infusion services. CONCLUSIONS This report is a novel institutional approach to accurately surveil, attribute, and calculate ambulatory CLABSI data in a pediatric healthcare system.
Collapse
|
6
|
Adams SC, Gura KM, Seres DS, Kovacevich D, Maguire A, Herlitz J, Canada TW, Nishikawa R, Boullata J. Safe care transitions for patients receiving parenteral nutrition. Nutr Clin Pract 2022; 37:493-508. [PMID: 35587169 DOI: 10.1002/ncp.10861] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 04/01/2022] [Accepted: 04/02/2022] [Indexed: 01/14/2023] Open
Abstract
Transitions of care require coordination between inpatient healthcare providers, care managers, outpatient/ambulatory providers, and the patient/caregiver and family members. Poor communication during transitions of care can affect health outcomes and economic costs for patients/caregivers, healthcare providers, and healthcare systems. The goal of this paper is to identify risk-prone processes in the transition of care for patients requiring parenteral nutrition (PN) between healthcare environments, including the hospital, home, skilled nursing facility, and long-term acute care hospital settings. To facilitate the evaluation of the transition, a sequential series of steps in the transition process were identified: initial notification, assessment in preparation for transfer, identifying the receiving organization, identifying accountable providers at each sending/receiving organization, communicating the nutrition care plan, implementing the plan and additional considerations regarding PN preparation and readmissions. Safety concerns with risk-prone processes are identified and recommended best practices are proposed for improving processes at each step of the transition. Pediatric considerations are included in the evaluation of the various steps in the transition of care. This paper was approved by the American Society for Parenteral and Enteral Nutrition (ASPEN) Board of Directors.
Collapse
Affiliation(s)
- Stephen C Adams
- Geisinger Home Infusion Services, Danville, Pennyslvania, USA
| | - Kathleen M Gura
- Boston Children's Hospital Boston, Boston, Massachusetts, USA
| | - David S Seres
- Institute of Human Nutrition, Columbia University Irving Medical Center, New York, New York, USA
| | - Debbie Kovacevich
- Home Care Services Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Jean Herlitz
- University of Chicago Medical Center, Chicago, Iillinois, USA
| | - Todd W Canada
- MD Anderson Cancer Center, University of Texas, Houston, Texas, USA
| | | | - Joseph Boullata
- JBoullata, PharmD Consulting Services, Philadelphia, Pennsylvania, USA
| | | |
Collapse
|
7
|
Jones BC, O’Sullivan B, Amin SP, Hill S, Eaton S, De Coppi P. Patient-level costing analysis of paediatric short bowel syndrome care in a specialist tertiary centre. Pediatr Surg Int 2022; 38:533-539. [PMID: 35211770 PMCID: PMC8913464 DOI: 10.1007/s00383-022-05074-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/24/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE To undertake a pilot study estimating patient-level costs of care for paediatric short bowel syndrome (SBS) from the healthcare provider perspective. METHODS A pilot group of patients with anatomical SBS was selected at a single specialist tertiary centre in the United Kingdom. The Patient Level Information and Costing System (PLICS) was used to extract costing data for all hospital-based activities related to SBS, from the implementation of PLICS in 2016 to April 2021. Patient-specific and pooled data were reported descriptively in per patient-year terms. RESULTS Five patients had full PLICS data available for the 5-year study period and 2 patients had 4 years of data. The median cost for hospital care of SBS was £52,834 per patient-year (range £1804-£331,489). The key cost drivers were inpatient beds, pharmacy, and staffing costs, which made up > 60% of annual costs. In the first 3 years following index admission (n = 2), there was a steady decline in the annual cost of care to a level comparable with patients with established SBS. CONCLUSION Patient-level cost of care analysis for SBS is feasible using PLICS. Hospital-related costs vary widely between and within individual patients over time. Key drivers of cost are related to complications of SBS.
