An Improvised Cost-Effective Repair Technique for Management of Broken Luer Connections of Tunneled Dialysis Catheter and Salvage Existing Catheter

Mechanical problems like break or crack in Luer connectors or hubs, clamps, and tubings are common non-infectious complications of tunneled dialysis catheters (TDC), which may lead to other TDC complications and the need to insert a new catheter. These can be tackled using TDC repair kits or spare parts, which are often not available, resulting in the insertion of a new TDC that increases morbidity, TDC-related procedures, and healthcare costs. We discuss two cases of broken Luer connections of TDC, which were managed by exchanging the broken Luer connector of TDC with the similar Luer connector of a temporary dialysis catheter. Both the repaired TDCs are thereafter functioning well. This improvised technique provides an easy, effective, long-lasting option that salvages the existing TDC and reduces the cost factor.

Outcomes and Cost Evaluation Related to a Single-Use, Disposable Ureteric Stent Removal System: a Systematic Review of the Literature

PURPOSE OF REVIEW

To present the latest evidence related to the outcomes and cost of single-use, disposable ureteric stent removal system (Isiris).

RECENT FINDINGS

Our review suggests that compared to a reusable flexible cystoscope (re-FC), a disposable flexible cystoscope (d-FC) with built-in grasper (Isiris) significantly reduced procedural time and provided a cost benefit when the latter was used in a ward or outpatient clinic-based setting. The use of d-FC also allowed endoscopy slots to be used for other urgent diagnostic procedures. Disposable FCs are effective and safe for ureteric stent removal. They offer greater flexibility and, in most cases, have been demonstrated to be cost-effective compared to re-FCs. They are at their most useful in remote, low-volume centres, in less well-developed countries and in centres where large demand is placed on endoscopy resources.

Effect of infusion set replacement intervals on catheter-related bloodstream infections (RSVP): a randomised, controlled, equivalence (central venous access device)-non-inferiority (peripheral arterial catheter) trial

BACKGROUND

The optimal duration of infusion set use to prevent life-threatening catheter-related bloodstream infection (CRBSI) is unclear. We aimed to compare the effectiveness and costs of 7-day (intervention) versus 4-day (control) infusion set replacement to prevent CRBSI in patients with central venous access devices (tunnelled cuffed, non-tunnelled, peripherally inserted, and totally implanted) and peripheral arterial catheters.

METHODS

We did a randomised, controlled, assessor-masked trial at ten Australian hospitals. Our hypothesis was CRBSI equivalence for central venous access devices and non-inferiority for peripheral arterial catheters (both 2% margin). Adults and children with expected greater than 24 h central venous access device-peripheral arterial catheter use were randomly assigned (1:1; stratified by hospital, catheter type, and intensive care unit or ward) by a centralised, web-based service (concealed before allocation) to infusion set replacement every 7 days, or 4 days. This included crystalloids, non-lipid parenteral nutrition, and medication infusions. Patients and clinicians were not masked, but the primary outcome (CRBSI) was adjudicated by masked infectious diseases physicians. The analysis was modified intention to treat (mITT). This study is registered with the Australian New Zealand Clinical Trials Registry ACTRN12610000505000 and is complete.

FINDINGS

Between May 30, 2011, and Dec, 9, 2016, from 6007 patients assessed, we assigned 2944 patients to 7-day (n=1463) or 4-day (n=1481) infusion set replacement, with 2941 in the mITT analysis. For central venous access devices, 20 (1·78%) of 1124 patients (7-day group) and 16 (1·46%) of 1097 patients (4-day group) had CRBSI (absolute risk difference [ARD] 0·32%, 95% CI -0·73 to 1·37). For peripheral arterial catheters, one (0·28%) of 357 patients in the 7-day group and none of 363 patients in the 4-day group had CRBSI (ARD 0·28%, -0·27% to 0·83%). There were no treatment-related adverse events.

INTERPRETATION

Infusion set use can be safely extended to 7 days with resultant cost and workload reductions.

FUNDING

Australian National Health and Medical Research Council.

Patient-Directed Home Drain Removal in Head and Neck Surgery

OBJECTIVES/HYPOTHESIS

The purpose of this study was to evaluate the efficacy and safety of at home drain removal in head and neck surgery patients.

METHODS

The study population included patients who underwent head and neck surgery at an academic tertiary care center between February 2020 and November 2020 and were discharged with one to four drains with instructions for home removal. Prior to discharge, patients received thorough drain removal education. Patients were prospectively followed to evaluate for associated outcomes.

