Optimizing Duration of Empiric Management of Suspected Central Line-Associated Bloodstream Infections in Pediatric Patients with Intestinal Failure.

OBJECTIVES: To assess whether a 24-hour length of hospitalization and empiric antibiotic therapy to exclude central line-associated bloodstream infection (CLABSI) in children with intestinal failure is potentially as safe as 48 hours, which is the duration most commonly used but not evidence based. STUDY DESIGN: A prospective single-institution observational cohort study was conducted among pediatric patients with intestinal failure from July 1, 2015, through June 30, 2018, to identify episodes of suspected CLABSI. The primary end point was time from blood sampling to positive blood culture. Secondary end points included presenting symptoms, laboratory test results, responses to a parent/legal guardian-completed symptom survey, length of inpatient stay, costs, and charges. RESULTS: Seventy-three patients with intestinal failure receiving nutritional support via central venous catheters enrolled; 35 were hospitalized with suspected CLABSI at least once during the study. There were 49 positive blood cultures confirming CLABSI in 128 episodes (38%). The median time from blood sampling to positive culture was 11.1 hours. The probability of a blood culture becoming positive after 24 hours was 2.3%. Elevated C-reactive protein and neutrophil predominance in white blood cell count were associated with positive blood cultures. Estimated cost savings by transitioning from a 48-hour to a 24-hour admission to rule-out CLABSI was $4639 per admission. CONCLUSIONS: A 24-hour duration of empiric management to exclude CLABSI may be appropriate for patients with negative blood cultures and no clinically concerning signs. A multi-institutional study would more robustly differentiate patients safe for discharge after 24 hours from those who warrant longer empiric treatment.

Hospital-Associated Cost of Endometriosis in Canada: A Population-Based Study.

STUDY OBJECTIVE: To describe the hospital-associated cost of endometriosis in Canada from April 2008 to March 2013. DESIGN: Population-based descriptive study. SETTING: Canada, with the exception of the province of Quebec. PATIENTS: All women aged 15 to 59 years discharged with endometriosis between April 2008 and March 2013. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Over 5 years, 47 021 women were admitted for endometriosis, resulting in a total hospital cost of Canadian dollars (CaD) $152.21 million (US dollars [US $] 147.79 million) and per-case cost of CaD $3237 (US $3143). Uterine endometriosis accounted for 28.29% of cases, ovarian endometriosis 27.44%, and other endometriosis 44.27%. Cost for uterine endometriosis was the highest at CaD $4137 (US $4017) per case, followed by ovarian endometriosis (CaD $3506; US $3404) and other endometriosis (CaD $2495; US $2422). The highest number of cases were in the groups aged 35 to 39 years (20.77%) and 40 to 44 years (20.44%). Hysterectomy accounted for 29.57% of surgical procedures. Encounters with hysterectomy were the costliest at CaD $5062 (US $4915) per case, followed by the ones with other surgical procedures at CaD $2477 (US $2405) per case, and admissions with no surgical procedure at CaD $2164 (US $2101) per case. CONCLUSION: The hospital cost associated with endometriosis was approximately CaD $30 million (US $29.56 million) per year, whereas uterine endometriosis, hysterectomy, and older age were found to have a higher average cost per case. Although this study focuses specifically on hospital admission and does not account for outpatient costs or indirect costs, it nonetheless highlights the economic burden of this debilitating disease on Canadian society during the study period.

Alvimopan Significantly Reduces Length of Stay and Costs Following Colorectal Resection and Ostomy Reversal Even Within an Enhanced Recovery Protocol.

