Quality corner: Safely using cephalosporins in almost all patients with penicillin allergies: Mini-review and suggested protocol to improve efficacy and surgical outcomes

Surgical site infections (SSI) are one of the most common gynecologic oncology postoperative complications and they have a significant deleterious impact on the healthcare system and in patients' outcomes. Cefazolin is the recommended antibiotic in women undergoing gynecologic surgical procedures that require that require prophylaxis. However, 10-20% of patients may report a penicillin allergy which can result in administration of a less effective antibiotic. This quality review evaluated the literature around this common perioperative issue and demonstrated that healthcare teams should consider the implementation of a protocol to safely use cefazolin in most patients with a penicillin allergy. Overall, literature shows this is a safe adjustment and would improve antimicrobial stewardship, decrease SSI rates, avoid acute kidney injury, and increase cost savings.

Disability and costs of IHD attributable to the consumption of trans-fatty acids in Brazil

OBJECTIVE

To estimate the disability and costs of the Brazilian Unified Health System for IHD attributable to trans-fatty acid (TFA) consumption in 2019.

DESIGN

This ecological study used secondary data from the Global Burden of Disease (GBD) Study 2019 to estimate the years lived with disability from IHD attributable to TFA in Brazil in 2019. Data on direct costs (purchasing power parity: 1 Int$ = R$ 2·280) were obtained from the Hospital and Ambulatory Information Systems of the Brazilian Unified Health System. Moreover, the total costs in each state were divided by the resident population in 2019 and multiplied by 10 000 inhabitants. The relationship between the socio-demographic index, disease and economic burden was investigated.

SETTING

Brazil and its twenty-seven states.

PARTICIPANTS

Adults aged ≥ 25 years of both sexes.

RESULTS

IHD attributable to TFA consumption resulted in 11 165 years lived with disability (95 % uncertainty interval 932–18 462) in 2019 in Brazil. A total of Int$ 54 546 227 (95 % uncertainty interval 4 505 792–85 561 810) was spent in the Brazilian Unified Health System in 2019 due to IHD attributable to TFA, with the highest costs of hospitalisations, for males and individuals aged ≥ 50 years or over. The highest costs were observed in Sergipe (Int$ 6508/10 000; 95 % uncertainty interval 576–10 265), followed by the two states from the South. Overall, as the socio-demographic index increases, expenditures increase.

CONCLUSIONS

TFA consumption results in a high disease and economic IHD burden in Brazil, reinforcing the need for more effective health policies, such as industrial TFA elimination, following the international agenda.

Evaluating the impact of the Community Helpers Program on adolescents 12-18 years old in Edmonton, Canada

INTERVENTION

Alberta Health Services (AHS) Community Helpers Program (CHP) to enhance mental health among youth.

RESEARCH QUESTION

Identifying the impact of CHP on mental illness-related acute care use among adolescents aged 12-18 years in Edmonton and determining cost avoidance.

METHODS

Using administrative data from AHS, public school catchment area data from the Edmonton Public School Board, and area-level socioeconomic deprivation status indicators from the Pampalon deprivation index, we applied geographical regression discontinuity design to estimate the effect of CHP implementation on depression-, anxiety-, and suicide-related acute care use (emergency department visits and inpatient admissions). Cost data were derived from Interactive Health Data Application of Alberta Health. The study period (2002-2022) included pre (2002-2011) and post (2012-2020) CHP implementation periods.

RESULTS

CHP had statistically significant impact when distance from the boundary (catchment area identifier to divide the sample into treated and control groups) was between 600 and 800 m. About 90 and 80 fewer anxiety- and depression-related visits (per 1000 visits) were observed among individuals aged 12-15 and 16-18 years, respectively, in catchment areas of the public schools where CHP was implemented. Impact of CHP on suicide-related visits was only statistically significant among individuals aged 12-15 years. Annual cost reduction ranged from $161,117 to $269,255 for anxiety- and depression-related visits.

CONCLUSION

Findings show contextual effect of CHP; i.e., being potentially exposed to the program reduced the likelihood of anxiety- and depression-related visits. Costs of CHP implementation could be compared with the avoided costs to assess economic benefits of implementing CHP.

Nail fixation of unstable trochanteric fractures with or without cement augmentation: A cost-utility analysis in the United States: Cost-utility of cement augmentation

OBJECTIVES

Recent clinical studies have shown favorable outcomes for cement augmentation for fixation of trochanteric fracture. We assessed the cost-utility of cement augmentation for fixation of closed unstable trochanteric fractures from the US payer's perspective.

METHODS

The cost-utility model comprised a decision tree to simulate clinical events over 1 year after the index fixation surgery, and a Markov model to extrapolate clinical events over patients' lifetime, using a cohort of 1,000 patients with demographic and clinical characteristics similar to that of a published randomized controlled trial (age ≥75 years, 83 % female). Model outputs were discounted costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio (ICER) over a lifetime. Deterministic and probabilistic sensitivity analyses were performed to assess the impact of parameter uncertainty on results.

RESULTS

Fixation with augmentation reduced per-patient costs by $754.8 and had similar per-patient QALYs, compared to fixation without augmentation, resulting in an ICER of -$130,765/QALY. The ICER was most sensitive to the utility of revision surgery, mortality risk ratio after the second revision surgery, mortality risk ratio after successful index surgery, and mortality rate in the decision tree model. The probability that fixation with augmentation was cost-effective compared with no augmentation was 63.4 %, 58.2 %, and 56.4 %, given a maximum acceptable ceiling ratio of $50,000, $100,000, and $150,000 per QALY gained, respectively.

CONCLUSION

Fixation with cement augmentation was the dominant strategy, driven mainly by reduced costs. These results may support surgeons in evidence-based clinical decision making and may be informative for policy makers regarding coverage and reimbursement.

Autologous Skin Cell Suspension for Full-Thickness Skin Defect Reconstruction: Current Evidence and Health Economic Expectations

Despite differing etiologies, acute thermal burn injuries and full-thickness (FT) skin defects are associated with similar therapeutic challenges. When not amenable to primary or secondary closure, the conventional standard of care (SoC) treatment for these wound types is split-thickness skin grafting (STSG). This invasive procedure requires adequate availability of donor skin and is associated with donor site morbidity, high healthcare resource use (HCRU), and costs related to prolonged hospitalization. As such, treatment options that can facilitate effective healing and donor skin sparing have been highly anticipated. The RECELL® Autologous Cell Harvesting Device facilitates preparation of an autologous skin cell suspension (ASCS) for the treatment of acute thermal burns and FT skin defects. In initial clinical trials, the approach showed superior donor skin-sparing benefits and comparable wound healing to SoC STSG among patients with acute thermal burn injuries. These findings led to approval of RECELL for this indication by the US Food and Drug Administration (FDA) in 2018. Subsequent clinical evaluation in non-thermal FT skin wounds showed that RECELL, when used in combination with widely meshed STSG, provides donor skin-sparing advantages and comparable healing outcomes compared with SoC STSG. As a result, the device received FDA approval in June of 2023 for treatment of FT skin defects caused by traumatic avulsion or surgical excision or resection. Given that health economic advantages have been demonstrated for RECELL ± STSG versus STSG alone when used for burn therapy, it is prudent to examine similarities in the burn and FT skin defect treatment pathways to forecast the potential health economic advantages for RECELL when used in FT skin defects. This article discusses the parallels between the two indications, the clinical outcomes reported for RECELL, and the HCRU and cost benefits that may be anticipated with use of the device for non-thermal FT skin defects.

[Effects of upstream laboratory processes on the digitization of histological slides]

BACKGROUND

Several factors in glass slide (GS) preparation affect the quality and data volume of a digitized histological slide. In particular, reducing contamination and selecting the appropriate coverslip have the potential to significantly reduce scan time and data volume.

GOALS

To objectify observations from our institute's digitization process to determine the impact of laboratory processes on the quality of digital histology slides.

MATERIALS AND METHODS

Experiment 1: Scanning the GS before and after installation of a central console in the microtomy area to reduce dirt and statistical analysis of the determined parameters. Experiment 2: Re-coverslipping the GS (post diagnostics) with glass and film. Scanning the GS and statistical analysis of the collected parameters.

CONCLUSION

The targeted restructuring in the laboratory process leads to a reduction of GS contamination. This causes a significant reduction in the amount of data generated and scanning time required for the digitized sections. Film as a coverslip material minimizes processing errors in contrast to glass. According to our estimation, all the above-mentioned points lead to considerable cost savings.

Shorter length of stay and significant cost savings with ambulatory surgery primary unilateral total knee arthroplasty in Asians using enhanced recovery protocols

Introduction

Enhanced recovery after surgery (ERAS) in total knee arthroplasty (TKA) has reduced the length of stay (LOS) and cost of TKA in the Western population. Asians had been identified to be at higher odds of non-home discharge following TKA due to cultural differences. The efficacy of ERAS in TKA for Asian patients is less known. We aimed to investigate the efficacy of ERAS in reducing the LOS, transition to ambulatory surgery, improving home discharges, and reducing cost in an Asian population following TKA.

