Cost modelling incorporating procalcitonin for the risk stratification of febrile infants ≤60 days old.

Objectives: Procalcitonin testing is recommended to discriminate febrile young infants at risk of serious bacterial infections (SBI). However, this test is not available in many clinical settings, limited largely by cost. This study sought to evaluate contemporary real-world costs associated with the usual care of febrile young infants, and estimate impact on clinical trajectory and costs when incorporating procalcitonin testing. Methods: We assessed hospital-level door-to-discharge costs of all well-appearing febrile infants aged ≤60 days, evaluated at a tertiary paediatric hospital between April/2016 and March/2019. Emergency Department and inpatient expense data for usual care were obtained from the institutional general ledger, validated by the provincial Ministry of Health. These costs were then incorporated into a probabilistic model of risk stratification for an equivalent simulated cohort, with the addition of procalcitonin. Results: During the 3-year study period, 1168 index visits were included for analysis. Real-world median costs-per-infant were the following: $3266 (IQR $2468 to $4317, n=93) for hospitalized infants with SBIs; $2476 (IQR $1974 to $3236, n=530) for hospitalized infants without SBIs; $323 (IQR $286 to $393, n=538) for discharged infants without SBIs; and, $3879 (IQR $3263 to $5297, n=7) for discharged infants subsequently hospitalized for missed SBIs. Overall median cost-per-infant of usual care was $1555 (IQR $1244 to $2025), compared to a modelled cost of $1389 (IQR $1118 to $1797) with the addition of procalcitonin (10.7% overall cost savings; $1,816,733 versus $1,622,483). Under pessimistic and optimistic model assumptions, savings were 5.9% and 14.9%, respectively. Conclusions: Usual care of febrile young infants is variable and resource intensive. Increased access to procalcitonin testing could improve risk stratification at lower overall costs.

Feasibility and Cost Analysis of Ambulatory Endovascular Aneurysm Repair.

PURPOSE: We sought to compare the costs of ambulatory endovascular aneurysm repair (a-EVAR) and inpatient EVAR (i-EVAR) at up to 1-year of follow-up. MATERIALS AND METHODS: A retrospective cohort study of consecutive patients undergoing elective EVAR between April 2016 and December 2018 at two academic centers. Patients planned for a-EVAR were compared with i-EVAR. Costs at 30 days and 1 year were extracted. These included operating room (OR) use, bed occupancy, laboratory and imaging, emergency department (ED) visits, readmissions, and reinterventions. Baseline characteristics were compared. Multiple regression model was used to identify predictors of increased EVAR costs. Repeated measures analysis of variance (ANOVA) was used to compare cost differences at 30 days and 1 year via an intention-to-treat analysis. Bonferroni post hoc test compared between-group differences. A p value<0.05 was considered statistically significant. RESULTS: One hundred seventy patients were included. Most underwent percutaneous EVAR (>94%) under spinal anesthesia (>84%). Ambulatory endovascular aneurysm repair was successful in 84% (84/100). Ambulatory endovascular aneurysm repair patients (76±8 years) were younger than i-EVAR (78±9 years). They also had a smaller mean aneurysm diameter (56±6 mm) compared with i-EVAR (59±6 mm). Emergency department visits, readmissions, and reinterventions were similar up to 1 year (all p=NS). Ambulatory endovascular aneurysm repair costs showed a non-statistically significant reduction in total costs at 30 days and 1 year by 27% and 21%, respectively. Patients younger than 85 years and males had a 30-day cost reduction by 34% (p=0.027) and 33% (p=0.035), respectively with a-EVAR. CONCLUSIONS: Same-day discharge is feasible and successful in selected patients. Patients younger than 85 years and males have a short-term cost benefit with EVAR done in the ambulatory setting without increased complications or reinterventions. CLINICAL IMPACT: This study shows the overall safety of ambulatory EVAR with proper patient selection. These patient had similar post-intervention complications to inpatients. Same day discharge also resulted in short-term reduction in costs in male patients and patients younger than 85 years.

Chronic pain-related consultations to the emergency department of children with complex pain conditions: A retrospective analysis of healthcare utilization and costs.

Background: There is limited information regarding the effects of pediatric chronic pain management on the number and cost of chronic pain-related emergency department (ED) consultations. Aim: This retrospective study aimed to evaluate the number and costs of chronic pain-related ED consultations of children and adolescents with chronic pain conditions at the Montreal Children's Hospital (MCH). Methods: Charts of patients followed by the Edwards Family Interdisciplinary Center for Complex Pain (CCP) of the MCH between April 2017 and December 2018 were reviewed. ED consultations, specialist consultations, medication prescriptions, hospital admissions, and outpatient consultation referrals were assessed for the period of 1 year before and after the patients' first consultation with the CCP. Associated costs were also calculated. Results: One-hundred sixty-eight patients were included in the analysis. Fifty-one percent consulted the ED and had 151 chronic pain-related ED consultations within 1 year before their initial CCP consultation. In the year following their first CCP consultation, 52 patients (31%) consulted the ED, of which 24 consultations were chronic pain-related (84% reduction). There was an 81% reduction in the costs associated with chronic pain-related ED consultations within 1 year after CCP management. In addition, there was a significant reduction in ED interventions within 1 year after CCP management, though there was no change in medication prescriptions, hospital admissions, or subspecialist consultations. Conclusion: Children and adolescents with chronic pain conditions had fewer chronic pain-related ED consultations within 1 year after the first evaluation by an interdisciplinary center for complex pain, contributing to reduced ED costs.

Contexte : L'information sur les effets de la prise en charge de la douleur chronique pédiatrique sur le nombre et le coût des consultations liées à la douleur chronique au service des urgences est limitée.Objectif : Cette étude rétrospective visait à évaluer le nombre et le coût des consultations liées à la douleur chronique des enfants et des adolescents souffrant de douleur chronique au service des urgences de l'Hôpital de Montréal pour enfants.Méthodes : Les dossiers de patients suivis par le Centre interdisciplinaire de la famille Edwards pour la douleur complexe (CCP) de l'Hôpital de Montréal pour enfants entre avril 2017 et décembre 2018 ont été examinés. Les consultations au service des urgences, les consultations de spécialistes, les ordonnances de médicaments, les admissions à l'hôpital et les références pour consultation externe ont été évaluées pour la période d'un an avant et après la première consultation des patients auprés du CCP. Les coûts associés ont également été calculés.Résultats : Cent soixante-huit patients ont été inclus dans l'analyse. Cinquante et un pour cent ont consulté le service des urgences dans le cadre de 151 consultations liées à la douleur chronique au service des urgences au cours de l'année précédant leur première consultation au CCP. Dans l'année suivant leur première consultation au CCP, 52 patients (31 %) ont consulté le service des urgences. Vingt-quatre de ces consultations étaient liées à la douleur chronique (une réduction de 84 %). Une réduction de 81 % des coûts associés aux consultations liées à la douleur chronique au service des urgences a été observée dans l'année suivant la prise en charge par le CCP. En outre, une réduction significative des interventions du services des urgences dans l'année suivant la prise en charge par le CCP a été observée, bien quéil néy ait pas eu de changement dans les ordonnances de médicaments, les admissions à léhôpital ou les consultations de sous-spécialistes.Conclusion : Les enfants et les adolescents souffrant de douleur chronique ont consulté le service des urgences pour la douleur chronique moins souvent dans l'année suivant la première évaluation par un centre interdisciplinaire pour la douleur complexe, contribuant ainsi à réduire les coûts du service des urgences.