Cost-consequence analysis of different active flowable hemostatic matrices in cardiac surgical procedures

BACKGROUND

A recent retrospective comparative effectiveness study found that use of the FLOSEAL Hemostatic Matrix in cardiac surgery was associated with significantly lower risks of complications, blood transfusions, surgical revisions, and shorter length of surgery than use of SURGIFLO Hemostatic Matrix. These outcome improvements in cardiac surgery procedures may translate to economic savings for hospitals and payers.

OBJECTIVE

The objective of this study was to estimate the cost-consequence of two flowable hemostatic matrices (FLOSEAL or SURGIFLO) in cardiac surgeries for US hospitals.

METHODS

A cost-consequence model was constructed using clinical outcomes from a previously published retrospective comparative effectiveness study of FLOSEAL vs SURGIFLO in adult cardiac surgeries. The model accounted for the reported differences between these products in length of surgery, rates of major and minor complications, surgical revisions, and blood product transfusions. Costs were derived from Healthcare Cost and Utilization Project's National Inpatient Sample (NIS) 2012 database and converted to 2015 US dollars. Savings were modeled for a hospital performing 245 cardiac surgeries annually, as identified as the average for hospitals in the NIS dataset. One-way sensitivity analysis and probabilistic sensitivity analysis were performed to test model robustness.

RESULTS

The results suggest that if FLOSEAL is utilized in a hospital that performs 245 mixed cardiac surgery procedures annually, 11 major complications, 31 minor complications, nine surgical revisions, 79 blood product transfusions, and 260.3 h of cumulative operating time could be avoided. These improved outcomes correspond to a net annualized saving of $1,532,896. Cost savings remained consistent between $1.3m and $1.8m and between $911k and $2.4m, even after accounting for the uncertainty around clinical and cost inputs, in a one-way and probabilistic sensitivity analysis, respectively.

CONCLUSIONS

Outcome differences associated with FLOSEAL vs SURGIFLO that were previously reported in a comparative effectiveness study may result in substantial cost savings for US hospitals.

Reduction of postoperative hypothermia with a new warming device: a prospective randomized study in off-pump coronary artery surgery

Hypothermia has been used for decades in cardiac surgery to limit the ischemic insult to the heart. With the diffusion of off-pump coronary artery surgery, the practice of arresting and cooling the heart has been abandoned. At University of Miami Miller School of Medicine, we tested a new warming device by performing a prospective study in which 50 patients were randomized to either the use of the Kimberly-Clark warming system or to standard methods of control of body temperature. The two groups were compared in terms of core body temperature (CBT), intra- and postoperative blood loss, blood products transfusions, extubation time, intensive care unit (ICU) and hospital length of stay and incidence of infections. Five patients in the control group and 0 patients in the study group dropped their CBT below 35 degrees C during the operation (P<0.01). Total blood loss, measured in terms of cell-saver and chest tube drainage, was 27 % and 14 % less for the study group (P<0.01). Hospital length of stay was 1.2 day less in the study group (P<0.01). The Kimberly-Clark Patient Warming System allowed for better control of core body temperature during off pump coronary artery bypass surgery compared to traditional techniques. This translated in less intra and postoperative blood loss and shorter hospital length of stay. Other advantages, such as decreased blood-products transfusions, decreased incidence of infections, decreased ICU length of stay and overall reduction of costs might be evident on larger study groups.

Gastrointestinal emergencies in patients with acute intestinal graft-versus-host disease

Acute intestinal graft-versus-host disease (GVHD) develops in about 30-50% of allogeneic bone-marrow transplant recipients: 10-20% have gastrointestinal emergencies (hemorrhage or perforation). Mortality reaches 30-60% in patients with acute, grade 2-4 GVHD. We studied 36 bone marrow recipients in whom acute intestinal GVHD developed. Seven had gastrointestinal emergencies: 4 severe gastrointestinal bleeding and 3 acute peritonitis. Three patients with gastrointestinal bleeding and one patient with peritonitis responded to medical therapy. Three needed surgery: one with bleeding and two with peritonitis, while 1 patient had embolization. Of the 7, two patients died, one after embolization and one after surgery. Two of the three surgically-treated cases are still alive several years after operation. From this experience we feel that surgery for gastrointestinal bleeding in acute GVHD is indicated only when medical treatment fails. Severe neutropenia, thrombocytopenia (<10.000 x mm3) and blood cultures positive for CMV have an unfavorable prognostic value.

Videoassisted transhiatal esophagectomy for cancer

Blunt transhiatal esophagectomy is largely performed in selected cases of esophageal cancer according to the experience of Mark Orringer. We have recently performed eleven consecutive videolaparoscopy assisted transhiatal esophagectomies in order to help esophageal dissection and to avoid injuries to mediastinal structures. In our experience the routine use of laparoscopic assistance during transhiatal esophageal dissection improves the safety of this technique and lowers postoperative complications. The results of neoadjuvant treatments (radio-chemotherapy) recently reported emphasize the role of transhiatal esophagectomy for cancer.

[Video-assisted closed-thorax esophagectomy in cancer. A technical proposal]

Blunt transhiatal esophagectomy is largely performed in selected cases of esophageal cancer following the experience of Mark Orringer. We have recently performed five consecutive video-laparoscopy-assisted transhiatal esophagectomies in order to help the esophageal dissection and to avoid injuries to mediastinal structures. In our experience a routine use of laparoscopic assistance during transhiatal esophageal dissection improves the safety of this technique and lowers postoperative complications. The results recently reported from neoadjuvant treatments (radio-chemotherapy) emphasize the role of transhiatal esophagectomy for cancer.

