Resource utilization and costs for robotic-assisted and manual total knee arthroplasty - a premier healthcare database study

INTRODUCTION

The impact of robotic-assisted total knee arthroplasty (rTKA) vs. traditional, manual TKA (mTKA) on hospital costs is not well documented and is analyzed herein.

RESEARCH DESIGN AND METHODS

Patients in the Premier billing Healthcare Database undergoing elective rTKA or mTKA ("index') in the in- or outpatient setting for knee osteoarthritis between Oct 1^st, 2015, to September 30th, 2021, were identified. Variables included patient demographics and comorbidities and hospital characteristics. Matched rTKA vs. mTKA cohorts were created using direct (on provider characteristics, age, gender, race and Elixhauser index) and propensity score matching (fixation type, comorbidities). Index and 90-day inflation-adjusted costs and healthcare utilization (HCU) were analyzed for both cohorts, using generalized linear models.

RESULTS

16,714 rTKA patients were matched to 51,199 mTKA patients. Average 90-day hospital cost reached $17,932 and were equivalent for both cohorts (rTKA vs. mTKA: $132 (95% confidence interval; -$19 to $284). There was a 2.7% (95%CI: 2.2%-3.3%) increase in home or home health discharge, and a 0.4% (95%CI: 0%-0.8%) decrease in 90-day hospital knee related re-visit in the rTKA vs. mTKA group.

CONCLUSIONS

Cost-neutrality of rTKA vs. mTKA was observed, with a potential for lowered immediate post-operative HCU in the rTKA vs. mTKA cohorts.

Surgical treatment, complications, reoperations, and healthcare costs among patients with clavicle fracture in England

INTRODUCTION

The clinical and economic burden of clavicle fractures in England is not well documented. This study evaluated rates of surgical treatment, post-surgical complications, reoperations and costs in patients with clavicle fractures using the Clinical Practice Research Datalink (CPRD) database.

METHODS

CPRD data were linked to National Health Service Hospital Episode Statistics data. Patients with a diagnosis of clavicle fracture between 2010-2018 were selected in CPRD (date of fracture = index date). Of those, patients with surgical intervention within 180 days from index fracture were identified. Rates of post-surgical complications (i.e., infection, non-union, and mal-union), reoperations (for device removal or for postoperative complications), post-operative costs and median time to reoperations were evaluated up to 2 years after surgery.

RESULTS

21,340 patients with clavicle fractures were identified (mean age 35.0 years(standard deviation (SD): 26.5), 66.7% male). Surgery was performed on 672 patients (3.2% of total cohort) at an average 17.1 (SD: 25.2) days post-fracture. Complications (i.e., infection, non-union, or malunion) affected 8.1% of surgically treated clavicle fracture patients; the rate of infection was 3.5% (95% CI, 1.7%- 5.2%), non-union 4.4% (95% CI, 2.4%-6.5%), and mal-union 0.3% (95% CI, 0%-0.7%). Adjusting for age, gender, comorbidities and time to surgery, the all-cause reoperation rate was 20.2% (13.2%-30.0%) and the adjusted rate of reoperation for implant removal was 17.0% (10.7%-25.9%)-84% of all-cause reoperations were thus performed for implant removal. Median time to implant removal was 254 days. The mean cost of reoperations for all causes was £5,000. The most expensive reoperations were for cases that involved infection (mean £6,156).

CONCLUSIONS

Complication rates following surgical clavicle fracture care averaged 8.1%. However, reoperation rates exceed 20%, the vast majority of reoperations being performed for device removal. Technologies to alleviate secondary device removal surgeries would address a significant clinical unmet need.

Assessment of risk and economic burden of surgical site infection (SSI) posthysterectomy using a U.S. longitudinal database

BACKGROUND

Surgical site infection posthysterectomy has significant impact on patient morbidity, mortality, and health care costs. This study evaluates incidence, risk factors, and total payer costs of surgical site infection after hysterectomy in commercial, Medicare, and Medicaid populations using a nationwide claims database.

METHODS

IBM MarketScan databases identified women having hysterectomy between 2014 and 2018. Deep-incisional/organ space (DI/OS) and superficial infections were identified over 6 months postoperatively with risk factors and direct infection-associated payments by insurance type over a 24-month postoperative period.