Methods

Retrospective analysis was performed on 634 TKA patients in 2017 (pre- ERAS) and 584 TKA patients who had undergone ERAS in 2022 in a tertiary hospital.

Results

Patients in 2022 (ERAS) were older (69 ± 7 vs. 68 ± 7 years old, p < 0.001) and had a higher proportion of patients with poorer function (p < 0.001). The LOS reduced from 5.4 days (95% CI:5.2-5.6) to 2.9 days (95% CI:2.7-3.2) (p < 0.001) with about 49 % of patients transitioning to ambulatory surgery and having a LOS of 1.4 days (95 %CI:1.3-1.5). The proportion of patients being discharged home in 2022 (78.9 %) was higher compared to 2017 (62.2 %) (p < 0.001). This saved the hospital 1817.4 inpatient ward bed days, which translated to S$2,124,540.60 of cost saving in a year, and up to S$2397.28 for the individual patient.

Conclusion

ERAS after TKA was able to safely achieve LOS comparable to the western population and allowed transition to ambulatory knee replacement in the Asian population. Consequently, this led to higher proportion of home discharges and achieved significant cost saving and hospital bed days.

POCUS-first for nephrolithiasis: A Monte Carlo simulation illustrating cost savings, LOS reduction, and preventable radiation

OBJECTIVES

Non-contrast computed tomography (NCCT) is the gold standard for nephrolithiasis evaluation in the emergency department (ED). However, Choosing Wisely guidelines recommend against ordering NCCT for patients with suspected nephrolithiasis who are <50 years old with a history of kidney stones. Our primary objective was to estimate the national annual cost savings from using a point-of-care ultrasound (POCUS)-first approach for patients with suspected nephrolithiasis meeting Choosing Wisely criteria. Our secondary objectives were to estimate reductions in ED length of stay (LOS) and preventable radiation exposure.

METHODS

We created a Monte Carlo simulation using available estimates for the frequency of ED visits for nephrolithiasis and eligibility for a POCUS-first approach. The study population included all ED patients diagnosed with nephrolithiasis. Based on 1000 trials of our simulation, we estimated national cost savings in averted advanced imaging from this strategy. We applied the same model to estimate the reduction in ED LOS and preventable radiation exposure.

RESULTS

Using this model, we estimate a POCUS-first approach for evaluating nephrolithiasis meeting Choosing Wisely guidelines to save a mean (±SD) of $16.5 million (±$2.1 million) by avoiding 159,000 (±18,000) NCCT scans annually. This resulted in a national cumulative decrease of 166,000 (±165,000) annual bed-hours in ED LOS. Additionally, this resulted in a national cumulative reduction in radiation exposure of 1.9 million person-mSv, which could potentially prevent 232 (±81) excess cancer cases and 118 (±43) excess cancer deaths annually.

CONCLUSION

If adopted widely, a POCUS-first approach for suspected nephrolithiasis in patients meeting Choosing Wisely criteria could yield significant national cost savings and a reduction in ED LOS and preventable radiation exposure. Further research is needed to explore the barriers to widespread adoption of this clinical workflow as well as the benefits of a POCUS-first approach in other patient populations.

Operating Room Recycling: Opportunities to Reduce Carbon Emissions Without Increases in Cost

BACKGROUND

The healthcare industry is a major contributor to greenhouse gas emissions. Within the hospital, operating rooms are responsible for the largest proportion of emissions due to high resource utilization and waste generation. Our aim was to generate estimates of greenhouse gas emissions avoided and cost implications following implementation of a recycling program across operating rooms at our freestanding children's hospital.

METHODS

Data were collected from three commonly performed pediatric surgical procedures: circumcision, laparoscopic inguinal hernia repair, and laparoscopic gastrostomy tube placement. Five cases of each procedure were observed. Recyclable paper and plastic waste was weighed. Emission equivalencies were determined using the Environmental Protection Agency Greenhouse Gas Equivalencies Calculator. Institutional cost of waste disposal was $66.25 United States Dollars (USD)/ton for recyclable waste and $67.00 USD/ton for solid waste.

RESULTS

The proportion of recyclable waste ranged from 23.3% for circumcision to 29.5% for laparoscopic gastrostomy tube placement. The amount of waste redirected from landfill to a recycling stream could result in annual avoidance of 58,500 to 91,500 kg carbon dioxide equivalent emissions, or 6583 to 10,296 gallons of gasoline. Establishing a recycling program would not require additional cost and could lead to modest cost savings (range $15 to 24 USD/year).

CONCLUSIONS

Incorporation of recycling into operating rooms has the potential to reduce greenhouse gas emissions without increased cost. Clinicians and hospital administrators should consider operating room recycling programs as they work towards improved environmental stewardship.

LEVEL OF EVIDENCE

Level VI - evidence form a single descriptive or qualitative study.

A reduction in hospital length of stay reduces costs for colorectal surgery: an economic evaluation of the National Surgical Quality Improvement Program in Singapore

PURPOSE

In 2017, the National Surgical Quality Improvement Program (NSQIP) was introduced in the Department of Colorectal Surgery at Singapore General Hospital as a pilot quality improvement initiative. This study aimed to examine the cost-effectiveness of NSQIP by evaluating its effects on surgical outcomes, length of stay (LOS), and costs.

METHODS

We retrospectively reviewed patients undergoing colorectal surgery (2017-2020). Patients were divided into two cohorts: pre-NSQIP (2017-2018) and post-NSQIP (2019-2020). Outcomes evaluated were 30-day postoperative complications, LOS, and costs. Total cost-savings from NSQIP intervention's impact on LOS were estimated using a decision model with a one-way sensitivity analysis. Multivariate logistic regression was performed to identify factors for prolonged LOS.

RESULTS

1905 patients underwent colorectal surgery, with 996 in the pre-NSQIP cohort and 909 in the post-NSQIP cohort. A significant reduction in overall postoperative complications of 4.7% was observed in the post-NSQIP cohort (36.5% vs. 31.8%, p = 0.029). Patients in the post-NSQIP cohort had a shorter median LOS (8.0 vs. 6.0 days, p < 0.001). The implementation of NSQIP resulted in an 8.5% decrease in prolonged LOS > 6 days (p < 0.001), saving S$0.31 million on LOS. Total costs per case were reduced by 20.8% following NSQIP (S$39,539.05 vs. S$31,311.93, p < 0.001).

CONCLUSION

Implementing NSQIP has significantly reduced overall postoperative complications, LOS, and costs and achieved cost savings following colorectal surgery.

Remote patient monitoring to facilitate same-day discharge after laparoscopic sleeve gastrectomy: a pilot evaluation

BACKGROUND

Limited hospital inpatient capacity, exacerbated by SARS-CoV-2 (COVID-19) and associated staffing shortages, has driven interest in converting surgeries historically done as inpatient procedures to same-day surgeries (SDS). Remote patient monitoring (RPM) has the potential to increase safety and confidence in SDS but has had mixed success in a bariatric population.

OBJECTIVES

Assess the feasibility of and adherence to a protocol offering patients same-day laparoscopic sleeve gastrectomy (SG) supported by RPM with an updated wearable device. Secondary outcomes were readmissions, costs, adherence, and clinical alarm rates.

SETTING

Academic, military tertiary referral center (United States).

METHODS

A single-center, retrospective case control study of patients undergoing SG, comparing SDS with RPM to patients admitted to the hospital for SG during this time. Patients for SDS were selected by set inclusion/exclusion criteria and patient/surgeon preference, and perioperative management was standardized.

RESULTS

Twenty patients were enrolled in the SDS group, then compared with 53 inpatients. Inpatients were older (46 versus 39, P = .006), but with no significant differences in sex, preoperative body mass index, or co-morbidities. RPM wearable and blood pressure adherence was found to be 97% and 80%, respectively. Readmission rates were similar (10% versus 7.5%, P > .05). RPM alarm rates were .5 (0-1.3) per patient for each 24-hour home monitoring period. SDS patients also demonstrated the potential for cost savings over inpatient SG, depending on the number of patients monitored per day as well as the healthcare setting.

CONCLUSIONS

SG as SDS with RPM was a feasible approach. It should be evaluated in other surgical procedures and higher-risk patient populations.

[Initiative for a shift from inpatient to outpatient treatment]

A shift from inpatient to outpatient treatment is necessary to offset the severe lack of nursing staff in Germany. A central role is played by the catalogue announced for outpatient surgical procedures, which will contain many formerly inpatient procedures. Context factors have been defined to make the decision for inpatient treatment more reproducible. In the end, the remuneration of outpatient procedures will decide whether the infrastructural changes will be successful in daily practice.

The potential impact of increased recombinant zoster vaccine coverage on the burden of herpes zoster among adults aged 50-59 years

INTRODUCTION

Recombinant zoster vaccine (RZV) is recommended in the US for prevention of herpes zoster (HZ) in adults aged ≥50 years. Vaccination rates remain suboptimal for adults 50-59 years compared with adults ≥50 years overall. The objective of this study was to model changes in outcomes associated with improved RZV vaccination coverage in US adults 50-59 years.