[Results of conservative surgery in T1 breast carcinoma. Our experience in 66 treated cases]

Between 1989 and 1991, 66 women affected by breast cancer smaller than 2 cm in diameter, were treated with conservative procedure plus radiotherapy. Conservative procedure consisted in quadrantectomy and axillary dissection of the 3 axillary nodes levels. Neoplasms were grouped according to TNM classification. Eleven were classified as Tis, 9 as T1aN0M0, 12 as T1bN0M0, one case T1bN1M0, 24 as T1cN0M0 and finally 9 as T1cN1M0. Actuarial 5-year survival rate was related to TNM. It has been reported to be 100% in Tis and T1aN0M0 neoplasms; 91.7% in pT1bN0M0 tumors, 95.8% in pT1cN0M0 neoplasms, 55.6% in patients affected with pT1cN1M0 tumors. According to the relationship between receptor status of the neoplasm and survival, this was 88.9% in ER+ and 77.8% in ER- tumors, and 97.1% against 71.4% (p < 0.05) in PR+ and PR- neoplasms respectively. Two patients presented (3%) local recurrence which were treated by means of a tumorectomy and radiotherapy. Both patients are still living and disease free after 6 and 9 months from re-operation.

[Effectiveness of quarterly assessment of CEA, TPA and GICA serum levels in gastric and colorectal carcinomas: Prospective study of 174 patients undergoing radical surgery]

One-hundred seventy four consecutive patients who underwent curative resection for gastric and colorectal cancer between 1983 and 1985, were studied prospectively to evaluate the roles of sequential CEA, TPA and GICA determinations and independent clinical examinations, in the early diagnosis of resectable recurrences. Sixty-six recurrences (33 from gastric and 33 from colorectal cancer) were detected between 6 and 42 months after primary surgery. In gastric cancer CEA, TPA and GICA showed a sensitivity of 64%, 73%, and 60%, and a specificity of 67%, 65% and 54% respectively. Nine patients (27%) underwent surgical treatment for the recurrent disease, and 4 of them (44.4%) had resectable recurrence, for a total resectability rate of 12%. Out of these four patients, three patients are still living after 12, 36 and 44 months respectively from re-operation without evidence of neoplastic disease. In one of these patients re-operation was performed on the basis of the elevation of the three markers, without any other clinical sign of disease, this patient had a resectable solitary hepatic recurrence. In colorectal cancer CEA, TPA and GICA showed a sensitivity of 73%, 73%, and 49%, and a specificity of 77%, 87%, and 97% respectively. Fourteen patients (42.4%) underwent surgical treatment for the recurrent disease, and 8 of them (57%) showed a resectable recurrence, for a total resectability rate of 24.2%. Six patients are still living after 9, 16, 21, 31, 41 and 53 months respectively from reoperation without evidence of neoplastic disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Hepatic uptake and biliary secretion of bile acids in the perfused rat liver

Hepatic uptake and biliary secretion have been evaluated in the isolated perfused rat liver for cholic, chenodeoxycholic, ursodeoxycholic acid, both free and taurine-conjugated; the physicochemical properties of the bile acids have also been calculated and related to these experimental parameters. Cholic acid disappearance rate from the perfusate was the fastest, followed by that of ursodeoxycholic and chenodeoxycholic; it was also faster for taurine-conjugated bile acids than for their respective unconjugated forms. The recovery in bile was higher for conjugated than for unconjugated bile acids, and among each class, was higher for cholic than for chenodeoxycholic and ursodeoxycholic. The hepatic uptake correlated negatively (r = -0.99) with the bile acid lipophilicity, while the biliary secretion correlated with the solubility of the molecules. These results show the effect of the physicochemical properties of BA on their hepatic handling, at the physiological concentration of BA in the portal blood.

Evaluation of the ileal absorption capacity for bile acids in the rabbit

The intestinal absorption of bile acids has so far been studied from the measurement of the biliary secretion after their intestinal infusion. In the present investigation, the ileal absorption capacity for two different bile acids has been evaluated by means of an intestinal perfusion technique and the simultaneous blood drainage from the mesenteric vein corresponding to the isolated loop. Taurocholic acid and unconjugated cholic acid were infused at different concentrations (0.5-10.0 mM), at a flow rate of 4 ml/min/cm intest. Taurocholic acid absorption increased to a maximum with dose, then reaching a plateau, suggesting that a saturable process had taken place. Cholic acid uptake showed a saturable, possibly active, process, together with a nonsaturable one. These results are consistent with the physicochemical properties of the two bile acids. The technique seems so far suitable for the study of the intestinal absorption of substances undergoing the enterohepatic circulation, since it provides a direct measure of the absorbed fraction, without any distortion arising from the hepatic uptake and biliary secretion.

Phenotypic markers associated with gastrointestinal Aeromonas hydrophila isolates from symptomatic children

Aeromonas hydrophila gastroenteritis was detected in 12 pediatric patients during a 5-month period. Chief complaints included bloody diarrhea, fever, vomiting, and abdominal pain. Severe symptoms in two patients necessitated hospitalization and supportive care. Phenotypic characteristics associated with enterotoxigenicity of A. hydrophila strains demonstrated that all 12 isolates were cytotoxic to HeLa cells and most were lysine decarboxylase positive (75%). A correlation existed between the presence of the five virulence-associated markers of two isolates of A. hydrophila and the severity of disease. Although the length and symptoms of gastroenteritis varied among all 12 patients, most had self-limiting diarrhea. The frequent occurrence of A. hydrophila gastroenteritis in pediatric patients warrants a greater appreciation of this agent as a significant cause of diarrhea, especially in summer.