BACKGROUND: Alvimopan accelerates GI recovery after colorectal resection. Data on real-world cost-effectiveness have been mixed. OBJECTIVE: This study aimed to evaluate if adding alvimopan to an enhanced recovery pathway reduces length of stay. DESIGN: Patients undergoing colorectal resection or ostomy reversal for the year before and after the introduction of alvimopan were evaluated. SETTING: This study was conducted at a single academic medical center. PATIENTS: Patients undergoing elective colorectal resection (488) or ostomy reversal (148) were included. MAIN OUTCOME MEASURES: The primary outcomes measured were length of stay and prolonged length of stay defined as >75th percentile for each procedure. RESULTS: Two hundred eighty-six patients (45%) received alvimopan. Alvimopan and no-alvimopan groups had similar demographics, comorbidities, operative indication, and case mix. In the alvimopan group, more of the colorectal resections were laparoscopic (87% vs 79%, p = 0.015). Length of stay was reduced with alvimopan (6.2 vs 4.9 days, p = 0.003), and this effect persisted when controlling for procedure type, approach, and ASA class (decreased length of stay by 1.0 day, p = 0.014). The alvimopan group had lower risk of prolonged length of stay (14.7% vs 23.1%, p = 0.007) and ileus (10.8% vs 16.2%, p = 0.05). On multivariable analysis, no alvimopan use (OR, 1.8; 95% CI, 1.2-2.7), ASA ≥3 (OR, 2.0; 95% CI, 1.3-3.1), and history of cardiac surgery (OR, 2.8; 95% CI, 1.2-6.5) were significant predictors of prolonged length of stay. Alvimopan use was associated with a lower risk of infectious complications other than surgical site infection (2.8% vs 6.7%, p = 0.025), and did not increase risk of any adverse outcomes. The addition of alvimopan to the protocol resulted in cost savings of $708.39 per patient. LIMITATIONS: Data collected from a single center limit external validity. CONCLUSIONS: The introduction of alvimopan to a postoperative protocol following elective colorectal resection or ostomy reversal significantly reduces length of stay and is associated with cost savings even within an enhanced recovery protocol. See Video Abstract at http://links.lww.com/DCR/A911.

Pre-emptive Intestinal Transplant: The Surgeon's Point of View.

Pre-emptive transplantation is a well-established practice for certain types of end-organ failure such as in the use of kidney transplantation. For irreversible intestinal failure, total parenteral nutrition (TPN) remains the gold standard, due to the suboptimal long-term results of intestinal transplantation. As such, the only role for pre-emptive transplantation, if at all, will be for patients identified to be at high risk of complications and mortality while on definitive long-term TPN. In these patients, the timing of early listing and transplantation could become life-saving, taking into account that mortality on the waiting list is still the highest for intestinal candidates. The development of simulation models or pre-transplant scoring systems could help in selecting patients based on potential outcome on TPN or with transplantation, and recent reports from high-volume centers identify few underlying pathologic conditions and some TPN complications as at higher risk of increased morbidity and mortality. A pre-emptive transplant could be used as a rehabilitative procedure in a well-selected case-by-case scenario, among TPN patients at risk of liver failure, repeated central line infections, mesenteric infarction, short bowel syndrome (SBS) <50 cm or with end stoma, congenital mucosal disease, desmoid tumors: These conditions must be carefully evaluated, not to underestimate the clinical stage nor to over-estimate the impact of a temporary situation. At the present time, diseases with a variable and unpredictable course, such as intestinal dysmotility disorders, or quality of life and financial issues are still far from being considered as indications for a pre-emptive transplant.

Randomized Trial on Fast Track Care in Colorectal Surgery for Deep Infiltrating Endometriosis.

STUDY OBJECTIVE: To study the application of a fast-track care protocol in colorectal surgery for deep infiltrating endometriosis. Bowel endometriosis is an infrequent but not rare condition that often needs intestinal surgery and imposes a high economic burden on society. DESIGN: Prospective randomized trial (Canadian Task Force classification I). SETTING: Tertiary referral center. PATIENTS: Two hundred twenty-seven patients with preoperative evidence of bowel endometriosis. INTERVENTIONS: We randomly assigned 227 patients with preoperative evidence of bowel endometriosis to a fast-track protocol (no preoperative bowel preparation, early restoration of diet, no postoperative antibiotics, and early postoperative mobilization) or conventional care for laparoscopic intestinal surgery. Randomization was obtained on a double-blind, date-based schedule, and all procedures were performed by a homogenous group of expert surgeons. Surgical outcomes and a health economic evaluation were assessed. MEASUREMENTS AND MAIN RESULTS: The primary outcome was hospital stay. Patient's well-being and intraoperative and postoperative complications up to 30 days after surgery were also assessed. Subsequently, direct medical costs were analyzed. Patients assigned to the fast-track protocol were discharged earlier (median 3 vs 7 days, p < .001) with no significant differences in subjective well-being (p = .55). Operative details, postoperative complications, and need of temporary ileostomy were similar (p = .89) between groups as well as readmission rates within 30 days (p = .69). The application of a fast-track protocol resulted in an overall significant reduction of costs (USD 6699 vs 8674, p < .01), and differences were more evident in cases of protective stoma (7652 vs 8793, p < .05) and surgery with postoperative complications (10 835 vs 14 005, p < .01). CONCLUSION: The application of a fast-track care protocol for laparoscopy in cases of pelvic and intestinal endometriosis does not increase the risk of complications and ensures a reduction of medical costs.