METHODS

A multicohort Markov model compared a scenario using real-world vaccination coverage for US adults 50-59 years in 2020 versus scenarios assuming higher coverage. Outcomes, based on a lifetime horizon, included HZ cases and complications avoided, quality-adjusted life-years (QALY), and costs. Model inputs included HZ epidemiology, RZV vaccine efficacy, coverage, adverse events, and costs, based on published literature and US sources. Some inputs were updated from previous models, including real-world estimates of RZV coverage, series completion, and reflecting longer-term data on waning of vaccine efficacy. The model utilized a cohort size of 42,756,488 individuals based on the 2020 US population census.

RESULTS

The model projected that increasing RZV coverage in adults 50-59 years from 7.3 % to 14.6 % (to coverage for adults 60-64 years in 2020) would avoid an additional 504,468 HZ cases, 42,077 postherpetic neuralgia cases, and 56,247 cases of other HZ-associated complications. The increase in vaccine coverage would result in higher vaccination-related costs of $1,172,411,566, but the avoided HZ cases and complications would be expected to result in direct cost savings of $721,973,386 and indirect cost savings of $593,497,480 from avoided productivity loss. Overall, a gain of 5,230 discounted QALYs and cost savings of $143,059,299 from a societal perspective would be realized.

CONCLUSION

Modestly higher RZV coverage in US adults 50-59 years could reduce the clinical burden associated with HZ and may result in societal cost savings. These findings demonstrate the potential value of increasing RZV vaccination in this population.

Optimizing spine surgery instrument trays to immediately increase efficiency and reduce costs in the operating room

Background

Over-crowded surgical trays result in perioperative inefficiency and unnecessary costs. While methodologies to reduce the size of surgical trays have been described in the literature, they each have their own drawbacks. In this study, we compared three methods: (1) clinician review (CR), (2) mathematical programming (MP), and (3) a novel hybrid model (HM) based on surveys and cost analysis. While CR and MP are well documented, CR can yield suboptimal reductions and MP can be laborious and technically challenging. We hypothesized our easy-to-implement HM would result in a reduction of surgical instruments in both the laminectomy tray (LT) and basic neurosurgery tray (BNT) that is comparable to CR and MP.

Methods

Three approaches were tested: CR, MP, and HM. We interviewed 5 neurosurgeons and 3 orthopedic surgeons, at our institution, who performed a total of 5437 spine cases, requiring the use of the LT and BNT over a 4-year (2017-2021) period. In CR, surgeons suggested which surgical instruments should be removed. MP was performed via the mathematical analysis of 25 observations of the use of a LT and BNT tray. The HM was performed via a structured survey of the surgeons' estimated instrument usage, followed by a cost-based inflection point analysis.

Results

The CR, MP, and HM approaches resulted in a total instrument reduction of 41%, 35%, and 38%, respectively, corresponding to total cost savings per annum of $50,211.20, $46,348.80, and $44,417.60, respectively.

Conclusions

While hospitals continue to examine perioperative services for potential inefficiencies, surgical inventory will be increasingly scrutinized. Despite MP being the most accurate methodology to do so, our results suggest that savings were similar across all three methods. CR and HM are significantly less laborious and thus are practical alternatives.

Medical Nutrition Therapy Provided by Dietitians is Effective and Saves Healthcare Costs in the Management of Adults with Dyslipidemia

PURPOSE OF REVIEW

Referral to nutrition care providers in the USA such as registered dietitian nutritionists (RDNs) for medical nutrition therapy (MNT) remains low. We summarize research on the effectiveness of MNT provided by dietitians versus usual care in the management of adults with dyslipidemia. Improvements in lipids/lipoproteins were examined. If reported, blood pressure (BP), fasting blood glucose (FBG) glycated hemoglobin (A1c), body mass index (BMI), and cost outcomes were also examined.

RECENT FINDINGS

The synthesis of three systematic reviews included thirty randomized controlled trials. Multiple MNT visits (3-6) provided by dietitians, compared with usual care, resulted in significant improvements in total cholesterol (mean range: - 4.64 to - 20.84 mg/dl), low-density lipoprotein cholesterol (mean range: - 1.55 to - 11.56 mg/dl), triglycerides (mean range: - 15.9 to - 32.55 mg/dl), SBP (mean range: - 4.7 to - 8.76 mm Hg), BMI (mean: - 0.4 kg/m2), and A1c (- 0.38%). Cost savings from MNT were attributed to a decrease in medication costs and improved quality of life years (QALY). Multiple MNT visits provided by dietitians compared with usual care improved lipids/lipoproteins, BP, A1c, weight status, and QALY with significant cost savings in adults with dyslipidemia and justify a universal nutrition policy for equitable access to MNT.

Obesity Burden and Impact of Weight Loss in Saudi Arabia: A Modelling Study

BACKGROUND

Obesity and its complications are associated with morbidity, mortality and high economic cost in Saudi Arabia. Estimating this impact at the population level and potential benefits to be gained from obesity reduction is vital to underpin policy initiatives to prevent disease risks.

METHODS

We combined data in an adapted version of the value of weight loss simulation model, to predict reductions in complication rates and cost savings achievable with 15% weight loss in Saudi Arabia over 10 years. To obtain model inputs, we conducted a systematic literature review (SLR) to identify data on the prevalence of obesity and its complications in Saudi Arabia, and surveyed specialist physicians and hospital administrators in public (governmental) and private healthcare sectors. We used combinations of age, sex, obesity and type 2 diabetes (T2D) rates in Saudi Arabia to sample a United Kingdom (UK) cohort, creating a synthetic Saudi Arabia cohort expected to be representative of the population.

RESULTS

The synthetic Saudi Arabia cohort reflected expected comorbidity prevalences in the population, with a higher estimated prevalence of T2D, hypertension and dyslipidaemia than the UK cohort in all age groups. For 100,000 people with body mass index 30-50 kg/m², it was estimated that 15% weight loss would lead to a 53.9% reduction in obstructive sleep apnoea, a 37.4% reduction in T2D and an 18.8% reduction in asthma. Estimated overall cost savings amounted to 1.026 billion Saudi Arabian Riyals; the largest contributors were reductions in T2D (30% of total cost savings for year 10), dyslipidaemia (26%) and hypertension (19%).

CONCLUSIONS

Sustained weight loss could significantly alleviate the burden of obesity-related complications in Saudi Arabia. Adopting obesity reduction as a major policy aim, and ensuring access to support and treatment should form an important part of the transformation of the healthcare system, as set out under 'Vision 2030'.

Venous Sinus Stenting: Safety and Health Care Resource Evaluation for Optimal Recovery in an Evolving Health Care Environment

BACKGROUND

Increasing evidence supports the effectiveness of venous sinus stenting (VSS) with favorable outcomes, safety, and expenses compared with shunting for idiopathic intracranial hypertension. Yet, no evidence is available regarding optimal postoperative recovery, which has increasing importance with the burdens on health care imposed by the coronavirus disease 2019 pandemic. We examined adverse events and costs after VSS and propose an optimal recovery pathway to maximize patient safety and reduce stress on health care resources.

METHODS

A retrospective review was undertaken of elective VSS operations performed from May 2008 to August 2021 at a single institution. Primary data included hospital length of stay, intensive care unit (ICU) length of stay, adverse events, need for ICU interventions, and hospital costs.

RESULTS

Fifty-three patients (98.1% female) met the inclusion criteria. Of these patients, 51 (96.2%) were discharged on postoperative day (POD) 1 and 2 patients were discharged on POD 2. Both patients discharged on POD 2 remained because of groin hematomas from femoral artery access. There were no major complications or care that required an ICU. Eight patients (15.1%) were lateralized to other ICUs or remained in a postanesthesia care unit because the neurosciences ICU was above capacity. Total estimated cost for initial recovery day in a neurosciences ICU room was $2361 versus $882 for a neurosurgery/neurology ward room. In our cohort, ward convalescence would save an estimated $79,866 for bed placement alone and increase ICU bed availability.

CONCLUSIONS

Our findings reaffirm the safety of VSS. These patients should recover on a neurosurgery/neurology ward, which would save health care costs and increase ICU bed availability.

Annual cost-savings with the implementation of estrogen-receptor-only testing on Ductal Carcinoma in Situ specimens

BACKGROUND

In DCIS, ER status is an important marker. The utility of concomitant PR testing remains unclear.

METHODS

A single-institution retrospective cohort study was performed with a comparative analysis of the NCDB to assess annual cost-savings with omission of routine PR testing. National Medicare payment standards determined PR staining costs to be $124.92.

RESULTS

150 institutional DCIS cases with receptor data were identified. 104 (69%) were ER+/PR+, 16 (11%) were ER+/PR-, and none were ER-/PR+. Omission of routine PR testing would have resulted in $18,738 saved annually. Within the NCDB, 34,100 DCIS cases had receptor data: 29,277 (85.9%) patients were ER+, and 26,008 (76%) were both ER/PR+. 211 (0.6%) patients were ER-/PR+. Annual national cost-savings with omission of routine PR-testing would have been $4.3 million.