RESULTS

One hundred patients were evaluated in the study. There was record for ninety-seven patients receiving education at discharge. The most common methods of education were face-to-face education and written instructions with educational video link provided. Of 123 drains upon discharge, 110 drains (89.4%) were removed at home while 13 (10.6%) were removed in office. Most drains were located in the neck (86.4%). There was one seroma, two hematomas, two drain site infections, and five ED visits; however, none of these complications were directly associated with the action of drain removal at home. Calculated cost savings for travel and lost wages was $259.82 per round trip saved.

CONCLUSIONS

The results demonstrate that home drain removal can provide a safe and efficacious option for patients following head and neck surgery. This approach was safe and associated with patient cost savings and better utilization of provider's time. Furthermore, patients and healthcare providers avoided additional in-person encounters and exposures during the COVID-19 pandemic. Our findings warrant further investigation into cost savings and formal patient satisfaction associated with home drain removal.

LEVEL OF EVIDENCE

4 Laryngoscope, 2021.

Cardiac implantable electronic device (CIED) infections are expensive and associated with prolonged hospitalisation: UK Retrospective Observational Study

Background

There are limited reports outlining the financial cost of treating cardiac implantable electronic device (CIED) infection outside the United States. This study aimed to determine the average treatment cost of CIED infection in a large UK tertiary referral centre and compared costs of different treatment pathways that are recognised in the management of CIED infection (early versus delayed re-implantation).

Methods

We retrospectively analysed cost and length of stay (LOS) data for consecutive patients undergoing infected CIED extraction with cardiac resynchronization therapy (CRT-D [with defibrillator], CRT-P [with pacemaker]), implantable cardioverter-defibrillators (ICDs) and permanent pacemakers (PPMs).

Results

Between January 2013 and March 2015, complete data was available for 84 patients (18 [21.4%] CRT-D, 24 [28.6%] ICDs and 42 [50.0%] PPMs). When all cases were considered the cost of infection ranged from £5,139 (PPM) to £24,318 (CRT-D). Considering different treatment strategies; 41 (48.8%) underwent CIED extraction and re-implantation during the same admission (early re-implant strategy (ER). 43 (51.2%) underwent extraction, but were then discharged home to be re-admitted for day-case re-implantation (delayed re-implant strategy (DR)). Median LOS was significantly shorter in DR compared to ER (5.0 vs. 18.0 days, p<0.001). The total cost of CIED infection episode was similar for both treatment strategies (median £14,241.48 vs. £14,741.70 including wearable defibrillator (Lifevest) and outpatient antibiotics costs, ER vs. DR; p = 0.491).

Conclusion

CIED infections are expensive and associated with significant health-economic burden. When all device types were considered, a DR strategy is associated with reduced LOS without an increased cost penalty.

[Economic Analysis of the Costs of Hospital Stay of Patients with Infection as a Complication of Total Replacements - Part 2: Total Hip Arthroplasty]

PURPOSE OF THE STUDY The study aims to quantify the costs of a hospital stay of patients with periprosthetic joint infection after total hip arthroplasty throughout the period of treatment. MATERIAL AND METHODS The group included patients who have been treated at our department for infection as a complication of total hip replacement since 1 January 2011, who have been provided with treatment (including complications) exclusively at the departments of Nemocnice České Budějovice, a.s. and whose treatment can be considered completed in 2019. The patients were included in the study regardless of the type of infection and method of treatment. The group consisted of 36 patients (16 men and 20 women). There were 3 cases of early postoperative infection, 14 cases of late postoperative infection and 19 cases of hematogenous infection. The group includes 8 patients treated by a one-stage reimplantation, 19 patients managed by a two-stage reimplantation, 6 patients treated by a revision surgery with implant retention, and 3 patients in whom only the implant removal was possible. In selected patients, all the reported points for all the hospital stays and costs incurred on a separately charged material were ascertained and the final sum was compared with the reimbursement obtained by the hospital in the DRG system valid for the respective year of treatment. The total costs were analysed and also an analysis by type of infection and method of treatment was carried out. RESULTS The average costs of managing infection as a complication of total hip arthroplasty at our department amounted to CZK 320 065 (CZK 56 995 - CZK 953 614), the reimbursement in respect of the monitored cases in the DRG system equalled CZK 220 503 (CZK 89 149 - CZK 589 974). The aforementioned suggests that the average loss per treated patient is CZK 99 562 (CZK + 63 372 - CZK -428 499). DISCUSION Care associated with infections as a complication of total hip arthroplasty is very costly and these costs are not fully covered by the reimbursement from the health insurance companies. In the Czech Republic, these costs have not been quantified as yet, therefore it is only possible to compare the costs with international publications arriving at similar conclusions and with own monitoring of the costs of periprosthetic joint infections after total hip arthroplasty. The most economically efficient is the one-stage replacement which, however, is not suitable for all the patients, and the two-stage reimplantation continues to be the gold standard. In our study, the most expensive was found to be the treatment of periprosthetic joint infection after total hip arthroplasty, in which also the highest financial loss is reported. CONCLUSIONS Due to the very high costs of treatment for periprosthetic joint infections after total hip arthroplasty, it is necessary to exert maximum efforts to prevent periprosthetic joint infections and to consider a change in the method of financing, particularly in centres to which patients are referred from other centres in order to make this treatment economically viable. Key words:total hip arthroplasty, PJI - periprosthetic joint infection, economic analysis.