Clinical and financial impact of hospital readmissions after colorectal resection: predictors, outcomes, and costs.

BACKGROUND: After passage of the Affordable Care Act, 30 -day hospital readmissions have come under greater scrutiny. Excess readmissions for certain medical conditions and procedures now result in penalizations on all Medicare reimbursements. OBJECTIVE: The purpose of this work was to define the risk factors, outcomes, and costs of 30-day readmissions after colorectal surgery. DESIGN: Adults undergoing colorectal surgery were studied using data from the University HealthSystem Consortium. Univariate and multivariable analyses were used to identify patient-related risk factors for, and 30-day outcomes of, readmission after colorectal surgery. SETTINGS: This study was conducted at an academic hospital and its affiliates. PATIENTS: Adults ≥18 years of age who underwent colorectal surgery for cancer, diverticular disease, IBD, or benign tumors between 2008 and 2011 were included in this study. MAIN OUTCOME MEASURES: Readmission within 30 days of index discharge was the main outcome measured. RESULTS: A total of 70,484 patients survived the index hospitalization after colorectal surgery; 9632 (13.7%) were readmitted within 30 days of discharge. The strongest independent predictors of readmission were length of stay ≥4 days (OR 1.44; 95% CI 1.32-1.57), stoma (OR 1.54; 95% CI 1.46-1.51), and discharge to skilled nursing (OR 1.62; 95% CI 1.49-1.76) or rehabilitation facility (OR 2.93; 95% CI 2.53-3.40). Of those readmitted, half of the readmissions occurred within 7 days, 13% required the intensive care unit, 6% had a reoperation, and 2% died during the readmission stay. The median combined total direct hospital cost was more than 2 times higher ($26,917 vs $13,817; p < 0.001) for readmitted than for nonreadmitted patients. LIMITATIONS: Follow-up was limited to 30 days after initial discharge. CONCLUSIONS: Readmissions after colorectal resection occur frequently and incur a significant financial burden on the health-care system. Future studies aimed at targeted interventions for high-risk patients may reduce readmissions and curb escalating health-care costs.

The economic costs of home parenteral nutrition: Systematic review of partial and full economic evaluations.

BACKGROUND & AIMS: Home parenteral nutrition (HPN) is indicated in patients with chronic intestinal failure. The aim of the current study was to review existing scientific literature of full or partial economic evaluations associated to HPN. METHODS: A bibliographic database search was undertaken in PubMed (MEDLINE), Embase and Scopus, complemented by a reference list search. We combined search terms regarding HPN and costs/health economics. The inclusion criteria included: a) population: all population and age groups; b) intervention: partial or full HPN; c) comparator: no parenteral nutrition, continued or intermittent hospital based PN, other nutritional interventions or no comparator; d) outcomes: cost outcomes and economic evaluations associated to HPN. A different quality assessment tool was used for each of the different type of economic approach. RESULTS: Twenty-three papers were included in the final review. 21 were partial economic evaluations (16 cost-of-illness studies and 5 cost analyses), and 2 were full economic evaluations, both cost-utility analysis. Most studies investigated costs from a healthcare perspective (n = 18), therefore they included only direct costs. Three studies included personal costs for HPN patient. None of the studies included productivity costs. CONCLUSIONS: Most scientific literature regarding the economic costs of HPN comes from partial economic evaluations, such as cost-of-illness studies and cost analysis. According to them, HPN is an expensive treatment, although cost saving when compared to hospital based parenteral nutrition (PN). Full economic evaluations proved HPN as being cost-effective than hospital based PN, however more research is needed to confirm this in all settings.

Infection with Blastocystis spp. and its association with enteric infections and environmental enteric dysfunction among slum-dwelling malnourished adults in Bangladesh.