CONCLUSION

PR testing for DCIS should be reserved only for patients with ER- DCIS undergoing breast conservation to determine the utility of adjuvant endocrine therapy.

Continuous Countercurrent Chromatography in Protein Purification

Continuous countercurrent chromatography can be applied for both capture and polishing steps in the downstream processing of biopharmaceuticals. This chapter explains the concept of countercurrent operation, focusing on twin-column processes and how it can be used to alleviate the trade-offs of traditional batch chromatography with respect to resin utilization/productivity and yield/purity. CaptureSMB and MCSGP, the main twin-column continuous countercurrent chromatography processes, are explained, and the metrics by which they are compared to single-column chromatography are identified. Practical hints for process design and application examples are provided. Finally, regulatory aspects, scale-up, and UV-based process control are covered.

The reuse of circular external fixator components: an assessment of safety and potential savings

PURPOSE

Cost-saving strategies are important, especially in a resource-constrained environment. One such strategy well supported in the literature is the reuse of temporary monolateral external fixator components, a strategy we utilize at our institution. The aim of the study was to determine the safety and cost saving associated with the reuse of definitive circular external fixator components in a resource-constrained environment.

METHOD

We performed a retrospective review of all adult patients who were treated with either new or reused circular external fixators from a single manufacturer between January and December 2017. Reused circular external fixator components, excluding half pins and wires, were subjected to an in-house reprocessing protocol. Cost savings were calculated as the difference between the price of a completely new frame and the amount invoiced for new components only in a reused frame.

RESULTS

Thirty-three patients were included in the study with an average age of 31.9 years. The mean duration of treatment with a circular external fixator was 5.8 months. No mechanical failure events were recorded during the study period. Our institution saved approximately 52% (R717 503.89) and 63% (R136 568.19) of expected total cost for hexapod and Ilizarov frames, respectively.

CONCLUSION

The strategy of reusing circular external fixator components is unconventional, and this study was conducted to evaluate the safety and potential savings in a resource-constrained environment. We demonstrated this practice to be reasonably safe and to result in significant cost savings which might be relevant in low-and-middle-income countries.

Analysis of real-world length of stay data and costs associated with use of autologous skin cell suspension for the treatment of small burns in U.S. centers

BACKGROUND

Autologous skin cell suspension (ASCS) is a treatment for acute thermal burn injuries associated with significantly lower donor skin requirements than conventional split-thickness skin grafts (STSG). Projections using the BEACON model suggest that among patients with small burns (total body surface area [TBSA]<20 %), use of ASCS± STSG leads to a shorter length of stay (LOS) in hospital and cost savings compared with use of STSG alone. This study evaluated whether data from real-world clinical practice corroborate these findings.

MATERIALS AND METHODS

Electronic medical record data were collected from January 2019 through August 2020 from 500 healthcare facilities in the United States. Adult patients receiving inpatient treatment with ASCS± STSG for small burns were identified and matched to patients receiving STSG using baseline characteristics. LOS was assumed to cost $7554/day and to account for 70 % of overall costs. Mean LOS and costs were calculated for the ASCS± STSG and STSG cohorts.

RESULTS

A total of 151 ASCS± STSG and 2243 STSG cases were identified; 63.0 % of patients were male and the average age was 44.2 years. Sixty-three matches were made between cohorts. LOS was 18.5 days with ASCS± STSG and 20.6 days with STSG (difference: 2.1 days [10.2 %]). This difference led to bed cost savings of $15,587.62 per ASCS± STSG patient. Overall cost savings with ASCS± STSG were $22,268.03 per patient.

CONCLUSIONS

Analysis of real-world data shows that treatment of small burn injuries with ASCS± STSG provides reduced LOS and substantial cost savings compared with STSG, supporting the validity of the BEACON model projections.

[Postoperative wound care with custom-made wound dressings for hidradenitis suppurativa : Wound care after radical excision with secondary wound closure]

Hidradenitis suppurativa is a chronic, recurrent, autoinflammatory skin disease of the hair follicle and sebaceous glands in intertriginous skin areas. Treatment is based on clinical severity (typically classified according to Hurley stage). In advanced stages, radical excision of affected skin areas with secondary wound closure remains first-line treatment. Postoperative care in this setting should comprise nonadhesive wound dressings. The purpose of this article is to illustrate postoperative wound care after radical excision with secondary wound closure using nonadhesive, absorbent dressings for economical and effective care.

Cost savings in the Swiss healthcare system resulting from professional periodontal care

More than 740 million people worldwide are affected by periodontal disease and are at higher risk of secondary damage such as cardiovascular disease and type 2 diabetes, which place a considerable financial burden on healthcare systems. The aim of this study was to use a computer simulation to estimate the direct and indirect costs of prevention and treatment of gingivitis, periodontitis and related secondary damage in the Swiss population, paid both out of pocket (OOP) and from social welfare (SW). For three different scenarios, iterations with 200,000 simulated individuals over their assumed life span of 35 to 100 years corresponded to a period of four months in which an individual could move from one periodontal condition to the next, each associated with presumed direct and indirect treatment costs. Appropriate diagnosis and adherence to professional periodontal care had a strong benefit saving up to CHF 5.94 billion OOP and CHF 1.03 billion SW costs for the current Swiss population. Considering direct and indirect health care costs, the total expected costs for a 35-year-old individual until death were CHF 17'310 with minimal care and CHF 15'606 with optimal care, resulting in savings of CHF 1'704. In conclusion, early detection and appropriate treatment of periodontitis can help to reduce both overall costs of treating periodontitis and associated secondary damage, especially in the second half of life. These cost savings may further pay off on an individual level through regular supportive periodontal care, both for treatments paid out-of-pocket and those covered by social welfare.

Patient safety indicators from a spine surgery perspective: the importance of a specialty specific clinician working with the documentation team and the impact to your hospital

BACKGROUND CONTEXT

The Hospital Acquired Conditions (HAC) Reduction Program supports the Centers for Medicare and Medicaid Services (CMS) effort to prevent harm to patients by providing a financial incentive to reduce HACs. HAC scores are impacted by Patient Safety Indicators (PSIs), potentially preventable hospital-related events associated with harmful patient outcomes. PSIs are identified using International Classification of Diseases (ICD) coding; however, ICD coding does not always reflect the patient's true medical course.

PURPOSE

To evaluate the efficacy of and costs savings associated with a clinical documentation review process in tandem with clinician collaboration in identifying incorrectly generated PSIs.

STUDY DESIGN

Retrospective chart review.

PATIENT SAMPLE

All patients undergoing spine surgery at a single multi-surgeon tertiary spine center.

OUTCOME MEASURES

Occurrence of PSI.

METHODS

Over two 11-month periods, all PSIs attributable to spine surgery were determined. The number and type of spine related PSIs were compared before (Control) and after the implementation of a specialty specific clinical review (Intervention) to identify incorrectly generated PSIs. The financial impact of this intervention was calculated in the form of an annual cost savings to our hospital system.

RESULTS

During the Control phase, 61 PSIs were reported in 3368 spine cases, representing a total of 3.6 PSIs/month. During Intervention phase, 26 PSIs in 4,482 spine cases, resulting in a statistically significant decrease of 1.5 PSIs per month. The percentage of PSIs across all surgical cases attributable to spine surgery had a statistically significant decrease during the Intervention period compared to the Control period (16% vs. 10%, p=.034), resulting in the avoidance of a 1% CMS cost reduction, an annual cost saving of approximately $3-4 million dollars per year.

CONCLUSIONS

The implementation of a clinical documentation review process with clinician collaboration to ensure ICD-10 coding accurately reflects the patient's medical course leads to more accurate PSI reporting, with the potential for substantial cost-savings for hospitals from CMS reimbursement.

Breast Surgery Cost Savings Through Surgical Tray Instrument Reduction

INTRODUCTION

Removing unnecessary instruments from surgical trays used in the operating room conserves resources and time. We aimed to assess the cost savings impact of breast surgical tray instrument reduction.

METHODS

Breast surgeons at a single institution reviewed the standard surgical tray used for lumpectomies and mastectomies and removed underutilized instruments to create a breast-specific tray. This tray was used for all breast surgeries performed throughout the 2019 calendar year. Data for breast-specific tray usage, instrument reprocessing costs, and instrument maintenance costs for inspection, sharpening, aligning, and lubricating were retrospectively obtained.

RESULTS

The breast-specific tray was reduced from 82 to 65 instruments. The cost of reprocessing each instrument is $1.69. After 30 tray sterilizations, each tray was sent for maintenance at a cost of $2.00 per instrument. With 10 breast-specific trays in circulation, the trays were used a total of 656 times during the calendar year. Each tray was sent for maintenance an average of two times during this time period. Thus, instrument reduction resulted in $18,847 in instrument reprocessing and $680.00 in maintenance savings, with total annual cost savings of $19,527.