Current treatment status and medical costs for hemodialysis vascular access based on analysis of the Korean Health Insurance Database

BACKGROUND/AIMS

The Republic of Korea is a country where the hemodialysis population is growing rapidly. It is believed that the numbers of treatments related to vascular access-related complications are also increasing. This study investigated the current status of treatment and medical expenses for vascular access in Korean patients on hemodialysis.

METHODS

This was a descriptive observational study. We inspected the insurance claims of patients with chronic kidney disease who underwent hemodialysis between January 2008 and December 2016. We calculated descriptive statistics of the frequencies and medical expenses of procedures for vascular access.

RESULTS

The national medical expenses for access-related treatment were 7.12 billion KRW (equivalent to 6.36 million USD) in 2008, and these expenses increased to 42.12 billion KRW (equivalent to 37.67 million USD) in 2016. The population of hemodialysis patients, the annual frequency of access-related procedures, and the total medical cost for access-related procedures increased by 1.6-, 2.6-, and 5.9-fold, respectively, over the past 9 years. The frequency and costs of access care increased as the number of patients on hemodialysis increased. The increase in vascular access-related costs has largely been driven by increased numbers of percutaneous angioplasty.

CONCLUSION

The increasing proportion of medical costs for percutaneous angioplasty represents a challenge in the management of end-stage renal disease in Korea. It is essential to identify the clinical and physiological aspects as well as anatomical abnormalities before planning angioplasty. A timely surgical correction could be a viable option to control the rapid growth of access-related medical expenses.

Magnetic Stent Removal in a Nurse Led Clinic; a Nine Month Experience

Ureteric stents are frequently inserted post endourological procedures. However, subsequent endoscopic stent removal requires a second procedure for the patient and the availability of necessary resources. Longer duration of indwelling stents can lead to increased risk of symptoms and complications. The use of magnetic stents removed with a magnetic retrieval device (BlackStar©), offers an alternative which obviates the need for cystoscopy. We assessed the outcomes for this novel method of stent removal in our institution. A retrospective analysis was performed of all patients undergoing magnetic stent insertion and subsequent removal in a nurse-led clinic over a nine-month period. Patients were followed up with a prospective validated Ureteral Stent Symptoms Questionnaire (USSQ)3. A cost analysis was also performed. In total, 59 patients were treated using magnetic stents. The complication rate was low (6.7%). The median duration of indwelling stent was 5.8 days (range 1-11 days). Patients reported haematuria and lower urinary tract symptoms but >90% experienced no functional impairment with minimal days of employment lost (mean 0.75 days). All patients reported satisfaction with nurse-led stent removal and 97% were happy to have stents removed via this method in the future. The total financial savings were estimated at €47,790 over this period. Nurse-led removal of magnetic stents is safe and well tolerated by patients and enables expedient stent removal. It also provides a significant cost benefit and frees up valuable endoscopic resources.

Effect of battery longevity on costs and health outcomes associated with cardiac implantable electronic devices: a Markov model-based Monte Carlo simulation

Introduction

The effects of device and patient characteristics on health and economic outcomes in patients with cardiac implantable electronic devices (CIEDs) are unclear. Modeling can estimate costs and outcomes for patients with CIEDs under a variety of scenarios, varying battery longevity, comorbidities, and care settings. The objective of this analysis was to compare changes in patient outcomes and payer costs attributable to increases in battery life of implantable cardiac defibrillators (ICDs) and cardiac resynchronization therapy defibrillators (CRT-D).