BACKGROUND: Blastocystis spp. (Blastocystis) is a widely distributed gastrointestinal protist frequently reported in countries with tropical and sub-tropical climate. We sought to determine the factors associated with Blastocystis infection and investigate its role on biomarkers of intestinal health among slum-dwelling malnourished adults in Bangladesh. METHODOLOGY: Total 524 malnourished adults with a body mass index ≤18.5 kg/m2 were included in this analysis. Presence of Blastocystis in feces was evaluated by TaqMan Array Card assays. PRINCIPAL FINDINGS: Blastocystis was tested positive in 78.6% of the participants. Prevalence of infection with atypical strains of enteropathogenic Escherichia coli (aEPEC) (56% vs. 38%, p<0.001), and Trichuris trichiura (28% vs. 15%, p-value = 0.02) was significantly greater in adults with Blastocystis, while Giardia intestinalis was significantly lower (8% vs. 14%, p-value = 0.04) in Blastocystis positive adults. Malnourished adults who were living in households with high crowding index (aOR = 2.18; 95% CI = 1.11, 4.65; p-value = 0.03), and infected with aEPEC (aOR = 2.14; 95% CI = 1.35, 3.44; p-value = 0.001) and Trichuris trichiura (aOR = 1.97; 95% CI = 1.08, 3.77; p = 0.03) were more likely to be infected with Blastocystis. A significant negative relationship was observed between Blastocystis and fecal concentrations of alpha-1 antitrypsin (ß = -0.1; 95% CI = -1.7, -0.1; p-value<0.001) and Reg1B (ß = -3.6; 95% CI = -6.9, -3.0; p-value = 0.03). CONCLUSIONS: The study findings suggest that the presence of Blastocystis in human intestine influences gut health and may have potential pathogenic role in presence of other pathogens.

Cost-effectiveness of Intestinal Transplantation Compared to Parenteral Nutrition in Adults.

BACKGROUND: Intestinal transplantation (ITx) is the most expensive abdominal organ transplant. Detailed studies about exact costs and cost-effectiveness compared to home parenteral nutrition (HPN) therapy in chronic intestinal failure are lacking. The aim is to provide an in-depth analysis of ITx costs and evaluate cost-effectiveness compared to HPN. METHODS: To calculate costs before and after ITx, costs were analyzed in 12 adult patients. To calculate the costs of patients with uncomplicated chronic intestinal failure, 28 adults, stable HPN patients were studied. Total costs including surgery, admissions, diagnostics, HPN therapy, medication, and ambulatory care were included. Median (range) costs are given. RESULTS: Costs before ITx were €69 160 (€60 682-90 891) in year 2, and €104 146 (€83 854-186 412) in year 1. After ITx, costs were €172 133 (€122 483-351 407) in the 1st year, €40 619 (€3905-113 154) in the 2nd year, and dropped to €15 743 (€4408-138 906) in the 3rd year. In stable HPN patients, the costs were €83 402 (€35 364-169 146) in the 1st year, €70 945 (€31 955-117 913) in the 2nd year, and stabilized to €60 242 (€29 161-238 136) in the 3rd year. CONCLUSIONS: ITx, although initially very expensive, is cost-effective compared to HPN in adults by year 4, and cost-saving by year 5.

Unexpected findings on laparoscopy for suspected acute appendicitis: a pro for laparoscopic appendectomy as the standard procedure for acute appendicitis.

PURPOSE: Evaluation of the feasibility, cost-effectiveness, time of surgery, morbidities, and other/additional findings during laparoscopy for suspected appendicitis. METHODS: Prospective evaluation of 148 laparoscopies for suspected acute appendicitis. RESULTS: Laparoscopic appendectomy was safe and cost-effective. No appendiceal stump leaks or wound infections occurred. Of the patients, 4.7% developed intra-abdominal abscesses. Mean time of all procedures was 47 min: 42 min for simple appendectomies (n = 126), 67 min for perforated appendicitis (n = 15), and 75 min for converted procedures (n = 7). Twenty-one of 148 (14.2%) patients had unexpected findings instead of appendicitis: inflamed epiploic appendices (three times), inflammatory disorders of intestine (five times), intestinal adhesions (two times), ovarian cysts (six times: one time with mesenteric lymphadenitis, one time ruptured), tubo-ovarian abscess (one time), tubal necrosis (one time), adnexitis with mesenteric lymphadenitis (one time), and acute cholecystitis (one time). These diagnoses might have been missed during conventional open appendectomy and were, if necessary, treated during laparoscopy. CONCLUSIONS: Laparoscopic appendectomy should be recommended as standard procedure for acute appendicitis.

Update on intestinal rehabilitation after intestinal transplantation.