CONCLUSIONS

Optimizing surgical trays by removing unused instruments yields significant cost savings and contributes to improved efficiency in the sterile processing department. As efforts to eliminate wasteful practices and reduce costs within the health care system continue, opportunities remain for standardization of trays across all surgical departments and institutions.

Streamlining surgical trays for common pediatric urology Procedures: A quality improvement initiative

INTRODUCTION

Procedures involving the external genitalia are the most common pediatric urologic operations. Our group identified excess instrumentation for these cases to be a potential cause of operating room (OR) inefficiency at our large, freestanding pediatric hospital. This quality improvement (QI) initiative aimed to streamline surgical instrumentation for the most-performed pediatric urologic procedures at our hospital.

MATERIAL AND METHODS

Six Sigma DMAIC methodology (Define, Measure, Analyze, Improve, Control) guided this multidisciplinary, iterative QI effort. A stakeholder team utilized data review, direct observations, and multiple in-person discussions to create a new "Groin-Penis Tray" (GPT) to replace a larger tray for the 90 most common pediatric urologic procedures. Suture preference cards and expectations about which sutures would be opened for each case were updated. The primary outcome was estimated yearly cost-avoidance due to reduced sterile processing. Additional outcomes included: instruments opened/case, % cases with complete trays, Mayo stand set-up time, and % cases with unused sutures. Balancing measures included: total median OR time and tray weights. Baseline and post-implementation measures were characterized and compared.

RESULTS

A QI professional, 10 pediatric urologists, 2 pediatric urology fellows, and multiple OR and sterile processing staff members participated. The Summary Figure compares baseline and post-implementation measurements. The number of instruments opened/case decreased from 146 to 65. Annual sterile reprocessing costs decreased by >$51,000. Median Mayo stand set-up time decreased from 7.3 to 3.5 min (p < 0.001). The number of cases with complete trays increased from 7/20 (35%) to 11/20 (55%, p = 0.34). The new GPT is 2.7 kg lighter than the prior tray. Median OR time remained stable (baseline: 91 min; post-implementation: 102 min, p = 0.44). The number of cases with suture waste decreased from 78% to 0% immediately post-implementation but increased to 40% one year later.

DISCUSSION

This systematic, iterative QI process spanned the course of ∼2 years, including planning, building, and updating new trays, then assessing longer-term success via the control phase. The new GPT is used for most pediatric urologic procedures at our hospital, and benefits include sterile reprocessing cost savings and ergonomics. Our team gained valuable experience related to assessing QI project scope, determining key stakeholders and roles, and strategies for sustainability that we will apply to future initiatives.

CONCLUSIONS

Streamlining surgical trays for common pediatric urologic procedures at a large freestanding children's hospital using established QI methodology reduced OR cost by >$51,000/year and Mayo stand set-up times without compromising balancing measures.

What are the short-term annual cost savings associated with kidney transplantation?

BACKGROUND

Kidney transplantation (KT) is often reported in the literature as associated with cost savings. However, existing studies differ in their choice of comparator, follow-up period, and the study perspective. Also, there may be unobservable heterogeneity in health care costs in the patient population which may divide the population into groups with differences in cost distributions. This study estimates the cost savings associated with KT from a payer perspective and identifies and characterizes both high and low patient cost groups.

METHOD

The current study was a population-based retrospective before-and-after study. The timespan involved at most three years before and after KT. The sample included end-stage kidney disease patients in Nova Scotia, a province in Canada, who had a single KT between January 1, 2011, and December 31, 2018. Each patient served as their control. The primary outcome measure was total annual health care costs. We estimated cost savings using unadjusted and adjusted models, stratifying the analyses by donor type. We quantified the uncertainty around the estimates using non-parametric and parametric bootstrapping. We also used finite mixture models to identify data-driven cost groups based on patients' pre-transplantation annual inpatient costs.

RESULTS

The mean annual cost savings per patient associated with KT was $19,589 (95% CI: $14,013, $23,397). KT was associated with a 24-29% decrease in mean annual health care costs per patient compared with the annual costs before KT. We identified and characterized patients in three cost groups made of 2.9% in low-cost (LC), 51.8% in medium-cost (MC) and 45.3% in high-cost (HC). Cost group membership did not change after KT. Comparing costs in each group before and after KT, we found that KT was associated with 17% mean annual cost reductions for the LC group, 24% for the MC group and 26% for the HC group. The HC group included patients more likely to have a higher comorbidity burden (Charlson comorbidity index ≥ 3).

CONCLUSIONS

KT was associated with reductions in annual health care costs in the short term, even after accounting for costs incurred during KT.

An economic evaluation of vial sharing of expensive drugs in automated compounding

Background Manual compounding of expensive cytotoxic drugs often leads to drug wastage, due to residual product in vials not being used. Aim To determine the cost savings that can be achieved by implementing an automated compounding process with a vial sharing strategy, instead of manually compounding drugs. Method The drug wastage during automated compounding was compared with that of three simulation scenarios using manual compounding, in a general teaching hospital. All automatically compounded preparations of rituximab, pemetrexed, bevacizumab, and trastuzumab from September 2019 and up until February 2020 were included. A vial sharing strategy was implemented during the automated compounding process (scenario 1). In this scenario, all residual drugs could be reused for up to seven days. Two of the simulation scenarios for manual compounding were executed using a batch compounding strategy, for an entire working day (scenario 2), and twice a day (scenario 3). The third manual compounding simulation was executed without making use of a batch compounding strategy (scenario 4). Results There was no drug wastage during automated compounding with vial sharing (scenario 1). The cost of drug wastage for 1001 preparations, over a period of six months for rituximab, pemetrexed, bevacizumab, and trastuzumab combined, were € 34,133 for scenario 2, € 46,688 for scenario 3, and € 88,255 for scenario 4. The estimated total cost savings between 2017, when the compounding robot was commissioned, and 2021, was more than € 280,000. Conclusion Vial sharing of expensive drugs during automated compounding can prevent drug wastage, resulting in an economic and environmental advantage as opposed to manual compounding.

Lifecycle cost analysis of an insulated duct with an air gap

The insulation materials are used to reduce heat loss to/from the ducts with additional investment. This study introduces an air gap between insulation and duct surface to reduce the quantity of insulation. It uses lifecycle cost (LCC) analysis to determine the economic benefits of the air gap, considering four insulation materials for insulating the duct and natural gas as an energy source for chiller operation. The preliminary data regarding design and operating parameters were obtained from a renowned pharmaceutical company. The duct's annual energy loss was estimated for given operation hours in a year using the preliminary data and ambient conditions. The estimated energy loss through the duct was fed in LCC analysis to determine the impact of the air gap on optimum insulation thickness (OIT) corresponding to the minimum LCC and payback period. Results revealed that OIT thickness for a duct with an air gap was lower than insulated duct without an air gap, resulting in maximum cost savings within a shorter payback period. Among different insulation materials, insulated duct with expanded polystyrene was investigated as cost-effective insulation material with maximum cost savings of USD (508.8-766.8)/m/year and a payback period of 1.15-1.17 years. On the contrary, the air gap was the most effective in terms of cost savings for the ducts insulated with rock wool. In conclusion, an air gap is a cost-effective design approach for duct applications.

Health and economic burden due to alcohol-associated liver diseases in the Union Territory of Delhi: A Markov probabilistic model approach

BACKGROUND

Nearly one-fifth of all deaths attributable to alcohol are due to liver diseases.

METHODS

The study employs a Markov Probabilistic Modeling approach considering various clinical spectrum of alcohol-associated liver diseases (ALD), to gauge the health and economic burden due to ALD for the national capital territory of Delhi, from March 2017 to February 2018. The health impact was estimated through Disability Adjusted Life Years (DALYs), years of life lost (YLL), and total deaths due to ALD. The economic burden of ALD was assessed assuming the current health-seeking preferences and assuming that all the diseased individuals are cared for in the public health systems. Sensitivity analysis was done by Monte Carlo simulations.

RESULTS

Total number of estimated deaths due to ALD in the national capital territory of Delhi for one year period from March 2017 was 8367. The DALYs due to ALD were estimated to be 0.247 million life years; this includes 0.178 million YLL and 0.069 million life years lost due to disability. The total cost of treating ALD was estimated to be 92.94 billion Indian rupees, if patients sought care based on current preferences and 55.52 billion Indian rupees if all diseased individuals were cared for in public health systems. The total excise revenue due to alcohol to the Government is being Indian rupees 43.1 billion in the said year.

CONCLUSION

The high burden of ALD in terms of lives lost, DALYs lost, and more than two times higher estimated expense for care than the revenue generation due to alcohol clearly indicates that it would be prudent to initiate social engineering and preventive strategies to lessen the growing burden of ALD in India. The Delhi model for health and economic burden of ALD could help the country develop policies for better health outcomes of these patients.