Methods and results

We developed a Monte Carlo Markov model simulation to follow patients through primary implant, postoperative maintenance, generator replacement, and revision states. Patients were simulated in 3-month increments for 15 years or until death. Key variables included Charlson Comorbidity Index, CIED type, legacy versus extended battery longevity, mortality rates (procedure and all-cause), infection and non-infectious complication rates, and care settings. Costs included procedure-related (facility and professional), maintenance, and infections and non-infectious complications, all derived from Medicare data (2004–2014, 5% sample). Outcomes included counts of battery replacements, revisions, infections and non-infectious complications, and discounted (3%) costs and life years. An increase in battery longevity in ICDs yielded reductions in numbers of revisions (by 23%), battery changes (by 44%), infections (by 23%), non-infectious complications (by 10%), and total costs per patient (by 9%). Analogous reductions for CRT-Ds were 23% (revisions), 32% (battery changes), 22% (infections), 8% (complications), and 10% (costs).

Conclusion

Based on modeling results, as battery longevity increases, patients experience fewer adverse outcomes and healthcare costs are reduced. Understanding the magnitude of the cost benefit of extended battery life can inform budgeting and planning decisions by healthcare providers and insurers.

Electronic supplementary material

The online version of this article (10.1007/s10840-017-0289-8) contains supplementary material, which is available to authorized users.

Implant Failure Rates and Cost Analysis of Contoured Locking Versus Conventional Plate Fixation of Distal Fibula Fractures

The authors analyzed 330 consecutive Weber B distal fibula fractures that occurred during a 3-year period and were treated with either a contoured locking plate or a conventional one-third tubular plate to compare the cost and failure rates of the 2 constructs. The primary outcomes were failure of the distal fibular implant and loss of reduction. Secondary outcomes were surgical wound infection requiring surgical debridement and/or removal of the fibular implant, and removal of the fibular plate for persistent implant-related symptoms. No failure of the fibular plates or distal fibular fixation occurred in either group. A total of 5 patients required surgical revision of syndesmotic fixation within 4 weeks of the index surgery. Of these patients, 1 was in the contoured locking plate group and 4 were in the one-third tubular plate group (P=.610). The rate of deep infection requiring surgical debridement and/or implant removal was 6.2% in the contoured locking plate group and 1.4% in the one-third tubular plate group (P=.017). The rate of lateral implant removal for either infection or symptomatic implant was 9.3% in the contoured locking plate group and 2.3% in the one-third tubular plate group (P=.005). A typical contoured locking plate construct costs $800 more than a comparable one-third tubular plate construct. Based on a calculated estimate of 60,000 locking plates used annually in the United States, this difference translates to a potential avoided annual cost of $50 million nationally. This study demonstrates that it is possible to treat Weber B distal fibula fractures with one-third tubular plates at a substantially lower cost than that of contoured locking plates without increasing complications. [Orthopedics. 2017; 40(6):e1024-e1029.].

Incidence and Costs Related to Lead Damage Occurring Within the First Year After a Cardiac Implantable Electronic Device Replacement Procedure

BACKGROUND

Inadvertent damage to leads for transvenous pacemakers, implantable cardioverter-defibrillators, and cardiac resynchronization therapy defibrillators is an important complication associated with generator-replacement procedures. We sought to estimate the incidence and costs associated with transvenous lead damage following cardiac implantable electronic device replacement.

METHODS AND RESULTS

Using the Truven Health Analytics MarketScan Commercial Research Database, we identified health care claims between 2009 and 2013 for lead damage following generator replacement. Patients were identified by claims with a procedure code for cardiac implantable electronic device replacement and then evaluated for 1 year. All follow-up visits for lead damage were identified, and incidence, risk factors, and hospitalization costs were determined. A total of 22 557 patients with pacemakers, 20 632 with implantable cardioverter-defibrillators, and 2063 with cardiac resynchronization therapy defibrillators met selection criteria. Incidence of lead damage was 0.46% for pacemaker replacement, 1.27% for implantable cardioverter-defibrillator replacement, and 1.94% for cardiac resynchronization therapy defibrillator replacement procedures (P<0.001). After adjusting for patient characteristics, patients with implantable cardioverter-defibrillators and cardiac resynchronization therapy defibrillators demonstrated risk of lead damage that was, respectively, double (hazard ratio 2.00, 95% CI 1.57-2.55) and >2.5 times (hazard ratio 2.58, 95% CI 1.73-3.83) that of patients with pacemakers. Lead revision or repair procedures were associated with increased inpatient hospitalization costs (mean $19 959 for pacemaker, $24 885 for implantable cardioverter-defibrillator, and $46 229 for cardiac resynchronization therapy defibrillator; P=0.048, Kruskal-Wallis test).