Collapse
Affiliation(s)
- Brendan C. Jones
- Developmental Biology and Cancer Research and Teaching Department, Great Ormond Street Institute of Child Health, University College London, London, UK ,Specialist Neonatal and Paediatric Surgery Unit, Great Ormond Street Hospital, London, UK
| | - Benjamin O’Sullivan
- Department of Paediatric Surgery, Bristol Royal Hospital for Children, Bristol, UK
| | | | - Susan Hill
- Department of Gastroenterology, Great Ormond Street Hospital, London, UK
| | - Simon Eaton
- Developmental Biology and Cancer Research and Teaching Department, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Paolo De Coppi
- Developmental Biology and Cancer Research and Teaching Department, Great Ormond Street Institute of Child Health, University College London, London, UK ,Specialist Neonatal and Paediatric Surgery Unit, Great Ormond Street Hospital, London, UK
| |
Collapse
|
8
|
Vernon-Roberts A, Lopez RN, Frampton CM, Day AS. Meta-analysis of the efficacy of taurolidine in reducing catheter-related bloodstream infections for patients receiving parenteral nutrition. JPEN J Parenter Enteral Nutr 2022; 46:1535-1552. [PMID: 35233792 PMCID: PMC9541343 DOI: 10.1002/jpen.2363] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 02/07/2022] [Accepted: 02/28/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Parenteral nutrition administered via central venous catheter is an established treatment option for people with intestinal failure. A serious complication of central venous catheters is the high risk of catheter-related blood stream infections (CRBSI). Catheter locking solutions are one strategy for CRBSI prevention, with the solution taurolidine showing beneficial effects. The aim of this meta-analysis was to identify and synthesize evidence to assess taurolidine efficacy against comparators for the prevention of CRBSI for people with intestinal failure on parenteral nutrition. METHODS Six health literature databases were searched for efficacy data of rate of CRBSI for taurolidine versus control among our study population, no study design limits were applied. Individual study data were presented for the number of CRBSI and catheter days, and rate ratio. Overall data were synthesized as a pooled risk ratio, with sub-group analysis by study design, control type, and taurolidine solution. RESULTS Thirty-four studies were included in the final analysis. At the individual level all studies showed superior efficacy of taurolidine versus control for prevention of CRBSI. When the data were synthesized, the pooled risk ratio was 0.49 (95% CI 0.46 to 0.53, p=<0.0001), indicating a 51% decreased risk of CRBSI through the use of taurolidine. Sub-group analysis showed no difference depending on study design (p=0.23), or control type (p=0.37), and a significant difference for taurolidine type (p=0.0005). CONCLUSION Taurolidine showed superior efficacy over controls regardless of study design or comparator group. The results show that taurolidine provides effective CRBSI reduction for people with intestinal failure on parenteral nutrition. This article is protected by copyright. All rights reserved.
Collapse
|
9
|
Ashkenazi-Hoffnung L, Shecter N, De-Vries I, Levy I, Scheuerman O, Yarden-Bilavsky H, Bernfeld Y, Mor M. Factors predicting efficacy of ethanol lock therapy as catheter salvage strategy for pediatric catheter-related infections. Pediatr Blood Cancer 2021; 68:e28856. [PMID: 33352003 DOI: 10.1002/pbc.28856] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 11/17/2020] [Accepted: 11/27/2020] [Indexed: 11/09/2022]
Abstract
AIM Catheter-related infections are difficult to cure, and failure rates are high. We aimed to evaluate the efficacy and safety of ethanol lock therapy (ELT) as catheter salvage strategy in children with central-line-associated bloodstream infection (CLABSI), and to identify factors associated with treatment failure. METHODS Data were collected of all the children who received ELT for treatment of CLABSI during 2013-2018 due to failure of standard therapy or multiple catheter-related infections. Univariate and multivariate analyses of risk-factors for ELT failure were performed. Catheter salvage rates were compared to those achieved using systemic antimicrobials alone in an historical control group. RESULTS A total of 123 ELT episodes among 95 patients were analyzed. The majority of patients had underlying hemato-oncological disorders. Approximately half the episodes occurred in patients with implantable ports. Early and late treatment failure rates of ELT were 16% (20/123) and 7% (9/123), respectively. Overall, successful catheter salvage was achieved in 78% (96/123) of episodes, compared to 54% using systemic antimicrobials alone (P < .001), including mycobacterium, candida, and most staphylococcus aureus infections. Adverse events were reported in 9% (11/123) of episodes and were mostly mechanical. Multivariate analysis identified four risk factors for ELT failure: Gram-positive bacteria, elevated C-reactive protein, signs of tunnel infection, and low absolute neutrophil counts. CONCLUSIONS Our findings support the use of ELT for catheter salvage in children with CLABSI who failed standard therapy or had multiple catheter-related infections. The identified variables associated with ELT failure may help identify patients who can most benefit from ELT.