Length of Stay and Costs with Autologous Skin Cell Suspension Versus Split-Thickness Skin Grafts: Burn Care Data from US Centers

INTRODUCTION

Autologous skin cell suspension (ASCS) significantly reduces donor skin requirements versus conventional split-thickness skin grafts (STSG) for thermal burn treatment. In analyses using the Burn-medical counter measure Effectiveness Assessment Cost Outcomes Nexus (BEACON) model, ASCS was associated with shorter hospital length of stay (LOS) and cost savings versus STSG. This study hypothesized that daily practice data from the USA would support these findings.

METHODS

Electronic medical record data from 500 healthcare facilities (January 2019-August 2020) were used to match adult patients who received inpatient burn treatment with ASCS (± STSG) to patients treated with STSG alone on the basis of sex, age, percent total body surface area (TBSA), and comorbidities. Based on BEACON analyses, LOS was assumed to represent 70% of total costs and used as a proxy to assess the data. Mean LOS, costs, and the incremental revenue associated with inpatient capacity changes were calculated.

RESULTS

A total of 151 ASCS and 2443 STSG patients were identified: 63.0% were male and average age was 44.5 years. Eight-one matches were made between cohorts. LOS was 21.7 days with ASCS and 25.0 days with STSG alone (difference 3.3 days [13.2%]). LOS was lower with ASCS than STSG in four of five TBSA intervals. The LOS difference led to hospital bed cost savings of $25,864 per ASCS patient; overall cost savings were $36,949 per patient. Similar cost savings were observed in TBSA groupings < 20% and ≥ 20%. The reduced LOS with ASCS translated into an increased capacity of 2.2 inpatients/bed annually, which increased hospital revenue by $92,283/burn unit bed annually.

CONCLUSIONS

Real-world data show that ASCS (± STSG) is associated with reduced LOS and cost savings versus STSG alone across all burn sizes, supporting the validity of the BEACON analyses. ASCS use may also increase patient capacity and throughput, leading to increased hospital revenue.

Vaccine wastage and cost saving after multi-dose vial policy implementation in Egypt: A success story

BACKGROUND

Prevention of disease through vaccination is one of the greatest public health successes. The Expanded Program of Immunization (EPI) previous policy stated that all vaccines had opened for immunization session had to be discarded at the end of the session, regardless to the type of the vaccine or the number of doses remaining in the vial. To bring wastage rate down, the WHO multi-dose vial policy (MDVP) was introduced. It stated that multi dose liquid vaccine vials, from which one or more doses have been administered, may be used for subsequent immunization session up to 28 days in the recommended manufacture storage conditions provided that certain condition must be met. The EPI in Egypt had adopted the MDVP in 2016. The current study aimed to evaluate the impact of implementation MDVP on vaccine wastage rate in Alexandria, and to estimate the cost reduction after that policy.

METHODS

Information regarding to vaccine doses consumed and children vaccinated were retrieved from medical districts and primary health care units for the period from January 1st 2014 to October 31st 2018. Interrupted time series design with control was conducted to determine the level change and trend change for the policy vaccines and for estimating the average cost saved after the policy.

RESULTS

The adoption of MDVP led to a significant reduction in the wastage rates of Pentavalent vaccine by 84.7%, DPT vaccine by 82.5% and OPV by 32%. Thus, by implementation of MDVP the estimated annual cost saved for the policy vaccine in all Egypt could be USD2,449,07995%CI826,076to12,219,869.

CONCLUSION

The implementation of MDVP in Alexandria made a significant reduction in the vaccine wastage rate which led to a saving in vaccine requirement and by consequence a cost saved.

Virtual Visits for Outpatient Burn Care during the COVID-19 Pandemic

Burn-injured patients must frequently travel long distances to regional burn centers, creating a burden on families and impairing clinical outcomes. Recent federal policies in response to the coronavirus pandemic have relaxed major barriers to conducting synchronous videoconference visits in the home. However, the efficacy and benefits of virtual visits relative to in-person visits remained unclear for burn patients. Accordingly, a clinical quality assurance database maintained during the coronavirus pandemic (3/3/2020 to 9/8/2020) for virtual and/or in-person visits at a comprehensive adult and pediatric burn center was queried for demographics, burn severity, visit quality, and distance data. A total of 143 patients were included in this study with 317 total outpatient encounters (61 virtual and 256 in-person). The savings associated with the average virtual visit were 130 ± 125 miles (mean ± standard deviation), 164 ± 134 travel minutes, &104 ± 99 driving costs, and &81 ± 66 foregone wage earnings. Virtual visit technical issues were experienced by 23% of patients and were significantly lower in pediatric (5%) than in adult patients (44%; p=0.006). This study is the first to assess the efficacy of synchronous videoconference visits in the home setting for outpatient burn care. The findings demonstrate major financial and temporal benefits for burn patients and their families. Technical issues remain an important barrier, particularly for the adult population. A clear understanding of these and other barriers may inform future studies as healthcare systems and payors move toward improving access to burn care through remote healthcare delivery services.

An economic model to assess the value of triclosan-coated sutures in reducing the risk of surgical site infection in a mastectomy in India

BACKGROUND

The comparison of triclosan-coated sutures (TCS) was made with conventional nonantimicrobial-coated sutures (NCS) to reduce surgical site infection (SSI). This study demonstrates the efficacy and economic outcome of TCS versus NCS for SSIs in mastectomy in India.

METHODS

In this retrospective analysis, 100 patients were included for both conditions-TCS and NCS-from a private and public hospital in India. A systematic literature search of available evidence for both SSI incidences and TCS efficacy data in India were gathered. We collected cost data from a private and public hospital, respectively, for mastectomy in India. The cost-effectiveness of TCS in comparison with the conventional NCS was calculated using a decision-tree deterministic model. We performed a one-way sensitivity analysis to compare TCS with NCS.

RESULTS

Cost savings with the use of TCS increased with an increase in SSI incidence and an increase in efficacy for mastectomies in both public and private hospitals. We found a base cost saving of Indian rupees (INR) 27,299 at a private hospital and INR 2,958 at a public hospital for mastectomies. The incremental cost of TCS suture was 0.01% in a private hospital whereas 0.17% in a public hospital.

CONCLUSION

The use of TCS resulted in reduced SSI incidence and cost savings for mastectomy in India.

Enhancing the value of the sFlt-1/PlGF ratio for the prediction of preeclampsia: Cost analysis from the Belgian healthcare payers' perspective

OBJECTIVE

To evaluate the economic impact of introducing the soluble fms-like tyrosine kinase (sFlt-1) to placental growth factor (PlGF) ratio test into clinical practice in Belgium for the prediction of preeclampsia (PE).

STUDY DESIGN

We developed a one-year time-horizon decision tree model to evaluate the short-term costs associated with the introduction of the sFlt-1/PlGF test for guiding the management of women with suspected PE from the Belgian public healthcare payers' perspective. The model estimated the costs associated with the diagnosis and management of PE in pregnant women managed in either a test scenario, in which the sFlt-1/PlGF test is used in addition to current clinical practice, or a no test scenario, in which clinical decisions are based on current practice alone. Test characteristics were derived from PROGNOSIS, a non-interventional study in women presenting with clinical suspicion of PE. Unit costs were obtained from Belgian-specific sources. The main model outcome was the total cost per patient.

RESULTS

Introduction of the sFlt-1/PlGF ratio test is expected to result in a cost saving of €712 per patient compared with the no test scenario. These savings are generated mainly due to a reduction in unnecessary hospitalizations.

CONCLUSIONS

The sFlt-1/PlGF test is projected to result in substantial cost savings for the Belgian public healthcare payers through reduction of unnecessary hospitalization of women with clinical suspicion of PE that ultimately do not develop the condition. The test also has the potential to ensure that women at high risk of developing PE are identified and appropriately managed.

A cost-effectiveness evaluation of Dance to Health: a dance-based falls prevention exercise programme in England

OBJECTIVES

This study aimed to evaluate whether the falls prevention programme Dance to Health provides the health system with an effective and cost-effective means to address the issue of older people's falls.

STUDY DESIGN

This study used a pre-post design; that is, the same assessment measures were used both before and after the programme.

METHODS

Analysis and modelling were conducted using monitoring data (frequencies including session attendance, falls, general practitioner (GP) and hospital visits), comprehensive financial information (including all costs related to the delivery of Dance to Health), and the Public Health England economic model: 'A return on investment tool for falls prevention programmes in older people based in the community'.

RESULTS

Findings from the research show that under the suggested health intervention, there was a 58% reduction in the number of falls. Furthermore, the results also demonstrate that Dance to Health offers a potential cost saving of more than £196m over a 2-year period, of which £158m is a potential cost saving for the NHS.

CONCLUSIONS

The evidence outlines that Dance to Health offers the health system a cost-effective means to address the issue of older people's falls and most importantly a method that produces strong results in terms of falls prevention.