RESULTS

Analysis identified 141,869 women; 7.8% Medicaid, 5.8% Medicare, and 3.9% commercially insured women developed deep-incisional/organ space surgical site infection, whereas 3.9% Medicaid, 3.2% Medicare, and 2.1% commercially insured women developed superficial infection within 6 months of index procedure. Deep-incisional/organ space risk factors were open approach (hazard ratio, 1.6; 95% confidence interval, 1.5-1.8) and payer type (Medicaid versus commercial [hazard ratio, 1.4; 95% confidence interval, 1.3-1.5]); superficial risk factors were payer type (Medicaid versus commercial [hazard ratio, 1.4; 95% confidence interval, 1.3-1.6]) and solid tumor without metastasis (hazard ratio, 1.4; 95% confidence interval, 1.3-1.6). Highest payments occurred with Medicare ($44,436, 95% confidence interval: $33,967-$56,422) followed by commercial ($27,140, 95% confidence interval: $25,990-$28,317) and Medicaid patients ($17,265, 95% confidence interval: $15,247-$19,426) for deep-incisional/organ space infection at 24-month posthysterectomy.

CONCLUSIONS

Real-world cost of managing superficial, deep-incisional/organ space infection after hysterectomy was significantly higher than previously reported. Surgical approach, payer type, and comorbid risk factors contributed to increased risk of infection and economic burden. Medicaid patients experienced the highest risk of infection, followed by Medicare patients. The study suggests adoption of a robust evidence-based surgical care bundle to mitigate risk of surgical site infection and economic burden is warranted.

Intramedullary Nail Breakage and Mechanical Displacement in Patients with Proximal Femoral Fractures: A Commercial and Medicare Supplemental Claims Database Analysis

Objective

This study evaluated the rates and patterns of intramedullary nail (IMN) breakage and mechanical displacement for proximal femur fractures and the factors associated with their occurrence.

Patients and Methods

Patients with subtrochanteric, intertrochanteric, or basicervical femoral neck fractures treated with IMN from 2016 to 2019 were identified from commercial and Medicare supplemental claims databases and were followed for up to two years. Kaplan–Meier analysis estimated the cumulative incidence of and patterns of breakage/mechanical displacement. Multivariable Cox regression models evaluated the factors associated with breakage/mechanical displacement.

Results

A total of 11,128 patients had IMN fixation for subtrochanteric, intertrochanteric, or basicervical femoral neck fractures: (mean SD) age 75.6 (16.4) years, 66.2% female, 74.3% Medicare supplemental vs 26.7% commercial insurance. Comorbidities included hypertension (62.9%), osteoporosis (27.3%), cardiac arrhythmia (23.1%), diabetes (30.7%), and chronic pulmonary disease (16.3%). Most fractures were closed (97.2%), intertrochanteric or basicervical femoral neck (80.1%), and not pathological (91.0%). The cumulative incidence of nail breakage over two years was 0.66% overall, 1.44% for combination fractures, 1.16% for subtrochanteric fractures, and 0.49% for intertrochanteric or basicervical fractures. The cumulative incidence of mechanical displacement was 0.37% overall, 0.43% for subtrochanteric fractures, 0.42% for combination fractures, and 0.36% for intertrochanteric or basicervical femoral neck fractures. Half of the breakages occurred within five months after surgery and half of the mechanical displacements occurred within 75 days. Age 50–64 (vs 75+) and subtrochanteric or pathological fracture were more commonly associated with nail breakage. Complicated hypertension was more commonly associated with mechanical displacement.

Conclusion

The incidence of IMN breakage and mechanical displacement in US commercial and Medicare supplemental patients with proximal femur fractures from 2016 to 2019 was low (0.66% and 0.37%, respectively up to two years). Age 50–64 (vs 75+) and subtrochanteric or pathological fracture were more commonly associated with breakage. Complicated hypertension was associated with mechanical displacement.