Collapse
Affiliation(s)
- Liat Ashkenazi-Hoffnung
- Day Hospitalization Department, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Pediatric Infectious Diseases Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Naama Shecter
- Department of Pediatrics A&B, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Irit De-Vries
- Department of Pharmacy, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Itzhak Levy
- Pediatric Infectious Diseases Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Oded Scheuerman
- Pediatric Infectious Diseases Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Pediatrics A&B, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Havatzelet Yarden-Bilavsky
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Pediatrics A&B, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Yael Bernfeld
- Department of Pharmacy, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Meirav Mor
- Pediatric Infectious Diseases Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
10
|
Talathi S, Mezoff E, Galloway D, Rahhal R. Anticipated impact of recent ethanol lock shortage and price increase on practice among pediatric intestinal rehabilitation programs across the United States. JPEN J Parenter Enteral Nutr 2021; 46:319-323. [PMID: 33914379 DOI: 10.1002/jpen.2128] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Ethanol lock use has been associated with significantly lower rates of central line-associated bloodstream infection (CLABSI) in children with intestinal failure. Concerns have been raised among intestinal rehabilitation program providers regarding the impact of recent changes in cost and availability of ethanol locks in the US. METHODS We conducted a survey among the members of the North American Society For Pediatric Gastroenterology, Hepatology & Nutrition Intestinal Rehabilitation Special Interest Group (NASPGHAN IR-SIG) regarding practice changes among providers to tackle this issue and the anticipated effect on CLABSI rates. RESULTS The results show that the vast majority of US participants use ethanol locks in their population with intestinal failure, with most anticipating or already experiencing reduction in access to ethanol locks. Most worrisome is that more than half of participating programs expect an increase in CLABSI rates in this vulnerable patient population as a consequence of limited access to ethanol locks. CONCLUSION Further multicenter prospective studies to assess the efficacy of alternative locking agents, besides ethanol, are needed in order to have readily available and affordable options for CLABSI prevention in the future.
Collapse
Affiliation(s)
- Saurabh Talathi
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, OU Center for Pediatric Intestinal Rehabilitation, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Ethan Mezoff
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Center for Intestinal Rehabilitation and Nutrition Support, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - David Galloway
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Riad Rahhal
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, University of Iowa, Iowa City, Iowa, USA
| |
Collapse
|
11
|
Raghu VK, Mezoff EA, Cole CR, Rudolph JA, Smith KJ. Cost-effectiveness of ethanol lock prophylaxis to prevent central line-associated bloodstream infections in children with intestinal failure in the United States. JPEN J Parenter Enteral Nutr 2021; 46:324-329. [PMID: 33908050 DOI: 10.1002/jpen.2130] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Central line-associated bloodstream infections (CLABSIs) lead to significant morbidity and mortality in children with intestinal failure (IF). Ethanol lock prophylaxis (ELP) greatly reduces CLABSI frequency with minimal side effects. However, in the United States, a recently approved orphan drug designation for dehydrated alcohol has greatly increased 70% ethanol cost from about $10/day to $1000/day. We examined the cost-effectiveness of ELP in relation to these changes. METHODS We simulated a previously developed IF Markov model over 1 year. Costs were measured in 2020 US dollars and effectiveness in quality-adjusted life-years (QALYs). CLABSI rate with and without ELP was estimated from the largest available comparative observational study. The primary outcome was incremental cost-effectiveness ratio (ICER) between treatments. Secondary outcomes included CLABSI frequency. Sensitivity analyses on all model parameters were performed. RESULTS In the base model, children with IF not using ELP accumulated $131,815 in costs and 0.32 QALYs per patient compared with $437,884 and 0.33 QALYs per patient in those using ELP. The ICER was nearly $17 million/QALY gained. ELP resulted in a 40% reduction in CLABSI frequency. ELP became cost-effective at $68/day and cost-saving at $63/day. Sensitivity analysis identified no other plausible parameter variation to reach the benchmark of $100,000/QALY gained. CONCLUSIONS At the current price, ELP is not cost-effective for CLABSI prevention in children with IF in the United States. This study highlights the critical need for the approval of an affordable lock therapy option to prevent CLABSIs in these children.
