RESUMO
BACKGROUND: Management of sedation, analgesia, and delirium influences morbidity, mortality, and quality of life in patients treated in intensive care. Assessing quality indicators as part of a quality management and assurance program is an established method to ensure process quality. Currently, there is limited research on the effect of evaluating quality indicators on economic outcomes. The aim of the study was to investigate the adherence to an indicator on management of sedation, analgesia and delirium, and explore potential effects on hospital economics and clinical outcomes. METHODS: In this retrospective cohort study, we analyzed routine data from 20,220 patient records from the hospital information system of a tertiary university hospital, collected from January 2012 to December 2019. We compared two predefined subgroups with either high indicator adherence or low indicator adherence regarding factors like disease severity scores, comorbidities, and outcome measures. We used logistic regression models to examine the influence of quality indicator adherence on economic measures such as Diagnosis-related group (DRG) incomes, revenue margins, and costs, and clinical outcomes. Additionally, we used propensity score matching to probe our findings. RESULTS: Overall revenue margins in this cohort were negative (-320). High adherence to the quality indicator was associated with a positive revenue margin (+197) compared to low adherence (-482). Higher adherence was also associated with lower costs. Additionally, high adherence was associated with reduced mortality (OR 0.84, 95% CI 0.75-0.95) and reduced duration of mechanical ventilation and hospital stay (17 hours and 1 day respectively). CONCLUSION: Higher adherence to a quality indicator for sedation, analgesia, and delirium management was associated with economic returns and costs. We also found an association with lower mortality and reduced length of stay. Further research on these associations may help identify opportunities for quality improvement without increased resource use.
Assuntos
Analgesia , Cuidados Críticos , Delírio , Humanos , Delírio/economia , Delírio/terapia , Estudos Retrospectivos , Masculino , Feminino , Alemanha , Pessoa de Meia-Idade , Idoso , Cuidados Críticos/economia , Analgesia/economia , Indicadores de Qualidade em Assistência à Saúde , Unidades de Terapia Intensiva/economiaRESUMO
OBJECTIVE: The demand for treating degenerative lumbar spinal disease has been increasing, leading to increased utilization of medical resources. Thus, we need to understand how the budget of insurance is currently used. The objective of the present study is to overview the utilization of the National Health Insurance Service (NHIS) by providing the direct insured cost between patients receiving surgery and patients receiving nonsurgical treatment for degenerative lumbar disease. METHODS: The NHIS-National Sample Cohort was utilized to select patients with lumbar disc herniation, spinal stenosis, spondylolisthesis or spondylolysis. A matched cohort study design was used to show direct medical costs of surgery (n = 2,698) and nonsurgical (n = 2,698) cohorts. Non-surgical treatment included medication, physiotherapy, injection, and chiropractic. The monthly costs of the surgery cohort and nonsurgical cohort were presented at initial treatment, posttreatment 1, 3, 6, 9, and 12 months and yearly thereafter for 10 years. RESULTS: The characteristics and matching factors were well-balanced between the matched cohorts. Overall, surgery cohort spent $50.84/patient/month, while the nonsurgical cohort spent $29.34/patient/month (p<0.01). Initially, surgery treatment led to more charge to NHIS ($2,762) than nonsurgical treatment ($180.4) (p<0.01). Compared with the non-surgical cohort, the surgery cohort charged $33/month more for the first 3 months, charged less at 12 months, and charged approximately the same over the course of 10 years. CONCLUSION: Surgical treatment initially led to more government reimbursement than nonsurgical treatment, but the charges during follow-up period were not different. The results of the present study should be interpreted in light of the costs of medical services, indirect costs, societal cost, quality of life and societal willingness to pay in each country. The monetary figures are implied to be actual economic costs but those in the reimbursement system instead reflect reimbursement charges from the government.