Patient Access to an Online Portal for Outpatient Radiological Images and Reports: Two Years' Experience

To assess the incidence of outpatient examinations delivered through a web portal in the Latium Region in 2 years and compare socio-demographic characteristics of these users compared to the total of examinations performed. All radiological exams (including MRI, X-ray and CT) performed from March 2017 to February 2019 were retrospectively analysed. For each exam, anonymized data of users who attended the exam were extracted and their characteristics were compared according to digital access to the reports. Overall, 9068 exams were performed in 6720 patients (55.8% males, median age 58 years, interquartile range (IQR) 46-70) of which 90.2% residents in Rome province, mainly attending a single radiological examination (77.3%). Among all exams, 446 (4.9%) were accessed, of which 190 (4.4%) in the first and 5.4% in the second year (p < 0.041). MRI was the type of exams mostly accessed (175, 7.0%). Being resident in the provinces of the Latium Region other than Rome was associated with a higher access rate (OR = 1.84, p = 0.001). Considering the overall costs sustained to implement a web portal which allows users a personal access to their own reports, if all users would have accessed/downloaded their exams, an overall users' and hospital savings up to €255,808.28 could have been determined. The use of a web portal could represent a consistent economical advantage for the user, the hospital and the environment. Even if increasing over time, the use of web portal is still limited and strategies to increase the use of such systems should be implemented.

Routine Use of Contrast on Admission Transthoracic Echocardiography for Heart Failure Reduces the Rate of Repeat Echocardiography during Index Admission

BACKGROUND

The authors retrospectively evaluated the impact of ultrasound enhancing agent (UEA) use in the first transthoracic echocardiographic (TTE) examination, regardless of baseline image quality, on the number of repeat TTEs and length of stay (LOS) during a heart failure (HF) admission.

METHODS

There were 9,115 HF admissions associated with admission TTE examinations over a 4-year period (5,337 men; mean age, 67.6 ± 15.0 years). Patients were grouped into those who received UEAs (contrast group) in the first TTE study and those who did not (noncontrast group). Repeat TTE examinations were classified as justified if performed for concrete clinical indications during hospitalization.

RESULTS

In the 9,115 admissions for HF (5,600 in the contrast group, 3,515 in the noncontrast group), 927 patients underwent repeat TTE studies (505 in the contrast group, 422 in the noncontrast group), which were considered justified in 823 patients. Of the 104 patients who underwent unjustified repeat TTE studies, 80 (76.7%) belonged to the noncontrast group and 24 to the contrast group. Also, UEA use increased from 50.4% in 2014 to 74.3%, and the rate of unjustified repeat studies decreased from 1.3% to 0.9%. The rates of unjustified repeat TTE imaging were 2.3% and 0.4% (in the noncontrast and contrast groups, respectively), and patients in the contrast group were less likely to undergo unjustified repeat examinations (odds ratio, 0.18; 95% CI, 0.12-0.29; P < .0001). The mean LOS was significantly lower in the contrast group (9.5 ± 10.5 vs 11.1 ± 13.7 days). The use of UEA in the first TTE study was also associated with reduced LOS (linear regression, β₁ = -0.47, P = .036), with 20% lower odds for odds of prolonged (>6 days) LOS.

CONCLUSIONS

The routine use of UEA in the first TTE examination for HF irrespective of image quality is associated with reduced unjustified repeat TTE testing and may reduce LOS during an index HF admission.

Modeling the Cost Savings of Continuous Pulse Oximetry and Capnography Monitoring of United States General Care Floor Patients Receiving Opioids Based on the PRODIGY Trial

INTRODUCTION

Despite the high incidence of respiratory depression on the general care floor and evidence that continuous monitoring improves patient outcomes, the cost-benefit of continuous pulse oximetry and capnography monitoring of general care floor patients remains unknown. This study modeled the cost and length of stay savings, investment break-even point, and likelihood of cost savings for continuous pulse oximetry and capnography monitoring of general care floor patients at risk for respiratory depression.

METHODS

A decision tree model was created to compare intermittent pulse oximetry versus continuous pulse oximetry and capnography monitoring. The model utilized costs and outcomes from the PRediction of Opioid-induced respiratory Depression In patients monitored by capnoGraphY (PRODIGY) trial, and was applied to a modeled cohort of 2447 patients receiving opioids per median-sized United States general care floor annually.

RESULTS

Continuous pulse oximetry and capnography monitoring of high-risk patients is projected to reduce annual hospital cost by $535,531 and cumulative patient length of stay by 103 days. A 1.5% reduction in respiratory depression would achieve a break-even investment point and justify the investment cost. The probability of cost saving is ≥ 80% if respiratory depression is decreased by ≥ 17%. Expansion of continuous monitoring to high- and intermediate-risk patients, or to all patients, is projected to reach a break-even point when respiratory depression is reduced by 2.5% and 3.5%, respectively, with a ≥ 80% probability of cost savings when respiratory depression decreases by ≥ 27% and ≥ 31%, respectively.

CONCLUSION

Compared to intermittent pulse oximetry, continuous pulse oximetry and capnography monitoring of general care floor patients receiving opioids has a high chance of being cost-effective.

TRIAL REGISTRATION

www.clinicaltrials.gov , Registration ID: NCT02811302.

Rising unemployment reduces the demand for healthcare services among people with cardiovascular disease: an Australian cohort study

Cardiovascular diseases (CVDs) remain a global health challenge due to number of deaths and use of healthcare services related to the condition. Although a plethora of studies have shown the impact of unemployment on health outcomes, evidence on the unemployment effects on the demand for expensive cardiac healthcare services is rare. This study exploits longitudinal cohort dataset to examine the impact of variations in local level unemployment rate on the demand for healthcare services among working aged people with CVD in Australia. Our findings show an inverse relationship between unemployment and the demand for healthcare services. Specifically, we find that a rising unemployment reduces the demand for primary and secondary healthcare services, with the largest effect observed for hospital admissions and hospitalisation days. We further show that rising unemployment at the local level has a greater impact on CVD patients with comorbidities and those who live in nonremote areas. Finally, our estimates suggest that increasing local level unemployment averts a substantial number of healthcare services use, leading to an unintended cost savings of $1.2 million to the health sector.

Evidence-Based Community Health Worker Program Addresses Unmet Social Needs And Generates Positive Return On Investment

Interventions that address socioeconomic determinants of health are receiving considerable attention from policy makers and health care executives. The interest is fueled in part by expected returns on investment. However, many current estimates of returns on investment are likely overestimated, because they are based on pre-post study designs that are susceptible to regression to the mean. We present a return-on-investment analysis that is based on a randomized controlled trial of Individualized Management for Patient-Centered Targets (IMPaCT), a standardized community health worker intervention that addresses unmet social needs for disadvantaged people. We found that every dollar invested in the intervention would return $2.47 to an average Medicaid payer within the fiscal year.

When Should Medicare Mandate Participation In Alternative Payment Models?

The Centers for Medicare and Medicaid Services continues to propose and implement alternative payment models (APMs) to shift Medicare payment away from fee-for-service and toward approaches that emphasize health care value. As APMs expand in scope, one critical question is whether they should engage providers on a voluntary or a mandatory basis. Clinicians and policy makers may view the benefits and drawbacks of these two modes of participation differently. In this Analysis we compare the benefits and drawbacks of mandatory and voluntary participation, based on clinical versus policy perspectives, and we argue that both modes are necessary for APMs to achieve the goal of improving value. Policy makers should match the mode of participation and related financial incentives to each clinical scenario in which an APM is implemented. We propose ways to coordinate mandatory and voluntary APMs based on clinical scenarios.

Is sterile exposure in perianal procedures necessary? A single-institution experience and results from a national survey

BACKGROUND

Surgical site infections (SSI) are the most common postoperative complications. To minimize the risk of SSI, there is a strict asepsis policy in the operating theatre. The aim of this study was to evaluate the risk and cost-saving benefit of performing perianal surgery in a non-sterile setting.

METHODS

All patients who had perianal surgery at our institution between January 2014 and December 2017 in a sterile (S) or non-sterile (NS) setting for an infectious or non-infectious cause were included. The primary outcome was the 30-day SSI rate. The secondary outcome was the reintervention rate. A questionnaire was sent to surgeons in the Netherlands to assess current policy with regard to asepsis in perianal procedures. Finally, a cost analysis was performed.

RESULTS

In total, 376 patients were included. The rate of SSI in infectious procedures was 13% (S) versus 14% (NS, p = 0.853) and 5.1% (S) versus 0.9% (NS) in non-infectious procedures (p = 0.071). Reintervention rates in infectious procedures were 3.4% (S) versus 8.6% (NS, p = 0.187) and 1.3% (S) versus 0.0% (NS) in non-infectious procedures (p = 0.227). The questionnaire revealed that most surgeons perform perianal surgery in a sterile setting although they did not consider this useful. The potential national cost-saving benefit of a non-sterile setting is €124.61 per patient.

CONCLUSIONS

This study suggests that it is safe to perform perianal surgery in a non-sterile setting with regard to the SSI and reintervention rate. Adjustment of the current practice will contribute to a reduction in healthcare expenses.