Collapse
Affiliation(s)
- Vikram Kalathur Raghu
- Division of Gastroenterology, Hepatology and Nutrition, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ethan A Mezoff
- Division of Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Conrad R Cole
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Jeffrey A Rudolph
- Division of Gastroenterology, Hepatology and Nutrition, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kenneth J Smith
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
12
|
Diamanti A, Calvitti G, Martinelli D, Santariga E, Capriati T, Bolasco G, Iughetti L, Pujia A, Knafelz D, Maggiore G. Etiology and Management of Pediatric Intestinal Failure: Focus on the Non-Digestive Causes. Nutrients 2021; 13:nu13030786. [PMID: 33673586 PMCID: PMC7997222 DOI: 10.3390/nu13030786] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 02/24/2021] [Indexed: 12/20/2022] Open
Abstract
Background: Intestinal failure (IF) is defined as reduction in functioning gut mass below the minimal amount necessary for adequate digestion and absorption. In most cases, IF results from intrinsic diseases of the gastrointestinal tract (digestive IF) (DIF); few cases arise from digestive vascular components, gut annexed (liver and pancreas) and extra-digestive organs or from systemic diseases (non-digestive IF) (NDIF). The present review revised etiology and treatments of DIF and NDIF, with special focus on the pathophysiological mechanisms, whereby NDIF develops. Methods: We performed a comprehensive search of published literature from January 2010 to the present by selecting the following search strings: “intestinal failure” OR “home parenteral nutrition” OR “short bowel syndrome” OR “chronic pseudo-obstruction” OR “chronic intestinal pseudo-obstruction” OR “autoimmune enteropathy” OR “long-term parenteral nutrition”. Results: We collected overall 1656 patients with well-documented etiology of IF: 1419 with DIF (86%) and 237 with NDIF (14%), 55% males and 45% females. Among DIF cases, 66% had SBS and among NDIF cases 90% had malabsorption/maldigestion. Conclusions: The improved availability of diagnostic and therapeutic tools has increased prevalence and life expectancy of rare and severe diseases responsible for IF. The present review greatly expands the spectrum of knowledge on the pathophysiological mechanisms through which the diseases not strictly affecting the intestine can cause IF. In view of the rarity of the majority of pediatric IF diseases, the development of IF Registries is strongly required; in fact, through information flow within the network, the Registries could improve IF knowledge and management.
Collapse
Affiliation(s)
- Antonella Diamanti
- Hepatology Gastroenterology and Nutrition Unit, “Bambino Gesù” Children Hospital, 00165 Rome, Italy; (T.C.); (G.B.); (D.K.); (G.M.)
- Correspondence: ; Tel.: +39-0668592189
| | - Giacomo Calvitti
- Pediatric Unit, Department of Medical and Surgical Sciences for Mothers, Children and Adults, University of Modena and Reggio Emilia, 41121 Modena, Italy; (G.C.); (L.I.)
| | - Diego Martinelli
- Metabolic Diseases Unit, “Bambino Gesù” Children Hospital, 00165 Rome, Italy;
| | - Emma Santariga
- Clinical Nutrition Unit, Department of Medical and Surgical Sciences, University Magna Graecia, 88100 Catanzaro, Italy; (E.S.); (A.P.)
| | - Teresa Capriati
- Hepatology Gastroenterology and Nutrition Unit, “Bambino Gesù” Children Hospital, 00165 Rome, Italy; (T.C.); (G.B.); (D.K.); (G.M.)
| | - Giulia Bolasco
- Hepatology Gastroenterology and Nutrition Unit, “Bambino Gesù” Children Hospital, 00165 Rome, Italy; (T.C.); (G.B.); (D.K.); (G.M.)
| | - Lorenzo Iughetti
- Pediatric Unit, Department of Medical and Surgical Sciences for Mothers, Children and Adults, University of Modena and Reggio Emilia, 41121 Modena, Italy; (G.C.); (L.I.)
| | - Arturo Pujia
- Clinical Nutrition Unit, Department of Medical and Surgical Sciences, University Magna Graecia, 88100 Catanzaro, Italy; (E.S.); (A.P.)
| | - Daniela Knafelz
- Hepatology Gastroenterology and Nutrition Unit, “Bambino Gesù” Children Hospital, 00165 Rome, Italy; (T.C.); (G.B.); (D.K.); (G.M.)
| | - Giuseppe Maggiore
- Hepatology Gastroenterology and Nutrition Unit, “Bambino Gesù” Children Hospital, 00165 Rome, Italy; (T.C.); (G.B.); (D.K.); (G.M.)