Healthcare resource utilization and costs for hip dislocation following primary total hip arthroplasty in the medicare population

AIM

To estimate 2-year healthcare resource utilization (HCRU) and costs of dislocation following primary total hip arthroplasty (THA).

MATERIALS AND METHODS

This retrospective evaluation used medical claims from the US Medicare database. Patients were eligible if they were ≥65 years old, underwent a primary elective inpatient THA between 1 January 2010 and 31 December 2016 (index), and had continuous Medicare coverage and enrollment ≥365 days prior to index (baseline). Exclusion criteria were prior THA, concomitant infection, non-Medicare primary payer, or enrolled in Medicare due to end-stage renal disease. One- and 2-year HCRU and costs across all service types and settings of care excluding retail pharmacy were evaluated. Propensity score matching and direct matching adjusted for confounding.

RESULTS

Among Medicare patients who underwent THA and met inclusion criteria (n = 450,355; mean age ∼74, and two-thirds female), 7,680 (1.7%) had a hip dislocation. After matching, 4,551 patients without and 4,551 patients with dislocation were selected. Percentage utilization, mean days of service, and claims payments amounts were significantly greater for patients with vs without THA dislocation for variables such as THA hospitalization, home health agency, skilled nursing facility, inpatient rehabilitation facility, other inpatient admission, long-term care hospital, and outpatient care. Findings were consistent for 1- and 2-year follow-up, although differences were more pronounced for 1-year. Per-patient-cost increases with dislocation were $19,590 over 1 year and $24,211 over 2 years. Two-thirds of the cost increase was due to other inpatient admission and the remaining one-third was due to skilled nursing facility, outpatient, inpatient rehabilitation facility, and home health agency costs.

LIMITATIONS

Administrative claims are not collected for research and lack clinical information. Results may not be generalizable to other patients or settings of care.

CONCLUSIONS

This large US retrospective database study demonstrated the substantial HCRU and cost burden of THA dislocation.

Survival analysis for all-cause revision following primary total hip arthroplasty with a medial collared, triple-tapered primary hip stem versus other implants in real-world settings

OBJECTIVE

Patients that undergo total hip replacement (THA) are at risk of revision surgery. This study evaluated the cumulative incidence of revision following a medial collared, triple tapered (MCTT) primary hip stem versus other implants in real-world settings using electronic medical records.

METHODS

This was a retrospective cohort study that used the Mercy Healthcare Systems - Orthopedics Database (MHSOD) to identify ACTIS total hip system, a MCTT primary hip stem for THA, and any other primary THA between 2016 and 2020. A Kaplan-Meier analysis was conducted to evaluate the risk of revision over time between the MCTT hip stem and other implants. In order to control for the confounding, a multivariable Cox model was developed to evaluate the risk of revision between the two groups.

RESULTS

There were 1213 patients treated with MCTT hip stem and 6916 patients treated with other implants. The Kaplan-Meier analysis showed statistically significant difference (p value = .006) in cumulative incidences for all-cause revisions between the MCTT hip stem and other implants. The cumulative incidence at 3 years was 1.08% (0.43-2.72%) for the MCTT hip stem, while it was 2.63% (2.19-3.16%) for other implants. After adjusting for patient demographics, clinical characteristics, prescribed medications, and surgeon characteristics, the multivariable Cox proportional hazard model showed the MCTT hip stem was statistically significantly associated with 57% lower risk of revisions compared with other implants (HR, 0.43; 95% CI, 0.19-0.97; p-value = .042).

CONCLUSIONS

This real-world study found that the incidence of revision after treatment with MCTT primary hip stem was significantly lower than for other implants.

High-concentration nonavian high-molecular weight hyaluronan injections and time-to-total knee replacement surgery

Aim: To examine the time-to-total knee replacement (TKR) surgery among patients with high-concentration nonavian high-molecular-weight hyaluronan injection (HMW-HA) compared with those without HA injections. Materials & methods: Using MarketScan^® Commercial claims all patients aged 18-64 who underwent TKR surgery between 2008 and 2017 were identified. Time-to-TKR surgery was compared between patients receiving Orthovisc^® (Anika Therapeutics Inc. Bedford MA, USA, referred to as nonavian HMW-HA) injections and patients who did not receive an HA injection. Results: The median time-to-TKR surgery was 893 days in the nonavian HMW-HA cohort and 399 days in the non-HA cohort (p < 0.001), a difference of 494 days (16.2 months). Conclusion: This study demonstrates that the time-to-TKR surgery is 16.2 months longer in patients who received treatment with nonavian HMW-HA injections.