Assuntos
Efeitos Psicossociais da Doença , Degeneração do Disco Intervertebral/economia , Estenose Espinal/economia , Espondilolistese/economia , Espondilólise/economia , Adulto , Idoso , Analgesia/economia , Analgesia/estatística & dados numéricos , Terapia por Exercício/economia , Terapia por Exercício/estatística & dados numéricos , Feminino , Humanos , Degeneração do Disco Intervertebral/cirurgia , Degeneração do Disco Intervertebral/terapia , Região Lombossacral/patologia , Masculino , Manipulação Quiroprática/economia , Manipulação Quiroprática/estatística & dados numéricos , Pessoa de Meia-Idade , Procedimentos Ortopédicos/economia , Procedimentos Ortopédicos/estatística & dados numéricos , Estenose Espinal/cirurgia , Estenose Espinal/terapia , Espondilolistese/cirurgia , Espondilolistese/terapia , Espondilólise/cirurgia , Espondilólise/terapiaRESUMO
BACKGROUND: Extensile lateral approach had been recognized as the gold standard technique for displaced intra-articular calcaneus fractures (DIACFs) while sinus tarsi approach had been increasingly valued by surgeons and comparative clinical outcome was shown in both techniques. Appropriate decisions could be made by the clinicians with the help of cost-utility analysis (CUA) about optimal healthcare for type II/III calcaneus fracture. METHOD: A single-center, retrospective study was conducted in which basic characteristics, clinical outcomes, and health care costs of 109 patients had been obtained and analyzed. Changes in health-related quality of life (HRQoL) scores, validated by EuroQol five-dimensional-three levels (EQ-5D-3L), were used to enumerate quality-adjusted life years (QALYs). Cost-effectiveness was determined by the incremental cost per QALY. RESULTS: One hundred nine patients were enrolled in our study including 62 in the ELA group and 47 in the STA group. There were no significant differences between these two groups in mean total cost, laboratory, and radiographic evaluation expense, surgery, anesthesia, and antibiotic expense. The expense of internal fixation materials ($3289.0 ± 543.9) versus ($2630.6 ± 763.7) and analgesia ($145.8 ± 85.6) versus ($102.9 ± 62.7) in ELA group were significantly higher than in the STA group (P < .001, P = .008, respectively). Visual Analogue Scale (VAS) scores showed significant difference at postoperative 3 and 5 days (P < .001). American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores and the Bohlers' and Gissane angle showed no significant differences between the two groups before and after the operation. The cost-effectiveness ratios of ELA and STA were $8766.8 ± 2835.2/QALY and $7914.9 ± 1822.0/QALY respectively, and incremental cost-effectiveness ratio (ICERs) of ELA over STA was $32110.00/QALY, but both showed no significant difference. CONCLUSION: Both ELA and STA techniques are effective operative procedures for the patients with calcaneus fracture. Moreover, STA seems to be more reasonable for its merits including less postoperative pain, and less expense of analgesia as well as internal fixation materials. LEVEL OF EVIDENCE: 5.
Assuntos
Calcâneo/cirurgia , Análise Custo-Benefício , Fixação Interna de Fraturas/economia , Fixação Interna de Fraturas/métodos , Custos de Cuidados de Saúde , Fraturas Intra-Articulares/economia , Fraturas Intra-Articulares/cirurgia , Adulto , Analgesia/economia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Dor Pós-Operatória/prevenção & controle , Qualidade de Vida , Anos de Vida Ajustados por Qualidade de Vida , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: We implemented local infiltration analgesia (LIA) as a technique of providing post-operative pain management and early mobilization after arthroplasty surgery and have progressively found patients able to go home earlier. This study compares the national data on hip and knee arthroplasty provided by the Royal Australasian College of Surgeons and Medibank Private with our outcomes using LIA and rapid recovery. METHODS: Prospective study of one surgeon including 200 knees, and 165 hips in the two years till June 2016. Variables included in comparison to the two groups were: length of stay, percentage of patients transferred to rehabilitation or intensive care unit (ICU), readmitted within 30 days and average separation cost. RESULTS: Hip replacement median length of stay in our series was two nights versus five nights, inpatient rehabilitation 7% versus 36%, ICU admission zero versus 4%, and readmissions 3.9% versus 6.0%, the average hospital separation cost in our series was $17 813 versus $26 734. Knee replacement median length of stay in our study was one night versus five nights, ICU 0.5% versus 3%, rehabilitation 4.5% versus 43%, and readmission 6% versus 7%, the average hospital separation cost in our group was $16 437 versus $27 505. CONCLUSION: The comprehensive approach of LIA and rapid recovery enables patients to have shorter hospitalization, lower rehabilitation incidence and a resultant reduction in health expenditure.