- Medical Sciences Department Ferrara University, 44121 Ferrara, Italy
| |
Collapse
|
13
|
The economic costs of home parenteral nutrition: Systematic review of partial and full economic evaluations. Clin Nutr 2021; 40:339-349. [DOI: 10.1016/j.clnu.2020.06.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 06/07/2020] [Accepted: 06/09/2020] [Indexed: 02/08/2023]
|
14
|
Fell GL, Cho BS, Anez-Bustillos L, Dao DT, Baker MA, Nandivada P, O'Loughlin AA, Hurley AP, Mitchell PD, Rangel S, Gura KM, Puder M. Optimizing Duration of Empiric Management of Suspected Central Line-Associated Bloodstream Infections in Pediatric Patients with Intestinal Failure. J Pediatr 2020; 227:69-76.e3. [PMID: 32687916 DOI: 10.1016/j.jpeds.2020.07.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 07/09/2020] [Accepted: 07/20/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To assess whether a 24-hour length of hospitalization and empiric antibiotic therapy to exclude central line-associated bloodstream infection (CLABSI) in children with intestinal failure is potentially as safe as 48 hours, which is the duration most commonly used but not evidence based. STUDY DESIGN A prospective single-institution observational cohort study was conducted among pediatric patients with intestinal failure from July 1, 2015, through June 30, 2018, to identify episodes of suspected CLABSI. The primary end point was time from blood sampling to positive blood culture. Secondary end points included presenting symptoms, laboratory test results, responses to a parent/legal guardian-completed symptom survey, length of inpatient stay, costs, and charges. RESULTS Seventy-three patients with intestinal failure receiving nutritional support via central venous catheters enrolled; 35 were hospitalized with suspected CLABSI at least once during the study. There were 49 positive blood cultures confirming CLABSI in 128 episodes (38%). The median time from blood sampling to positive culture was 11.1 hours. The probability of a blood culture becoming positive after 24 hours was 2.3%. Elevated C-reactive protein and neutrophil predominance in white blood cell count were associated with positive blood cultures. Estimated cost savings by transitioning from a 48-hour to a 24-hour admission to rule-out CLABSI was $4639 per admission. CONCLUSIONS A 24-hour duration of empiric management to exclude CLABSI may be appropriate for patients with negative blood cultures and no clinically concerning signs. A multi-institutional study would more robustly differentiate patients safe for discharge after 24 hours from those who warrant longer empiric treatment.
Collapse
Affiliation(s)
- Gillian L Fell
- Vascular Biology Program and Department of Surgery, Boston Children's Hospital, Boston, MA
| | - Bennet S Cho
- Vascular Biology Program and Department of Surgery, Boston Children's Hospital, Boston, MA
| | - Lorenzo Anez-Bustillos
- Vascular Biology Program and Department of Surgery, Boston Children's Hospital, Boston, MA
| | - Duy T Dao
- Vascular Biology Program and Department of Surgery, Boston Children's Hospital, Boston, MA
| | - Meredith A Baker
- Vascular Biology Program and Department of Surgery, Boston Children's Hospital, Boston, MA
| | | | - Alison A O'Loughlin
- Vascular Biology Program and Department of Surgery, Boston Children's Hospital, Boston, MA
| | - Alexis P Hurley
- Vascular Biology Program and Department of Surgery, Boston Children's Hospital, Boston, MA
| | - Paul D Mitchell
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, MA
| | - Shawn Rangel
- Department of Surgery, Boston Children's Hospital, Boston, MA
| | - Kathleen M Gura
- Department of Pharmacy, Boston Children's Hospital, Boston, MA
| | - Mark Puder
- Vascular Biology Program and Department of Surgery, Boston Children's Hospital, Boston, MA.
| |
Collapse
|
15
|
Raghu VK, Rudolph JA, Smith KJ. Cost-effectiveness of teduglutide in pediatric patients with short bowel syndrome: Markov modeling using traditional cost-effectiveness criteria. Am J Clin Nutr 2020; 113:172-178. [PMID: 33021637 PMCID: PMC9630124 DOI: 10.1093/ajcn/nqaa278] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 09/07/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Teduglutide use in pediatric patients with short bowel syndrome can aid in the achievement of enteral autonomy, but with a price of >$400,000 per y. OBJECTIVE The current study evaluated the cost-effectiveness of using teduglutide in conjunction with offering intestinal transplantation in US pediatric patients with short bowel syndrome. DESIGN A Markov model was used to evaluate the costs (in US dollars) and effectiveness [in quality-adjusted life years (QALYs)] of using teduglutide compared with offering intestinal transplantation. Parameters were estimated from published data where available. The primary effect modeled was the probability of weaning from parenteral nutrition while on teduglutide. Sensitivity analyses were performed on all model parameters. RESULTS Compared with offering only intestinal transplantation, adding teduglutide cost ${\$}$124,353/QALY gained. Reducing the cost of the medication by 16% allowed the cost to reach the typical benchmark of ${\$}$100,000/QALY gained. Probabilistic sensitivity analysis favored transplantation without offering teduglutide in 68% of iterations at a ${\$}$100,000/QALY threshold. Never using teduglutide created an opportunity cost of over ${\$}$100,000 per patient. CONCLUSIONS At its current price, teduglutide does not provide a cost-effective addition to transplantation in the treatment of pediatric short bowel syndrome. Further work should look to identify cost-reducing strategies, including alternative dosing regimens.