PURPOSE OF REVIEW: The past decade has seen improvements in patient selection and a greater range of surgical procedures available to patients with intestinal failure, and this, combined with more effective immunosuppressive regimens, has transformed survival after intestinal transplantation (ITx). Much more is known about optimizing rehabilitation of the engrafted intestine in the first 12 months after transplant, but it is also becoming apparent that there are some long-term health issues to consider. RECENT FINDINGS: The key issues in rehabilitation of ITx are the immunogenic nature of the intestinal graft, which means a higher risk of rejection and necessitates relatively high levels of immune suppression that promotes infections, including Epstein-Barr virus-driven lymphoma, viral gastroenteritis and renal impairment; and those related to the specifics of an intestinal allograft (nutritional support, chylous ascites, growth, food allergy, fat soluble vitamin deficiencies, metabolic bone disease). In this article, recent publications about approaches for establishing nutrition and methods for monitoring the health of the ITx patient are reviewed. SUMMARY: ITx appears to be cost-effective compared with parenteral nutrition, but ITx recipients continue to be vulnerable to infections, nutritional deficiencies and rejection over the long-term and, therefore, require support from and involvement of a multidisciplinary team for patients to become safely integrated with their local community.

Cost analysis of chronic intestinal failure.

BACKGROUND & AIMS: Chronic intestinal failure is a complex medical condition which is associated with high costs. These patients require long-term home parenteral nutrition (HPN) and costs are compounded by frequent admissions for the underlying disease and HPN. However, it is unknown what the specific costs subdivisions are and how they evolve over time. The aim of the study was to evaluate the cost dynamics of HPN care in a cohort of stable, long-term intestinal failure patients. METHODS: A retrospective analysis of our single-center long-term (>2 years), benign HPN population was performed. All relevant clinical and financial data were collected: costs of hospital admissions, diagnostics, treatments, out-patient clinics, home care, medication, materials and HPN education. The costs were tabulated and assigned by cause (HPN related, underlying disease-related or -unrelated). Patients with complicated intestinal failure (defined as impending loss of vascular access, liver failure or recurrent fluid/electrolyte disorders) were excluded. Data are presented as median (range). RESULTS: Thirty-seven patients (24 female; age 58.6 ± 13.3 years) were included in the study. HPN duration was 5.3 years (2.1-15.1) at 4.3 infusion days per week (1.5-7). Total cost of the first HPN year was €83,503 (35,364-256,780). HPN-related costs accounted for 69% (€57,593) vs 27% for underlying disease-related costs (€22,505) and 4% for disease-unrelated costs (€3065). HPN complications cost €16,077 in the first year and accounted for 31% of HPN costs. The total cost dropped by 15% in the second year to €71,311. This reduction was due to fewer hospital admissions and fewer HPN complications. This trend continued and by year 5 the annual cost was 40% cheaper compared to year 1 (€58,187 vs €83,503). CONCLUSIONS: HPN related costs accounted for the majority of the total expenses in IF patients. The costs declined after the first year due to a reduction in complications and hospital admissions.

Health care use in patients with chronic intestinal dysmotility before and after introducing a specialized day-care unit.

BACKGROUND & AIMS: Patients with chronic intestinal dysmotility (CID) have a lifelong disease, and no curative treatment is available. Interventions are needed to improve the care and support of the patients. The aim of this study was to measure health-care consumption in adult patients with CID before and after the introduction of a specialized day-care unit. METHODS: Retrospective analysis was made of medical and nursing records from 3 different health-care delivery systems: period I, traditional care (1987-1996); period II, outpatient clinic (1997-1999); and period III, specialized day-care unit (2000-2002). There were 54 patients (44 women) with a median age of 47 years (range, 22-80 years). RESULTS: The need for admissions to hospital care decreased from 80% to 35% of the patients after the introduction of the specialized day-care unit (P < .002). Also, the mean number of days in hospital care per patient and year was reduced from 39.4 to 3.3 days. The number of outpatient visits remained unaltered. The average cost per patient-year decreased from $32,698 during traditional health-care services to $9,681 after introducing the specialized day-care unit (P < .002). Irrespective of the form of care delivery, the majority of patients (67%-77%) needed daily treatment with analgesics, and 81%-84% needed nutritional support on a regular basis. CONCLUSIONS: Individually tailored care at a specialized day-care unit leads to substantially decreased needs for hospital stays and lower costs in patients with CID.

High concordance between trained nurses and gastroenterologists in evaluating recordings of small bowel video capsule endoscopy (VCE).