CONCLUSIONS

These findings establish the first objective assessment of the incidence, risk factors, and economic burden of lead damage following cardiac implantable electronic device replacement in the United States. New care algorithms are warranted to avoid these events, which impose substantial burdens on patients, physicians, and payors.

Economic impact of syndesmosis hardware removal

Ankle syndesmosis injuries are commonly seen with 5-10% of sprains and 10% of ankle fractures involving injury to the ankle syndesmosis. Anatomic reduction has been shown to be the most important predictor of clinical outcomes. Optimal surgical management has been a subject of debate in the literature. The method of fixation, number of screws, screw size, and number of cortices are all controversial. Postoperative hardware removal has also been widely debated in the literature. Some surgeons advocate for elective hardware removal prior to resuming full weightbearing. Returning to the operating room for elective hardware removal results in increased cost to the patient, potential for infection or complication(s), and missed work days for the patient. Suture button devices and bioabsorbable screw fixation present other options, but cortical screw fixation remains the gold standard. This retrospective review was designed to evaluate the economic impact of a second operative procedure for elective removal of 3.5mm cortical syndesmosis screws. Two hundred and two patients with ICD-9 code for "open treatment of distal tibiofibular joint (syndesmosis) disruption" were identified. The medical records were reviewed for those who underwent elective syndesmosis hardware removal. The primary outcome measurements included total hospital billing charges and total hospital billing collection. Secondary outcome measurements included average individual patient operative costs and average operating room time. Fifty-six patients were included in the study. Our institution billed a total of $188,271 (USD) and collected $106,284 (55%). The average individual patient operating room cost was $3579. The average operating room time was 67.9 min. To the best of our knowledge, no study has previously provided cost associated with syndesmosis hardware removal. Our study shows elective syndesmosis hardware removal places substantial economic burden on both the patient and the healthcare system.

Increasing Frequency of Left Ventricular Assist Device Exchanges in the United States

BACKGROUND

Recent reports indicate an increased prevalence and earlier onset of pump thrombosis and associated pump exchanges after left ventricular assist device (LVAD) implantation. Questions remain regarding the current rate and clinical effect of pump exchanges.

METHODS

All United States Medicare fee-for-service patients undergoing LVAD implantations (n = 3,166) between January 2009 and December 2012 were identified by procedural codes present on carrier claims collected by the Centers for Medicare & Medicaid Services. Pump exchange, pump removal, heart transplantation, and death were collected from subsequent carrier claim and denominator files. Comorbidities present before implantation were generated using the Elixhauser comorbidity index.

RESULTS

Compared with patients who received LVADs before March 1, 2011, LVAD recipients after March 1, 2011, were older on average (63.9 vs 62.2 years, p < 0.01), more likely to be male (82.3% vs. 79.4%, p = 0.04), and had a higher incidence of common comorbidities. The later cohort had higher occurrence of pump exchange by Kaplan-Meier time-to-event estimates and Fisher exact tests at 3 months (1.8 vs 0.8, p = 0.02), 6 months (3.3 vs 1.0, p < 0.01), and 12 months (4.9 vs 2.2, p < 0.01). Cox regression analysis found time-dependent pump exchange was associated with worse survival (hazard ratio, 2.5; 95% confidence interval, 1.8 to 3.62; p < 0.01) after adjusting for age, gender, and comorbidities.

CONCLUSIONS

Although LVAD exchanges remain relatively uncommon, a significant increase in the incidence of the procedure has occurred since March 1, 2011. Pump exchanges are highly associated with death, and further research is required to understand the cause of this disturbing trend and surveillance to determine its trajectory.

Comparison of hospital length of stay, costs, and readmissions of alteplase versus catheter replacement among patients with occluded central venous catheters

BACKGROUND

Central venous catheter (CVC) occlusion is common, affecting 30% of all CVCs.