Collapse
Affiliation(s)
| | - Jeffrey A Rudolph
- Departments of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Kenneth J Smith
- Departments of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| |
Collapse
|
16
|
Galloway DP, Mathis MS, Wilkinson LT, Venick RS, Wendel D, Cole CR, Martin CA. Effect of the COVID-19 Pandemic on Pediatric Intestinal Failure Healthcare Delivery. JPEN J Parenter Enteral Nutr 2020; 45:50-56. [PMID: 32941671 DOI: 10.1002/jpen.2000] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 08/18/2020] [Indexed: 01/13/2023]
Abstract
BACKGROUND The coronavirus disease 2019 (COVID-19) pandemic has influenced how healthcare is being provided, particularly in patients whose diagnoses require multidisciplinary care, such as pediatric intestinal failure (IF). We sought to ascertain the effects of the COVID-19 pandemic on healthcare delivery for pediatric patients with IF. METHODS A 20-question survey was administered to members of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Intestinal Rehabilitation (IR) Special Interest Group. Input values were "yes" and "no," along with a free-text response. Following a 10-day open survey period, data were divided into cohorts based on patient population size and disease burden by state. Analysis was then performed using the χ2 test application. RESULTS Responses from 29 centers were included in analysis. Centers that followed >50 patients on parenteral nutrition (PN) were more likely to have social workers present in telemedicine visits and observed more central line difficulties among families. Centers located in states with <40,000 reported cases of COVID-19 saw patients less frequently and were more likely to withhold changes to PN prescriptions. Additionally, the survey revealed a significant degree of financial hardship and food insecurity among families. CONCLUSION Many aspects of pediatric IF healthcare delivery have been impacted by the COVID-19 pandemic, both for care providers and caregivers. Despite the availability of telemedicine, IR centers should remain attentive to the global needs of the pediatric IF patient, as well as their families.
Collapse
Affiliation(s)
- David P Galloway
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of Alabama at Birmingham, Alabama, Birmingham, USA
| | - Michelle S Mathis
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of Alabama at Birmingham, Alabama, Birmingham, USA
| | - Linda T Wilkinson
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of Alabama at Birmingham, Alabama, Birmingham, USA
| | - Robert S Venick
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of California at Los Angeles, California, Los Angeles, USA
| | - Danielle Wendel
- Division of Gastroenterology and Hepatology, Seattle Children's Hospital, University of Washington School of Medicine, Washington, Seattle, USA
| | - Conrad R Cole
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, College of Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, USA
| | - Colin A Martin
- Department of Surgery, Division of Pediatric Surgery, University of Alabama at Birmingham, Alabama, Birmingham, USA
| |
Collapse
|
17
|
Keller S, Salinas A, Williams D, McGoldrick M, Gorski L, Alexander M, Norris A, Charron J, Stienecker RS, Passaretti C, Maragakis L, Cosgrove SE. Reaching consensus on a home infusion central line-associated bloodstream infection surveillance definition via a modified Delphi approach. Am J Infect Control 2020; 48:993-1000. [PMID: 31982215 DOI: 10.1016/j.ajic.2019.12.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 12/13/2019] [Accepted: 12/14/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND A consensus on a central line-associated bloodstream infection (CLABSI) surveillance definition in home infusion is needed to standardize measurement and benchmark CLABSI to provide data to drive improvement initiatives METHODS: Experts across fields including home infusion therapy, infectious diseases, and healthcare epidemiology convened to perform a 3-step modified Delphi approach to obtain input and achieve consensus on a candidate home infusion CLABSI definition. RESULTS The numerator criterion was identified by participants as involving one of the 2 following: (1) recognized pathogen isolated from blood culture and pathogen is not related to infection at another site, or (2) one of the following signs or symptoms: fever of 38°C (100.4°F), chills, or hypotension (systolic blood pressure ≤90 mm Hg), and one of the 2 following: (A) common skin contaminant isolated from 2 blood cultures drawn on separate occasions and organism is not related to infection at another site, or (B) common skin contaminant isolated from blood culture from patient with intravascular access device and provider institutes appropriate antimicrobial therapy. The criteria for a denominator included days from the day of admission with a central venous catheter to day of removal of central venous catheter. In addition, 11 inclusion criteria and 4 exclusion criteria were included. DISCUSSION Home infusion therapy and healthcare epidemiology experts developed candidate criteria for a home infusion CLABSI surveillance definition. CONCLUSIONS Home care and home infusion agencies can use this definition to monitor their own CLABSI rates and implement preventative strategies.