Defining readmissions among patients undergoing open reduction and internal fixation (ORIF) in claims database analyses

Objective: To evaluate the impact of using different readmissions definitions among patients undergoing open reduction and internal fixation (ORIF) of the femur, tibia, and fibula in claims databases.Methods: Patients from the IBM MarketScan Research Commercial and Medicare Databases receiving inpatient ORIF between 1 January 2010 and 31 January 2017 (index) were identified. Readmissions within 90 days were calculated starting from the index day of discharge to 2 days after discharge. Readmission rates were also reported after accounting for records for rehabilitation, aftercare, or transfer using discharge status, provider type, and Diagnosis Related Group (DRG) codes. For patients with "transferred" as the index hospitalization discharge status, readmissions were calculated 2 days after discharge.Results: A total of 82,692 patients with ORIF for femur, tibia or fibula were identified; mean (SD) age was 60.1 (23.1) years and nearly two-thirds were female (62.3%). For the index hospitalization, 41.6% patients had "transferred" as the discharge status. The readmission rate calculated from the same day as the discharge was 14.7%. Readmission rates calculated 1 and 2 days after index discharge were 8.5 and 7.7%. After accounting for rehabilitation, aftercare and transfer, the corrected readmission rate was 8.6%. Corrected readmission rates calculated 1 and 2 days after index discharge were 7.2 and 7.2%, respectively. The most common diagnosis associated with same day readmission was rehabilitation, whereas that was not observed with readmissions 1 and 2 days after discharge.Conclusions: The accuracy of identifying true admissions was improved by defining readmissions as occurring after the day of discharge and by accounting for rehabilitation, aftercare, and transfer.

Complications and its impact in patients with closed and open tibial shaft fractures requiring open reduction and internal fixation

Aim: To evaluate the rates of infection and nonunion and determine the impact of infections on healthcare resource use and costs following open and closed fractures of the tibial shaft requiring open reduction internal fixation. Methods: Healthcare use and costs were compared between patients with and without infections following pen reduction internal fixation using MarketScan^® databases. Results: For commercial patients, the rates of infection and nonunion ranged from 1.82 to 7.44% and 0.48 to 8.75%, respectively, over the 2-year period. Patients with infection had significantly higher rates of hospital readmissions, emergency room visits and healthcare costs compared with patients without infection. Conclusion: This real-world study showed an increasing rate of infection up to 2 years and infection significantly increased healthcare resource use and costs.

Real-world impact of the high concentration non-avian high molecular weight hyaluronan on pain medication use among osteoarthritis patients

Objective: A prior study found that hyaluronic acid (HA) treatment may help reduce pain medication use (such as steroids, non-steroidal anti-inflammatory drugs [NSAIDs] and opioids) among knee osteoarthritis (OA) patients in the real-world setting. This study aims to update the prior study results to include only the high concentration non-avian high molecular weight hyaluronan (HMW-HA) injectables using data from recent years.Study design: This was a retrospective cohort study utilizing IBM MarketScan Commercial data from 2008 to 2015.Methods: Commercially insured patients between 18 and 64 years of age who received high concentration non-avian HMW-HA (Orthovisc¹) between 1 January 2008 and 30 June 2015 were identified. Utilization of three prescription pharmacotherapies commonly used in the treatment for knee OA - NSAIDs, corticosteroid injections and opioids - in the 6 month pre and post periods was assessed. Utilization was measured as number of prescriptions and any prescription (yes/no). The independent variable was receiving the high concentration non-avian HMW-HA injection. Paired sample t-test and McNemar's test were used to assess pre-post changes.Results: The utilization of NSAIDs and steroids prescriptions was reduced significantly during the post period among the study cohort. The proportion of patients filling these prescriptions during the post period was also reduced (p < .001). In addition, the number of patients getting any opioid prescriptions was reduced significantly during the post period (p < .001).Conclusions: Based on this retrospective cohort study, the high concentration non-avian HMW-HA may offer effective pain alleviation among knee OA patients while reducing prescription pain medications such as steroids, NSAIDs and opioids.