Assuntos
Analgesia/métodos , Analgésicos/administração & dosagem , Artroplastia de Quadril/reabilitação , Artroplastia do Joelho/reabilitação , Deambulação Precoce , Dor Pós-Operatória/tratamento farmacológico , Adulto , Idoso , Idoso de 80 Anos ou mais , Analgesia/economia , Analgésicos/economia , Analgésicos/uso terapêutico , Artroplastia de Quadril/economia , Artroplastia do Joelho/economia , Austrália , Redução de Custos/estatística & dados numéricos , Quimioterapia Combinada , Deambulação Precoce/economia , Feminino , Custos Hospitalares/estatística & dados numéricos , Humanos , Injeções Intra-Articulares , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Dor Pós-Operatória/economia , Estudos Prospectivos , Resultado do TratamentoRESUMO
The experience of pain relief arises from physiological and psychological factors, and attributes such as the commercial features of analgesic treatments have been shown to influence placebo analgesia by affecting treatment expectations. Therefore, treatment valuation from price information should influence the placebo analgesic effect. This hypothesis was tested in a functional magnetic resonance imaging study in which healthy subjects were enrolled in a 2-day experiment. On day 1, the participants (nâ¯=â¯19) had treatment experiences with 2 different placebo creams during a conditioning session without receiving information on treatment price. On day 2, placebo analgesia was tested after providing price information (high vs low) while functional magnetic resonance imaging was performed. The results showed that the higher priced placebo treatment leads to enhanced pain relief. Placebo analgesia in response to the higher priced treatment was associated with activity in the ventral striatum, ventromedial prefrontal cortex, and ventral tegmental area. The behavioral results indicate that the experience of pain was influenced by treatment valuation from price. Our findings reveal that the context of values in pain control is associated with activity in expectation- and reward-related circuitry. PERSPECTIVE: Treatment with higher price was associated with enhanced placebo analgesia, and this effect was influenced by activities in expectation and reward processing brain areas. The context of value such as medical cost influences cognitive evaluation processes to modulate pain. Our study may help evaluate a patient's preference toward high-priced drugs.
Assuntos
Analgesia , Córtex Cerebral/fisiologia , Comportamento do Consumidor , Dor Nociceptiva/fisiopatologia , Dor Nociceptiva/terapia , Preferência do Paciente , Efeito Placebo , Recompensa , Creme para a Pele , Estriado Ventral/fisiologia , Área Tegmentar Ventral/fisiologia , Adulto , Analgesia/economia , Córtex Cerebral/diagnóstico por imagem , Comportamento do Consumidor/economia , Feminino , Humanos , Imageamento por Ressonância Magnética , Masculino , Dor Nociceptiva/diagnóstico por imagem , Preferência do Paciente/economia , Estimulação Física , Creme para a Pele/economia , Estriado Ventral/diagnóstico por imagem , Área Tegmentar Ventral/diagnóstico por imagem , Adulto JovemRESUMO
BACKGROUND: In women with abnormal uterine bleeding, fibroids are a frequent finding. In case of heavy menstrual bleeding and presence of submucosal type 0-1 fibroids, hysteroscopic resection is the treatment of first choice, as removal of these fibroids is highly effective. Hysteroscopic myomectomy is currently usually performed in the operating theatre. A considerable reduction in costs and a higher patient satisfaction are expected when procedural sedation and analgesia with propofol (PSA) in an outpatient setting is applied. However, both safety and effectiveness - including the necessity for re-intervention due to incomplete resection - have not yet been evaluated. METHODS: This study is a multicentre randomised controlled trial with a non-inferiority design and will be performed in the Netherlands. Women > 18 years with a maximum of 3 symptomatic type 0 or 1 submucosal fibroids with a maximum diameter of 3.5 cm are eligible to participate in the trial. After informed consent, 205 women will be randomised to either hysteroscopic myomectomy using procedural sedation and analgesia with propofol in an outpatient setting or hysteroscopic myomectomy using general anaesthesia in a clinical setting in the operating theatre. Primary outcome will be the percentage of complete resections, based on transvaginal ultrasonography 6 weeks postoperatively. Secondary outcomes are cost effectiveness, menstrual blood loss (Pictorial blood assessment chart), quality of life, pain, return to daily activities/work, hospitalization, (post) operative complications and re-interventions. Women will be followed up to one year after hysteroscopic myomectomy. DISCUSSION: This study may demonstrate comparable effectiveness of hysteroscopic myomectomy under procedural sedation and analgesia versus general anaesthesia in a safe and patient friendly environment, whilst achieving a significant cost reduction. TRIAL REGISTRATION: Dutch trial register, number NTR5357 . Registered 11th of August 2015.