OBJECTIVE

To compare length of stay (LOS), costs, and readmissions associated with the use of alteplase to clear catheter blockage to outcomes associated with catheter replacement.

DESIGN

Retrospective observational study utilizing a large hospital database.

PARTICIPANTS

Hospitalized patients treated for catheter occlusion from January 2006 to December 2011.

MAIN MEASURES

Univariate analyses of patient characteristics and treatment patterns and multivariable regression analyses of postocclusion hospital costs, LOS, and 30- and 90-day readmissions were conducted.

KEY RESULTS

We included 34,579 patients treated for a CVC occlusion by replacement (N=1028) or by alteplase (2 mg) administration (N=33,551). Patients receiving alteplase were somewhat younger than those having catheter replacement (60 ± 19 vs 62 ± 20 years old, P=0.0002). After adjusting for patient and hospital factors via regression modeling, average daily postocclusion costs were $317 lower for alteplase recipients than for catheter replacement patients (95% confidence interval [CI]: 238.22-392.24; P<0.0001). Adjusted total postocclusion costs were $1419 lower for alteplase recipients versus patients receiving catheter replacement (95% CI: 307.27-2458.12; P=0.0121). Postocclusion operating room/surgery, radiology, and supply costs were significantly lower for alteplase recipients (P<0.001). Average adjusted postocclusion LOS was similar for both groups (P>0.05). Odds of readmission were not significantly different at 30 or 90 days.

CONCLUSIONS

Among patients treated for an occluded CVC, alteplase-treated patients had lower daily and total postocclusion costs than patients receiving catheter replacement. Cost differences were mainly driven by lower operating room/surgery, radiology, and supplier costs.

Might digital drains speed up the time to thoracic drain removal?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was: might digital drains speed up the time to thoracic drain removal in terms of time till chest drain removal, hospital stay and overall cost? A total of 296 papers were identified as a result of the search as described below. Of these, five papers provided the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of the papers are tabulated. A literature search revealed that several single-centre prospective randomized studies have shown significantly earlier removal of chest drains with digital drains ranging between 0.8 and 2.1 days sooner. However, there was heterogeneity in studies in the management protocol of chest drains in terms of the use of suction, number of drains and assessment for drain removal. Some protocols such as routinely keeping drains irrespective of the presence of air leak or drain output may have skewed results. Differences in exclusion criteria and protocols for discharging home with portable devices may have biased results. Due to heterogeneity in the management protocol of chest drains, there is conflicting evidence regarding hospital stay. The limited data on cost suggest that there may be significantly lower postoperative costs in the digital drain group. All the studies were single-centre series generally including patients with good preoperative lung function tests. Further larger studies with more robust chest drain management protocols are required especially to assess length of hospital stay, cost and whether the results are applicable to a larger patient population.

The societal costs of femoral neck fracture patients treated with internal fixation

SUMMARY

The study rationale was to provide a detailed overview of the costs for femoral neck fracture treatment with internal fixation in the Netherlands. Mean total costs per patient at 2-years follow-up were <euro>19,425. Costs were higher for older, less healthy patients. Results are comparable to internationally published costs.

INTRODUCTION

The aim of this study was to provide a detailed overview of the cost and healthcare consumption of patients treated for a hip fracture with internal fixation. A secondary aim was to compare costs of patients who underwent a revision surgery with patients who did not.

METHODS

The study was performed alongside the Dutch sample of an international randomized controlled trial, concerning femoral neck fracture patients treated with internal fixation. Patient characteristics and healthcare consumption were collected. Total follow-up was 2 years. A societal perspective was adopted. Costs included hospital costs during primary stay and follow-up, and costs related to rehabilitation and changes in living situation. Costs were compared between non-revision surgery patients, implant removal patients, and revision arthroplasty patients.

RESULTS

A total of 248 patients were included (mean age 71 years). Mean total costs per patient at 2-years follow-up were <euro>19,425. In the non-revision surgery patients total costs were <euro>17,405 (N = 137), in the implant removal patients <euro>10,066 (N = 38), and in the revision arthroplasty patients <euro>26,733 (N = 67). The main contributing costs were related to the primary surgery, admission days, physical therapy, and revision surgeries.

CONCLUSIONS

The main determinant was the costs of admission to a rehabilitation center/nursing home. Costs were specifically high in elderly with comorbidity, who were less independent pre-fracture, and have a longer admission to the hospital and/or a nursing home. Costs were also higher in revision surgery patients. The 2-years follow-up costs in our study were comparable to published costs in other Western societies.