Surgical treatment, complications, and reimbursement among patients with clavicle fracture and acromioclavicular dislocations: a US retrospective claims database analysis

Aims: To assess rates of surgical treatment, post-surgical complications, reoperations, and reimbursement in patients with clavicle fractures and acromioclavicular (AC) dislocations. Materials and methods: This US retrospective study used data from patients with ≥1 diagnosis of clavicle fracture or AC dislocation (index) between 2012-2016. Surgical treatment was defined as a procedure within 4 weeks after clavicle fracture/AC dislocation. Rates of complications (infection, non-union, mal-union), reoperations (device removal or revisions), and all-cause healthcare reimbursement (adjusted to 2016$) were evaluated 2 years post-index among surgical patients. Results: A total of 95,243 patients with clavicle fracture and 52,100 patients with AC dislocation were identified. Mean (SD) age for clavicle fracture and AC dislocation was 23.8 (18.6) and 33.0 (15.6) years, respectively. Most clavicle fracture and AC dislocation patients were male (70.9% and 78.0%, respectively), and had few comorbidities (86.4% and 84.8% had a Charlson Comorbidity Index = 0 and 73.1% and 66.0% had Elixhauser = 0, respectively). Only 15.2% of clavicle fracture and 5.3% of AC dislocation patients received surgical treatment. Among patients undergoing surgical treatment, 2-year rates of infection, non-union, and mal-union were 1.0%, 4.2%, and 0.9%, respectively, for clavicle fracture, and 2.0%, 0.9%, and 0.1%, respectively, for AC dislocation. Reoperations occurred in 83.0% of clavicle fracture and 67.5% of AC dislocation patients. Mean (SD) 2-year reimbursement was $27,635 ($68,173) for clavicle fracture and $23,096 ($28,746) for AC dislocation. Limitations: Administrative claims data lack clinical information, limiting inferences that can be made. This data may not be generalizable to other patients. Conclusions: Rates of surgical treatment for clavicle fractures and AC dislocation and rates of infection, non-union, and mal-union among surgically-treated patients were low. However, surgical patients had high rates of device removal or revision surgery during 2-year follow-up. Improved surgical methods and technologies could reduce non-planned reoperations and device removals, thereby reducing healthcare system costs.

Complications in type III open tibial shaft fractures treated with open reduction and internal fixation

Aim: To estimate rates of fracture-related infection (FRI) and nonunion and assess the healthcare burden associated with FRI among patients with open reduction and internal fixation (ORIF) for Type III open tibial shaft fractures (TSFs). Methods: Patients with type III TSF requiring ORIF were identified using MarketScan® Database. Healthcare utilization and total costs were compared using generalized linear models. Results: The rates of FRI and nonunion were 35.99 and 36.94%, respectively, at 365 days. Patients with FRI had a significantly higher rate of readmission, emergency room visit and total healthcare costs compared with patients without FRI. Conclusion: Patients with an ORIF procedure for Type III TSF have a high risk of FRI and nonunion and; FRI significantly increased the healthcare burden.