BACKGROUND AND AIMS: . The video capsule endoscopy (VCE) is an accurate and validated tool to investigate the entire small bowel mucosa, but VCE recordings interpretation by the gastroenterologist is time-consuming. A pre-reading of VCE recordings by an expert nurse could be accurate and cost saving. We assessed the concordance between nurses and gastroenterologists in detecting lesions on VCE examinations. METHODS: This was a prospective study enrolling consecutive patients who had undergone VCE in clinical practice. Two trained nurses and two expert gastroenterologists participated in the study. At VCE pre-reading the nurses selected any abnormalities, saved them as "thumbnails" and classified the detected lesions as a vascular abnormality, ulcerative lesion, polyp, tumor mass, and unclassified lesion. Then, the gastroenterologist evaluated and interpreted the selected lesions and, successively, reviewed the entire video for potential missed lesions. The time for VCE evaluation was recorded. RESULTS: A total of 95 VCE procedures performed on consecutive patients (M/F: 47/48; mean age: 63 +/- 12 years, range: 27-86 years) were evaluated. Overall, the nurses detected at least one lesion in 54 (56.8%) patients. There was total agreement between nurses and gastroenterologists, no missing lesions being discovered at a second look of the entire VCE recording by the physician. The pre-reading procedure by nurse allowed a time reduction of medical evaluation from 49 (33-69) to 10 (8-16) minutes (difference: -79.6%). CONCLUSIONS: Our data suggest that trained nurses can accurately identify and select relevant lesions in thumbnails that subsequently were faster reviewed by the gastroenterologist for a final diagnosis. This could significantly reduce the cost of VCE procedure.

Intestinal rehabilitation for children with intestinal failure is cost-effective: a simulation study.

BACKGROUND: Children with intestinal failure (IF) depend on parenteral nutrition (PN). The goal in the treatment of IF is to wean children off PN through intestinal rehabilitation (IR). Although the healthcare burden of IF is enormous, to our knowledge there has been no previous cost-effectiveness analysis in pediatric IF including IR. OBJECTIVE: We sought to determine the cost-effectiveness of IR in terms of costs and life-years. DESIGN: We simulated the treatment of IF in children in a discrete-event model. Data for this model were derived from patient records, the Dutch Registry of Intestinal Failure and Transplantation, the Intestinal Transplant Registry, and the literature. The time horizon of the model was 40 y. Simulated patients were enrolled at a rate of 40 patients/mo for 10 y. Actual costs were calculated for hospital admissions, surgical interventions, endoscopies, PN, and immunosuppressive medication. We evaluated the cost-effectiveness of IR by comparing 1 scenario with IR with 1 scenario without IR. In the scenario with IR, a proportion of patients who represented those with the ability to wean off PN were assigned to IR. In the scenario without IR, all patients progressed to home PN (HPN). In both scenarios, a proportion of patients receiving HPN were eventually eligible for an intestinal transplantation. RESULTS: IR prolonged survival; the mean number of life-years per patient was 19.4 in the scenario with IR compared with 18.2 in the scenario without IR. Average total costs per patient were €819,292 in the scenario with IR compared with €1,176,830 in the scenario without IR (equivalent to 1,129,230 US$ and 1,622,025 US$, respectively, in January 2014); costs mainly included hospital admissions and PN. CONCLUSIONS: On the basis of our simulations, we concluded that IR improved the survival of children with IF and was associated with cost savings. Therefore, we consider IR to be a cost-effective treatment for children with IF.

Economic losses related to internal diseases in Japanese black cattle.

The objective of this study was to estimate the direct economic losses due to the condemnation of the liver and large intestine because of internal diseases (multifocal necrosis in the liver (MNL) and inflammation of the large intestine (ILI)), and the indirect losses because of reductions in carcass performance from MNL, bovine abdominal fat necrosis (BFN) and ILI using data from 5383 Japanese Black cattle. Direct losses were estimated by multiplying the price of the condemned part by the frequency of its occurrence owing to the disease. Similarly, indirect losses were estimated as the product of unit carcass price and reduction in carcass weight (CW) due to the disease. The direct impact on the beef cattle industry from MNL and ILI was estimated at around $1.29 million (US$1 = ¥120) per year. A least-squares analysis showed that MNL had no influence on any carcass trait, whereas BFN and ILI significantly reduced CW, rib eye area and darkened the beef. ILI also reduced rib thickness. The indirect losses from BFN and ILI were estimated as a maximum of $131.7 and $256.4 per animal and around $6.26 million and $4.03 million for the industry, respectively, mostly because of the reduction in CW.