Collapse
|
18
|
Vanegas Calderon O, Rahhal R. 30% Ethanol Locks Are Effective in Preventing Central Line–Associated Bloodstream Infections in Pediatric Intestinal Failure: A Pilot Study. Nutr Clin Pract 2020; 36:427-432. [DOI: 10.1002/ncp.10435] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
| | - Riad Rahhal
- Division of Pediatric Gastroenterology University of Iowa Iowa City Iowa USA
| |
Collapse
|
19
|
Raghu VK, Binion DG, Smith KJ. Cost-effectiveness of teduglutide in adult patients with short bowel syndrome: Markov modeling using traditional cost-effectiveness criteria. Am J Clin Nutr 2020; 111:141-148. [PMID: 31665212 PMCID: PMC7307185 DOI: 10.1093/ajcn/nqz269] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 10/03/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Adults with short bowel syndrome have a high mortality and significant morbidity due to unsuccessful attempts at rehabilitation that necessitate chronic use of parenteral nutrition (PN). Teduglutide is a novel therapy that promotes intestinal adaptation to improve rehabilitation but with a price >$400,000/y. OBJECTIVE The current study evaluated the cost-effectiveness of using teduglutide in US adult patients with short bowel syndrome. METHODS A Markov model evaluated the costs (in US dollars) and effectiveness (in quality-adjusted life years, or QALYs) of treatment compared with no teduglutide use, with a presumed starting age of 40 y. Parameters were obtained from published data or estimation. The primary effect modeled was the increased likelihood of reduced PN days per week when using teduglutide, leading to greater quality of life and lower PN costs. Sensitivity analyses were performed on all model parameters. RESULTS In the base scenario, teduglutide cost $949,910/QALY gained. In 1-way sensitivity analyses, only reducing teduglutide cost decreased the cost/QALY gained to below the typical threshold of $100,000/QALY gained. Specifically, teduglutide cost would need to be reduced by >65% for it to reach the threshold value. Probabilistic sensitivity analysis favored no teduglutide use in 80% of iterations at a $100,000/QALY threshold. However, teduglutide therapy was cost-saving in 13% of model iterations. CONCLUSIONS Teduglutide does not meet a traditional cost-effectiveness threshold as treatment for PN reduction in adult patients with short bowel syndrome compared with standard intestinal rehabilitation. Subpopulations that demonstrate maximum benefit could be cost-saving, and complete nonuse could lead to financial loss. Teduglutide becomes economically reasonable only if its cost is substantially reduced.
Collapse
Affiliation(s)
- Vikram K Raghu
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA,Address correspondence to VKR (e-mail: )
| | - David G Binion
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Kenneth J Smith
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| |
Collapse
|
20
|
Raphael BP, Takvorian-Bené M, Gallotto M, Tascione C, McClelland J, Rosa C, Dinan J, O'Connell B, Weinstock P. Learning Gaps and Family Experience, Nurse-Facilitated Home Parenteral Nutrition Simulation-Based Discharge Training: Proof-of-Concept Study. Nutr Clin Pract 2019; 36:489-496. [PMID: 31589007 DOI: 10.1002/ncp.10421] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Home parenteral nutrition (HPN) is a life-sustaining therapy for children and adults suffering with severe digestive diseases, yet complications are commonplace, and predischarge trainings are variable. High-fidelity simulation training provides participants with an immersive experience using realistic equipment, supplies, and scenarios. Simulation training is rapidly becoming a potential gold standard for healthcare but is currently underutilized for families and caregivers. METHODS We prospectively collected data on pediatric patients managed at a single HPN program from September 1, 2016, to September 30, 2018. Participants in a pilot simulation-based training program (orientation, high-fidelity mannequin, realistic homelike space, standardized clinical scenarios, and structured debriefing) were compared with historical controls. We excluded patients with short-term HPN use and strictly palliative goals of care. RESULTS Nineteen (90%) families participated in the pilot initiative with a median (interquartile range) age of 0.9 (3.7) years and diagnosis of short-bowel syndrome in 14 (74%). During teaching scenarios, learning gaps were identified for aseptic needleless changes (53%), HPN equipment setup (84%) with specific difficulty adding multivitamin (32%), and dressing changes (63%). Thirty-day readmission rates in simulation-based training group vs historical cases were 42% vs 63% (P = not significant). There was no difference in length of stay between groups. All (100%) simulation-based training group participants would recommend this learning experience to others. CONCLUSION HPN discharge training is a novel use for high-fidelity simulation to address family/caregiver satisfaction and to identify learning gaps. Further studies are needed to refine predischarge training materials and examine the impact on postdischarge outcomes.