Reoperations in intramedullary fixation of pertrochanteric hip fractures

Objective: This study evaluated the frequency of reoperation within 1 year of initial intramedullary fixation for patients with pertrochanteric hip fracture and compared 1-year healthcare resource utilization and cost burden for patients with and without reoperation. Methods: This is a retrospective evaluation of medical claims from the US Centers for Medicare and Medicaid Standard Analytic File. Patients aged ≥65 years who underwent fixation with an intramedullary implant for a pertrochanteric fracture between 2013 and 2015 were included. Healthcare resources that were evaluated included skilled nursing facility (SNF), inpatient rehabilitation facility (IRF), readmissions, and outpatient hospital visits. All-cause payments for these services comprised overall cost burden. Generalized Linear Models were used to evaluate healthcare resources and cost burden over 1-year post-surgery and to adjust for confounding between patients with and without a reoperation. Results: A total of 6,423 Medicare patients were included in the analysis. Mean (SD) age was 82.4 (7.8) years, 76.0% were female, and 93.3% were white. A second hip surgery within 1 year after the index fixation procedure was performed in 414 patients (6.4%): 121 (29.2%) contralateral, 115 (27.8%) ipsilateral, and 178 (43.0%) without specified laterality. After adjusting for confounding factors, Medicare patients with ipsilateral reoperations had statistically significantly higher readmissions (100% vs 32.5%, p < 0.0001), outpatient hospital visits (96.4% vs 88.8%, p = 0.018), admissions to a SNF (88.5% vs 80.4%, p = 0.024), and admissions to an IRF (38.8% vs 22.0%, p < 0.0001) compared to patients without reoperations. The adjusted mean total all-cause payments ($90,162 vs $55,131, p < 0.0001) during the 1-year follow-up were statistically significantly higher among patients with reoperations as compared to patients without reoperations. Conclusions: Patients who require a second hip surgery after initial fixation with an intramedullary implant for pertrochanteric hip fractures have significantly higher 1-year healthcare resource utilization and 63.5% higher costs than patients without reoperation.

Medical resource utilization and costs for total hip arthroplasty: benchmarking an anterior approach technique in the Medicare population

AIMS

The anterior approach (AA) for total hip arthroplasty (THA) is associated with more rapid recovery when compared to traditional approaches. The purpose of this study was to benchmark healthcare resource utilization and costs for patients with THA via AA relative to matched patients.

MATERIALS AND METHODS

This study queried Medicare claims data (2012-2014) to identify patients who received THA via an AA from experienced surgeons, and matched these patients to a control cohort (all THA approaches). Direct and propensity-score matching were employed to maximize similarity between patients and hospitals in the two cohorts. Hospital length of stay (LOS), the proportion of patients discharged to home or home health, and post-acute claim payments during the 90-day episode were assessed. Generalized estimating equations were applied to control for imbalances between the cohorts and clustering of outcomes within hospitals.

RESULTS

A total of 1,794 patients were included after patient matching. Patients who received AA had significantly lower mean hospital LOS vs patients in the control group (2.06 ± 1.36 vs 2.98 ± 1.58 days, p < .0001). The adjusted proportion of patients discharged to home was nearly 20 percentage points higher in the AA cohort vs the control cohort (87.3% vs 68.7%, p < .0001). Post-acute claim payments for AA patients were nearly 50% lower than those for control patients ($4,139 vs $7,465, p < .0001).

CONCLUSION

AA patients had significantly lower post-acute care resource use when compared to control patients. Further research is warranted to evaluate the cost effectiveness of AA among surgeons of varying experience levels.

Tuberculosis trends in California correctional facilities, 1993-2013

BACKGROUND

Incarcerated persons are disproportionately diagnosed with tuberculosis (TB). California has the second highest inmate population in the United States, but reports the highest number of cases.

OBJECTIVE

To describe the TB epidemiology among incarcerated patients in California.

METHODS

Trends in incidence were assessed using Poisson regression, and trends in percentage were assessed using weighted linear regression. Demographic and clinical characteristics were compared using χ2 or Mann-Whitney U tests.

RESULTS

During 1993-2013, of the 64 090 TB cases reported, 2323 (4%) were correctional facility residents. Incidence in correctional facilities decreased until 2006 (annual per cent change [APC] -12.3%, 95%CI -14.4 to -10.1), but has since stabilized (APC 4.4%, 95%CI -2.1 to 11.4). Compared with state prisoners, federal prisoners were more likely to be male (98%, P = 0.03), persons arriving in the United States within 5 years of diagnosis (62%, P < 0.001), and born in Mexico (88%, P = 0.02), whereas local jail inmates were more likely to have a history of substance use (75%, P < 0.001) and homelessness (35%, P < 0.001).

CONCLUSIONS

TB incidence in correctional facilities had steadily declined over the last two decades, but has recently leveled out. To promote further reduction in incidence among diverse incarcerated populations, health departments and correctional facilities should strengthen collaboration by conducting TB risk-based assessments.