Cost-effectiveness of intestinal transplantation for adult patients with intestinal failure: a simulation study.

BACKGROUND: Home parenteral nutrition (HPN) and intestinal transplantation (ITx) are the 2 treatment options for irreversible intestinal failure (IF). OBJECTIVE: This study simulated the disease course of irreversible IF and both of these treatments--HPN and ITx--to estimate the cost-effectiveness of ITx. DESIGN: We simulated IF treatment in adults as a discrete event model with variables derived from the Dutch Registry of Intestinal Failure and Intestinal Transplantation, the Intestinal Transplant Registry, hospital records, the literature, and expert opinions. Simulated patients were enrolled at a rate of 40/mo for 10 y. The maximum follow-up was 40 y. Survival was simulated as a probabilistic function. ITx was offered to 10% of patients with <12 mo of remaining life expectancy with HPN if they did not undergo ITx. Costs were calculated according to Dutch guidelines, with discounting. We evaluated the cost-effectiveness of ITx by comparing models conducted with and without ITx and by calculating the cost difference per life-year gained [incremental cost-effectiveness ratio (ICER)]. RESULTS: The average survival was 14.6 y without ITx and 14.9 y with ITx. HPN costs were €13,276 for treatment introduction, followed by €77,652 annually. The costs of ITx were ∼€73,000 during the first year and then €13,000 annually. The ICER was €19,529 per life-year gained. CONCLUSION: Our simulations show that ITx slightly improves survival of patients with IF in comparison with HPN at an additional cost of €19,529 per life-year gained.

The morbidity, mortality, and costs associated with Clostridium difficile infection.

Clostridium difficile infection (CDI) is the most common cause of infectious health care-associated diarrhea and is a major burden to patients and the health care system. The incidence and severity of CDI remain at historically high levels. This article reviews the morbidity, mortality, and costs associated with CDI.

Prediction models of Medicare 90-day postdischarge deaths, readmissions, and costs in bowel operations.

BACKGROUND: The 90-day postdischarge morbidity and mortality rates following elective and emergent bowel surgery remain poorly defined. METHODS: The 2009 to 2011 Medicare inpatient files for patients undergoing elective and emergent small and large bowel operations in 1,024 hospitals that passed present-on-admission coding accuracy standards had prediction models designed for inpatient mortality, prolonged postoperative length of hospital stay (prLOS), 90-day postdischarge mortality and readmissions, and total hospital costs. RESULTS: Of 118,758 patients studied, there was a 4.7% inpatient mortality rate and 7.3% prLOS among live discharges. An additional 7,586 deaths and 26,969 readmissions occurred within 90 days of discharge. Prolonged preoperative and prolonged postoperative hospitalizations were significant (P < .0001) variables in predicting postdischarge deaths and readmissions. Total hospital costs were increased by over $18,000 per adverse outcome. CONCLUSION: Postdischarge deaths and readmissions are more common than inpatient adverse events of death and prLOS in elective and emergent Medicare large and small bowel operations.

Effect of patient factors on hospital costs for major bowel surgery: implications for managed health care.

BACKGROUND: We examined the effects of patient factors on hospital resource consumption for patients who had undergone major bowel operation (diagnosis-related groups [DRGs] 148 and 149) at an urban, university hospital. METHODS: We performed cross-sectional analysis of computerized hospital discharge abstracts and charts of 491 consecutive discharges in these DRGs. Total hospital charges and length of stay were dependent variables. Independent variables included admission status, admission service, previous admissions, payer type, service type, diagnosis, reoperation, and death. RESULTS: Patient factors accounted for significant variability in resource consumption. By univariate analysis all of the above variables significantly affected total charges, and all but service type significantly affected length of stay. By multivariate analysis DRGs 148/149 alone explained 4.2% of the variance, whereas all the variables together increased R2 to 52.1%. Logistic regression of reoperation and of death as dependent variables suggested that patient factors also accounted for significant variance in these outcomes. CONCLUSIONS: Because patient factors may not be directly controllable by hospitals or physicians, differences among hospitals in costs and in "quality" may relate more to differences in patient mix than to efficiency. DRGs alone are not a sufficient management tool, and additional measures are needed to adequately measure both efficiency and quality.