Beyond ratios - flexible and resilient nurse staffing options to deliver cost-effective hospital care and address staff shortages: A simulation and economic modelling study

BACKGROUND

In the face of pressure to contain costs and make best use of scarce nurses, flexible staff deployment (floating staff between units and temporary hires) guided by a patient classification system may appear an efficient approach to meeting variable demand for care in hospitals.

OBJECTIVES

We modelled the cost-effectiveness of different approaches to planning baseline numbers of nurses to roster on general medical/surgical units while using flexible staff to respond to fluctuating demand.

DESIGN AND SETTING

We developed an agent-based simulation, where hospital inpatient units move between being understaffed, adequately staffed or overstaffed as staff supply and demand (as measured by the Safer Nursing Care Tool patient classification system) varies. Staffing shortfalls are addressed by floating staff from overstaffed units or hiring temporary staff. We compared a standard staffing plan (baseline rosters set to match average demand) with a higher baseline 'resilient' plan set to match higher than average demand, and a low baseline 'flexible' plan. We varied assumptions about temporary staff availability and estimated the effect of unresolved low staffing on length of stay and death, calculating cost per life saved.

RESULTS

Staffing plans with higher baseline rosters led to higher costs but improved outcomes. Cost savings from lower baseline staff mainly arose because shifts were left understaffed and much of the staff cost saving was offset by costs from longer patient stays. With limited temporary staff available, changing from low baseline flexible plan to the standard plan cost £13,117 per life saved and changing from the standard plan to the higher baseline 'resilient' plan cost £8,653 per life saved. Although adverse outcomes from low baseline staffing reduced when more temporary staff were available, higher baselines were even more cost-effective because the saving on staff costs also reduced. With unlimited temporary staff, changing from low baseline plan to the standard cost £4,520 per life saved and changing from the standard plan to the higher baseline cost £3,693 per life saved.

CONCLUSION

Shift-by-shift measurement of patient demand can guide flexible staff deployment, but the baseline number of staff rostered must be sufficient. Higher baseline rosters are more resilient in the face of variation and appear cost-effective. Staffing plans that minimise the number of nurses rostered in advance are likely to harm patients because temporary staff may not be available at short notice. Such plans, which rely heavily on flexible deployments, do not represent an efficient or effective use of nurses.

STUDY REGISTRATION

ISRCTN 12307968 Tweetable abstract: Economic simulation model of hospital units shows low baseline staff levels with high use of flexible staff are not cost-effective and don't solve nursing shortages.

The effect of reduced scan time on response assessment FDG-PET/CT imaging using Deauville score in patients with lymphoma

PURPOSE

[18F]Fluoro-deoxy-glucose positron emission tomography/computed tomography (FDG-PET/CT) is used for response assessment during therapy in Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL). Clinicians report the scans visually using Deauville criteria. Improved performance in modern PET/CT scanners could allow for a reduction in scan time without compromising diagnostic image quality. Additionally, patient throughput can be increased with increasing cost-effectiveness. We investigated the effects of reducing scan time of response assessment FDG-PET/CT in HL and NHL patients on Deauville score (DS) and image quality.

METHODS

Twenty patients diagnosed with HL/NHL referred to a response assessment FDG-PET/CT were included. PET scans were performed in list-mode with an acquisition time of 120 s per bed position(s/bp). From PET list-mode data images with full acquisition time of 120 s/bp and shorter acquisition times (90, 60, 45, and 30 s/bp) were reconstructed. All images were assessed by two specialists and assigned a DS. We estimated the possible savings when reducing scan time using a simplified model based on assumed values/costs for our hospital.

RESULTS

There were no significant changes in the visually assessed DS when reducing scan time to 90 s/bp, 60 s/bp, 45 s/bp, and 30 s/bp. Image quality of 90 s/bp images were rated equal to 120 s/bp images. Coefficient of variance values for 120 s/bp and 90 s/bp images was significantly < 15%. The estimated annual savings to the hospital when reducing scan time was 8000-16,000 €/scanner.

CONCLUSION

Acquisition time can be reduced to 90 s/bp in response assessment FDG-PET/CT without compromising Deauville score or image quality. Reducing acquisition time can reduce costs to the clinic.

The Financial Impact of an Inpatient Diabetes Management Service

CONTEXT

Diabetes is a leading metabolic disorder with a substantial cost burden, especially in inpatient settings. The complexity of inpatient glycemic management has led to the emergence of inpatient diabetes management service (IDMS), a multidisciplinary team approach to glycemic management.

OBJECTIVE

To review recent literature on the financial and clinical impact of IDMS in hospital settings.

METHODS

We searched PubMed using a combination of controlled vocabulary and keyword terms to describe the concept of IDMS and combined the search terms with a comparative effectiveness filter for costs and cost analysis developed by the National Library of Medicine.

FINDINGS

In addition to several improved clinical endpoints such as glycemic management outcomes, IDMS implementation is associated with hospital cost savings through decreased length of stay, preventing hospital readmissions, hypoglycemia reduction, and optimizing resource allocation. There are other downstream potential cost savings in long-term patient health outcomes and avoidance of litigation related to suboptimal glycemic management.

CONCLUSION

IDMS may play an important role in helping both academic and community hospitals to improve the quality of diabetes care and reduce costs. Clinicians and policymakers can utilize existing literature to build a compelling business case for IDMS to hospital administrations and state legislatures in the era of value-based healthcare.

Minimally important difference in cost savings: Is it possible to identify an MID for cost savings?

As healthcare costs continue to increase, studies assessing costs are becoming increasingly common, but researchers planning for studies that measure costs differences (savings) encounter a lack of literature or consensus among researchers on what constitutes "small" or "large" cost savings for common measures of resource use.  Other fields of research have developed approaches to solve this type of problem. Researchers measuring improvement in quality of life or clinical assessments have defined minimally important differences (MID) which are then used to define magnitudes when planning studies. Also, studies that measure cost effectiveness use benchmarks, such as cost/QALY, but do not provide benchmarks for cost differences. In a review of the literature, we found no publications identifying indicators of magnitude for costs. However, the literature describes three approaches used to identify minimally important outcome differences: (1) anchor-based, (2) distribution-based, and (3) a consensus-based Delphi methods. In this exploratory study, we used these three approaches to derive MID for two types of resource measures common in costing studies for: (1) hospital admissions (high cost); and (2) clinic visits (low cost). We used data from two (unpublished) studies to implement the MID estimation. Because the distributional characteristics of cost measures may require substantial samples, we performed power analyses on all our estimates to illustrate the effect that the definitions of "small" and "large" costs may be expected to have on power and sample size requirements for studies. The anchor-based method, while logical and simple to implement, may be of limited value in cases where it is difficult to identify appropriate anchors. We observed some commonalities and differences for the distribution and consensus-based approaches, which require further examination. We recommend that in cases where acceptable anchors are not available, both the Delphi and the distribution-method of MID for costs be explored for convergence.

Greening the office: Saving resources, saving money, and educating our patients

OBJECTIVE

Dermatologists can benefit from adopting environmental sustainability in the management of their practices. We can also use opportunities to share best practices in environmental stewardship concepts with our colleagues, patients, and communities. Herein, we review easy steps for any health care professional, and dermatologists in particular, to adopt environmental sustainability and become more active in the fight against climate change.

METHODS

This study included a select literature review, an identification of resources, and an overview of MyGreenDoctor.org.

RESULTS

Many simple, cost effective, energy saving resources were identified. A reference list of climate change resources for health are organizations to help with lower their carbon footprints, educating their staff and patients, and advocacy for better environmental stewardship is presented.

CONCLUSION

Going green is an easy process that can save money, boost morale, and help educate patients while reducing the carbon footprint of any size medical practice.

Reducing cost and waste in pediatric laparoscopic procedures

BACKGROUND

In 2017 the healthcare cost in the United States accounted for 17.9% of the Gross Domestic Product (GDP). Furthermore, healthcare facilities produce more than 4 billion pounds of waste annually. Interhospital and intersurgeon variabilities in surgical procedures are some of the drivers of high healthcare cost and waste. We sought to determine the effect of a monthly surgeon report card detailing the utilization and cost of disposable and reusable surgical supplies on cost and waste reduction for pediatric laparoscopic procedures.

METHODS

Starting in July 2017, surgeons were provided with an individual report with supply cost per case, high cost, and disposable supply utilization, and clinical outcomes. Cost, utilization, and clinical outcomes six quarters before and after the intervention were compared.

RESULTS

A total of 998 pediatric laparoscopic procedures were analyzed. We reduced the median supply cost per case by 43% after the intervention with total cost savings of $71,035 for the first four quarters. We also reduced the use of disposable trocars by 56% and the use of disposable harmonics and staplers by 33%.

CONCLUSIONS

Using a periodic surgeon report card, we significantly reduced supply cost and utilization of disposable items for all pediatric laparoscopic procedures performed at the University of Wisconsin American Family Children's Hospital.

TYPE OF STUDY

Cost effectiveness study.

LEVEL OF EVIDENCE

Level III.