Collapse
Affiliation(s)
- Bram P Raphael
- Division of Gastroenterology and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Melissa Takvorian-Bené
- Division of Gastroenterology and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Mary Gallotto
- Division of Gastroenterology and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Christina Tascione
- Division of Gastroenterology and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Jennifer McClelland
- Division of Gastroenterology and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Carolyn Rosa
- Division of Gastroenterology and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Jessica Dinan
- Boston Children's Hospital Simulator Program, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Brianna O'Connell
- Boston Children's Hospital Simulator Program, Boston Children's Hospital, Boston, Massachusetts, USA.,Child Life Services, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Peter Weinstock
- Harvard Medical School, Boston, Massachusetts, USA.,Boston Children's Hospital Simulator Program, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Anesthesiology, Critical Care and Pain Medicine, Boston, Massachusetts, USA
| |
Collapse
|
21
|
Seddik TB, Tian L, Nespor C, Kerner J, Maldonado Y, Gans H. Risk Factors of Ambulatory Central Line-Associated Bloodstream Infection in Pediatric Short Bowel Syndrome. JPEN J Parenter Enteral Nutr 2019; 44:500-506. [PMID: 31179578 DOI: 10.1002/jpen.1667] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2018] [Revised: 04/03/2019] [Accepted: 05/22/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND Children with short bowel syndrome (SBS) receiving home parenteral nutrition (HPN) are predisposed to ambulatory central line-associated bloodstream infection (A-CLABSI). Data describing risk factors of this infection in children are limited. METHODS Retrospective cohort, single-center, case-crossover study of children ≤18 years old with SBS receiving HPN from January 2012 to December 2016. Univariate and multivariate mixed effect Poisson regression identified the relative risk (RR) of A-CLABSI with proposed risk factors. RESULTS Thirty-five children were identified; median follow-up was 30 months. A-CLABSI rate was 4.2 per 1000 central line (CL) days. Univariate analysis identified younger age (RR: 0.92 per 12-month increase [95% confidence interval {CI}: 0.85-0.99; P = 0.036]), shorter small intestine length (RR: 0.96 per 10-cm increase [95% CI: 0.92-0.99; P = 0.008]), lower citrulline level (RR: 0.86 per 5-nmol/mL increase [95% CI: 0.75-0.99; P = 0.036]), and recent CL break (RR: 1.55 [95% CI: 1.06-2.28; P = 0.024]) as risk factors for A-CLABSI. Multivariate analysis showed increased A-CLABSI with clinical diagnosis of small intestine bacterial overgrowth (SIBO) (RR: 1.87 [95% CI: 1.1-3.17; P = 0.021]) and CL breaks (RR: 1.49 [95% CI: 1-2.22; P = 0.024]). CONCLUSIONS Factors influencing gut integrity increase A-CLABSI rate, supporting translocation as an important mechanism and target for prevention. Clinical diagnosis of SIBO increases A-CLABSI rate, but whether dysbiosis or diarrhea is responsible is an area for future research. CL maintenance is crucial, and prevention of breaks would likely decrease A-CLABSI rate.
Collapse
Affiliation(s)
- Talal B Seddik
- Pediatric Infectious Diseases, Stanford University, Stanford, California, USA
| | - Lu Tian
- Biomedical Data Science-Administration, Stanford University, Stanford, California, USA
| | - Colleen Nespor
- Pediatric Gastroenterology, Lucile Packard Children's Hospital, Palo Alto, California, USA
| | - John Kerner
- Pediatric Gastroenterology, Stanford University, Stanford, California, USA
| | - Yvonne Maldonado
- Pediatric Infectious Diseases, Stanford University, Stanford, California, USA
| | - Hayley Gans
- Pediatric Infectious Diseases, Stanford University, Stanford, California, USA
| |
Collapse
|