Assuntos
Analgesia/economia , Anestesia Geral/economia , Miomectomia Uterina/economia , Neoplasias Uterinas/economia , Neoplasias Uterinas/cirurgia , Adulto , Analgesia/métodos , Anestesia Geral/métodos , Análise Custo-Benefício , Feminino , Humanos , Histeroscopia/economia , Laparotomia/economia , Pessoa de Meia-Idade , Países Baixos , Manejo da Dor , Satisfação do Paciente , Miomectomia Uterina/métodosRESUMO
PURPOSE OF REVIEW: The current review focuses on precise anesthesia for video-assisted thoracoscopic surgery (VATS) with the goal of enhanced recovery. RECENT FINDINGS: VATS has become an established and widely used minimally invasive approach with broad implementation on a variety of thoracic operations. In the current environment of enhanced recovery protocols and cost containment, minimally invasive VATS operations suggest adoption of individualized tailored, precise anesthesia. In addition to a perfect lung collapse for surgical interventions with adequate oxygenation during one lung ventilation, anesthesia goals include a rapid, complete recovery with adequate postoperative analgesia leading to early discharge and minimized costs related to postoperative inpatient services. The components and decisions related to precise anesthesia are reviewed and discussed including: letting patients remain awake versus general anesthesia, whether the patient should be intubated or not, operating with or without muscle relaxation, whether to use different separation devises, operating with different local and regional blocks and monitors. CONCLUSION: The determining factors in designing a precise anesthesic for VATS operations involve consensus on patients' tolerance of the associated side effects, the best practice or techniques for surgery and anesthesia, the required postoperative support, and the care team's experience.
Assuntos
Analgesia/métodos , Anestesia/métodos , Anestésicos/efeitos adversos , Dor Pós-Operatória/terapia , Cirurgia Torácica Vídeoassistida/efeitos adversos , Manuseio das Vias Aéreas/economia , Manuseio das Vias Aéreas/métodos , Analgesia/efeitos adversos , Analgesia/economia , Anestesia/efeitos adversos , Anestesia/economia , Anestésicos/administração & dosagem , Tomada de Decisão Clínica , Custos Hospitalares , Humanos , Tempo de Internação/economia , Monitorização Intraoperatória/economia , Monitorização Intraoperatória/métodos , Dor Pós-Operatória/etiologia , Período Pós-Operatório , Cirurgia Torácica Vídeoassistida/métodos , Fatores de TempoRESUMO
AIMS: To estimate the cost to hospitals of materials (i.e. medications, equipment, and supplies) required to administer common interventions for post-surgical analgesia after total knee arthroplasty (TKA), including single-injection peripheral nerve block (sPNB), continuous peripheral nerve block (cPNB), periarticular infiltration of multi-drug cocktails, continuous epidural analgesia, intravenous patient-controlled analgesia (IV PCA), and local infiltration of bupivacaine liposome injectable suspension (BLIS). MATERIALS AND METHODS: This analysis was conducted using a mixed methods approach combining published literature, publicly available data sources, and administrative data, to first identify the materials required to administer these interventions, and then estimate the cost to the hospital of those materials. Medication costs were estimated primarily using the Wholesale Acquisition Costs (WAC), the cost of reusable equipment was obtained from published sources, and costs for disposable supplies were obtained from the US Government Services Administration (GSA) database. Where uncertainty existed about the technique used when administering these interventions, costs were calculated for multiple scenarios reflecting different assumptions. RESULTS: The total cost of materials (i.e. medications, equipment, and supplies) required to provide post-surgical analgesia was $41.88 for sPNB with bupivacaine; $756.57 for cFNB with ropivacaine; $16.38 for periarticular infiltration with bupivacaine, morphine, methylprednisolone, and cefuroxime; $453.84 for continuous epidural analgesia with fentanyl and ropivacaine; $178.94 for IV PCA with morphine; and $319.00 for BLIS. LIMITATIONS: This analysis did not consider the cost of healthcare providers required to administer these interventions. In addition, this analysis focused on the cost of materials and, therefore, did not consider aspects of relative efficacy or safety, or how the choice of intervention for post-surgical analgesia might impact outcomes such as length of stay, re-admissions, discharge status, adverse events, or total hospitalization costs. CONCLUSIONS: This study provided an estimate of the costs to hospitals for materials required to administer commonly used interventions for post-surgical analgesia after TKA.