Cost-effectiveness analysis of clinically indicated versus routine replacement of peripheral intravenous catheters

BACKGROUND

Millions of peripheral intravenous catheters are used worldwide. The current guidelines recommend routine catheter replacement every 72-96 h. This practice requires increasing healthcare resource use. The clinically indicated catheter replacement strategy is proposed as an alternative.

OBJECTIVES

To assess the cost effectiveness of clinically indicated versus routine replacement of peripheral intravenous catheters.

METHODS

A cost-effectiveness analysis from the perspective of Queensland Health, Australia, was conducted alongside a randomized controlled trial. Adult patients with an intravenous catheter of expected use for longer than 4 days were randomly assigned to receive either clinically indicated replacement or third-day routine replacement. The primary outcome was phlebitis during catheterization or within 48 h after catheter removal. Resource use data were prospectively collected and valued (2010 prices). The incremental net monetary benefit was calculated with uncertainty characterized using bootstrap simulations. Additionally, value of information (VOI) and value of implementation analyses were performed.

RESULTS

The clinically indicated replacement strategy was associated with a cost saving per patient of AU$7.60 (95% confidence interval [CI] 4.96-10.62) and a non-significant difference in the phlebitis rate of 0.41% (95% CI -1.33 to 2.15). The incremental net monetary benefit was AU$7.60 (95% CI 4.96-10.62). The expected VOI was zero, whereas the expected value of perfect implementation of the clinically indicated replacement strategy was approximately AU$5 million over 5 years.

CONCLUSION

The clinically indicated catheter replacement strategy is cost saving compared with routine replacement. It is recommended that healthcare organizations consider changing to a policy whereby catheters are changed only if clinically indicated.

Routine versus clinically indicated replacement of peripheral intravenous catheters: a randomised controlled equivalence trial

BACKGROUND

The millions of peripheral intravenous catheters used each year are recommended for 72-96 h replacement in adults. This routine replacement increases health-care costs and staff workload and requires patients to undergo repeated invasive procedures. The effectiveness of the practice is not well established. Our hypothesis was that clinically indicated catheter replacement is of equal benefit to routine replacement.

METHODS

This multicentre, randomised, non-blinded equivalence trial recruited adults (≥18 years) with an intravenous catheter of expected use longer than 4 days from three hospitals in Queensland, Australia, between May 20, 2008, and Sept 9, 2009. Computer-generated random assignment (1:1 ratio, no blocking, stratified by hospital, concealed before allocation) was to clinically indicated replacement, or third daily routine replacement. Patients, clinical staff, and research nurses could not be masked after treatment allocation because of the nature of the intervention. The primary outcome was phlebitis during catheterisation or within 48 h after removal. The equivalence margin was set at 3%. Primary analysis was by intention to treat. Secondary endpoints were catheter-related bloodstream and local infections, all bloodstream infections, catheter tip colonisation, infusion failure, catheter numbers used, therapy duration, mortality, and costs. This trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12608000445370.

FINDINGS

All 3283 patients randomised (5907 catheters) were included in our analysis (1593 clinically indicated; 1690 routine replacement). Mean dwell time for catheters in situ on day 3 was 99 h (SD 54) when replaced as clinically indicated and 70 h (13) when routinely replaced. Phlebitis occurred in 114 of 1593 (7%) patients in the clinically indicated group and in 114 of 1690 (7%) patients in the routine replacement group, an absolute risk difference of 0·41% (95% CI -1·33 to 2·15%), which was within the prespecified 3% equivalence margin. No serious adverse events related to study interventions occurred.

INTERPRETATION

Peripheral intravenous catheters can be removed as clinically indicated; this policy will avoid millions of catheter insertions, associated discomfort, and substantial costs in both equipment and staff workload. Ongoing close monitoring should continue with timely treatment cessation and prompt removal for complications.

FUNDING

Australian National Health and Medical Research Council.

[Extraction of chronically implanted transvenous pacing and defibrillator leads - cost analysis]

Due to the rapid increase in the number of patients with implanted pacemakers (PM) or cardioverter-defibrillators (ICD), the incidence of complications of this method of treatment also increases. In many cases the only solution is transvenous extraction of previously implanted PM/ICD system. The publication is an attempt to assess the real cost of performing such procedures.