The impact of β-amyloid positron emission tomography on the diagnostic and treatment decisions of dementia experts

Aim: Amyloid positron emission tomography (aPET) measurement of Alzheimer's disease (AD) pathology could improve the accurate diagnosis of cognitive disorders. Appropriate use criteria recommend that only dementia experts order aPET. Materials & methods: We surveyed 145 dementia experts about their current approaches to evaluation and treatment and the likely influence of aPET. Results: Experts expected aPET to alter diagnostic procedures and patient management and also increase diagnostic certainty. They anticipated confirming AD or altering pharmacological treatment following positive results more than excluding AD following negative results. Experts familiar with aPET reported changes that were more consistent with appropriate use criteria and published evidence. Conclusions: Knowledge about aPET strongly influenced effects on diagnostic certainty and changed clinical practice. Dementia experts may need additional training to achieve optimal benefit from aPET.

Use of Angiotensin-Converting Enzyme Inhibitors, Angiotensin Receptor Blockers, and Risk of Dementia in Heart Failure

OBJECTIVE

To test the effect of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin-receptor blockers (ARBs) on reducing the risk of dementia in patients with heart failure (HF).

METHODS

This retrospective, longitudinal study used a cohort of HF patients identified from a local Medicare advantage prescription drug plan. Multivariable time-dependent Cox model and marginal structural model using inverse-probability-oftreatment weighting were used to estimate the risk of developing dementia. Adjusted dementia rate ratios were estimated among current and former ACEI/ARB users, as compared with nonusers.

RESULTS

Using the time-dependent Cox model, the adjusted dementia rate ratios (95% confidence-interval) among current and former users were 0.90(0.70-1.16) and 0.89 (0.71-1.10), respectively. Use of marginal structural model resulted in similar effect estimates for current and former users as compared with the nonusers.

CONCLUSION

This study found no difference in risk of dementia among the current and former users of ACEI/ARB as compared with the nonusers in an already at-risk HF population.

Clinical and economic impact of TENS in patients with chronic low back pain: analysis of a nationwide database

This study evaluated patients who were given transcutaneous electrical nerve stimulation (TENS) compared with a matched group without TENS prior to intervention and at 1-year follow-up. Patients who were treated with TENS had significantly fewer hospital and clinic visits, used less diagnostic imaging (31 vs 46 events per 100 patients), had fewer physical therapy visits (94 vs 107), and required less back surgery (7.5 vs 9.2 surgeries) than patients receiving other treatment modalities. Total annual costs for chronic low back pain patients without neurological involvement were lower in TENS patients ($17,957 vs $17,986 for non-TENS), even when the cost of the device was taken into account.

Comparative effectiveness of different angiotensin-converting enzyme inhibitors on the risk of hospitalization in patients with heart failure

Aims: Existing randomized controlled trials do not address the comparative effectiveness of different angiotensin-converting enzyme inhibitors (ACEIs) on hospitalization due to heart failure (HF)-hospitalization in patients with HF. We sought to examine the effect of four ACEIs on HF-hospitalization in a large real-world HF population. Methods: The study was a retrospective analysis of a national cohort of patients with HF identified from the Department of Veterans Affairs (TX, USA). A multiple propensity score analysis was used to balance 47 baseline patient characteristics between the different ACEIs. The effect of different ACEIs on time to HF-hospitalization was assessed using the multiple propensity score-weighted multivariable Cox proportional hazard model. Results: The study included 139,994 patients with 69.50% (97,293) on lisinopril, 21.79% (30,503) on fosinopril, 8.41% (11,775) on captopril and 0.30% (423) on enalapril. Propensity scores balanced nearly all differences between different ACEIs groups. Enalapril (hazard ratio [HR]: 0.800; 95% CI: 0.492–1.297), fosinopril (HR: 0.971; 95% CI: 0.877–1.074), and lisinopril (HR: 1.005; 95% CI: 0.918–1.101) when compared with captopril were found to have similar effectiveness in reducing HF-hospitalizations. Conclusion: In patients with HF, we found that the four ACEIs are equally effective in reducing HF-hospitalization in day-to-day practice.