Hydroview lens implant calcification: 186 exchanges at a district general hospital

AIM

This paper describes the experience at a district general hospital of coping with an abrupt onset of calcification of Hydroview intraocular lens (IOL) implants requiring exchange surgery mostly for symptoms of glare, even though the visual acuities were relatively good.

METHODS

In this retrospective study, the operative details of 174 consecutive lens exchanges by one surgeon were retrieved from the surgeon's notes. Of these, pre and post-operative details of 106 consecutive patients were obtained from the hospital notes.

RESULTS

Of the 174 lens exchanges, all were sutureless except one and 31 eyes (18%) had had previous capsulotomies. Of 143 eyes with intact posterior capsules, eight (5.6%) needed anterior vitrectomy. Lens replacements were in the bag in 136 (95%), in the sulcus in five (3.5%), and in the anterior chamber in two (1.5%). Of the 31 eyes with previous capsulotomies, 10 (32%) needed anterior vitrectomy. Lens replacements were in the bag in 22 (71%) and in the sulcus in the remaining nine cases (29%). Postoperatively the best-corrected visual acuity was improved in 53%, remained the same in 35%, and deteriorated in 12%.

CONCLUSION

The lens exchange procedure was mostly predictable with satisfactory visual results allowing preoperative counselling of risks to be similar to that for cataract surgery. The onset and resolution of the period of implantation of lenses requiring exchange has not been explained.

Repair of the pectus deformity: results of the Ravitch approach in the current era

BACKGROUND

Recent publications have advocated a minimally invasive approach to repair of the pectus deformity. Efforts to evaluate this new approach have been hampered by lack of comparative information regarding outcomes of the standard Ravitch approach. We use a modified Ravitch procedure, and present our series as a basis for comparison.

METHODS

Records of 69 consecutive patients undergoing repair of the pectus deformity were retrospectively reviewed. Modifications included a minimal incision and a new technique to address sternal angulation. A patient satisfaction survey evaluated the patients' perception of the outcome.

RESULTS

We found one wound infection (1.4%). Five patients (7.2%) had a seroma, and were treated as outpatients. Because the minimally invasive approach is used for pectus excavatum, we divided our series into excavatum and carinatum subsets. The subset of 44 pectus excavatum patients had a mean postoperative length of stay (LOS) of 2.9 days. The median patient satisfaction score was 4 on a scale of 1 to 5, at an average of 4.75 years after repair. The subset of 25 pectus carinatum patients had a mean LOS of 2.4 days and a median patient satisfaction score of 5.

CONCLUSIONS

The modified Ravitch procedure yields excellent results with low morbidity, hospital LOS, and cost, combined with high patient satisfaction. These current data will be useful for comparison as newer techniques for pectus repair continue to evolve.

Cost-effectiveness of three strategies of managing tunnelled, cuffed haemodialysis catheters in clinically mild or asymptomatic bacteraemias

BACKGROUND

Immediate tunnelled, cuffed catheter (TCC) removal is the current standard of care when bacteraemia is associated with severe clinical symptoms. When minimal or no symptoms are present, the optimal strategy of TCC management is controversial. The following three strategies have been proposed: TCC 'salvage' (antibiotic administration without TCC removal), TCC exchange over a guidewire with antibiotics or immediate TCC removal with delayed reinsertion and antibiotics.

METHODS

We developed a decision-analytic model to assess the cost-effectiveness of each strategy for episodes of TCC-associated bacteraemia presenting with minimal symptoms, in a hypothetical cohort of haemodialysis patients followed for a 3 month period. Data regarding the probability of treatment failure due to recurrent infection for each strategy, secondary infectious complications and patient mortality were obtained from existing clinical trials and from the 1998 United States Renal Data System database. Costs were substituted with the current 2000 New York hospital charges.

RESULTS

Tunnelled, cuffed catheter exchange over a guidewire was associated with a reduction in net charges of $5241 and $750 when compared with TCC salvage and immediate TCC removal, respectively. The expected 3 month patient survival for TCC guidewire exchange and immediate TCC removal were similar (93%), whereas survival for TCC salvage was worse (89%). Tunnelled, cuffed catheter guidewire exchange remained the most cost-effective strategy when the probability of treatment failure with recurrent bacteraemia in 3 months was <25% for this strategy.

CONCLUSIONS

Tunnelled, cuffed catheter guidewire exchange is the most cost-effective strategy of catheter management when mild or no symptoms are present.