Assuntos
Analgesia Controlada pelo Paciente/economia , Analgésicos Opioides/economia , Artroplastia do Joelho/métodos , Custos Hospitalares , Dor Pós-Operatória/tratamento farmacológico , Idoso , Analgesia/economia , Analgesia/métodos , Analgesia Epidural/economia , Analgesia Epidural/métodos , Analgesia Controlada pelo Paciente/métodos , Analgésicos Opioides/uso terapêutico , Artroplastia do Joelho/efeitos adversos , Estudos de Coortes , Análise Custo-Benefício , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Bloqueio Nervoso/economia , Bloqueio Nervoso/métodos , Manejo da Dor/economia , Manejo da Dor/métodos , Medição da Dor , Dor Pós-Operatória/fisiopatologia , Estudos Retrospectivos , Medição de Risco , Estados UnidosRESUMO
BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is one of the most commonly performed procedures for the treatment of obesity. Patients with obesity are more prone to experience opioid-related adverse events (ORAE). OBJECTIVES: The objective of this study is to determine if a multimodal analgesia protocol (MAP) reduces ORAE and provides effective pain relief for patients after LSG. SETTING: This study was conducted at University Hospital, Singapore. METHODS: The MAP consists of mandatory pre-operative etoricoxib, intra-operative acetaminophen, and post-operative acetaminophen with optional post-operative tramadol. We identified and collected data for patients who underwent LSG between May 2010 and November 2015 and compared patients before and after the implementation of the MAP. RESULTS: One hundred fifty-eight patients were included and 68 patients were treated with the MAP. There were no differences in age, gender, body mass index, ethnicity, or comorbidities between the two groups except for the incidence of hypertension (p = 0.015). There was a significant reduction in the incidence of ORAE from 33.3 to 8.8% (p < 0.001) after the implementation of the MAP. There was also a significant reduction in the use of opioids intra-operatively from 58.2 to 43.6 mg (p < 0.001) and post-operatively from 23.7 to 0.7 mg (p < 0.001). Pain scores were similar at 1, 6, and 48 post-operatively, while pain scores were significantly reduced at 12 (p = 0.033) and 24 h (p = 0.02) post-operatively. Multivariate analysis showed that these results remained significant. CONCLUSION: Our study suggests that a MAP reduces ORAE and provides effective pain relief for patients undergoing LSG.
Assuntos
Analgesia/métodos , Analgésicos Opioides/efeitos adversos , Analgésicos/uso terapêutico , Gastrectomia , Obesidade Mórbida/cirurgia , Dor Pós-Operatória/prevenção & controle , Adulto , Analgesia/efeitos adversos , Analgesia/economia , Analgésicos/economia , Índice de Massa Corporal , Custos de Medicamentos , Feminino , Gastrectomia/efeitos adversos , Gastrectomia/métodos , Humanos , Laparoscopia/efeitos adversos , Laparoscopia/métodos , Masculino , Pessoa de Meia-Idade , Obesidade Mórbida/epidemiologia , Dor Pós-Operatória/economia , Dor Pós-Operatória/epidemiologia , Dor Pós-Operatória/etiologia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Período Pós-Operatório , Singapura/epidemiologiaRESUMO
BACKGROUND: Common standard practice after complex arthroscopic elbow surgery includes hospital admission for 72 h. The authors hypothesized that an expedited care pathway, with 24 h of hospital admission and ambulatory brachial plexus analgesia and continuous passive motion at home, results in equivalent elbow range of motion (ROM) 2 weeks after surgery compared with standard 72-h hospital admission. METHODS: A randomized, single-blinded study was conducted after obtaining approval from the research ethics board. Forty patients were randomized in a 1:1 ratio using a computer-generated list of random numbers into an expedited care pathway group (24-h admission) and a control group (72-h admission). They were treated equally aside from the predetermined hospital length of stay. RESULTS: Patients in the control (n = 19) and expedited care pathway (n = 19) groups achieved similar elbow ROM 2 weeks (119 ± 18 degrees and 121 ± 15 degrees, P = 0.627) and 3 months (130 ± 18 vs. 130 ± 11 degrees, P = 0.897) postoperatively. The mean difference in elbow ROM at 2 weeks was 2.6 degrees (95% CI, -8.3 to 13.5). There were no differences in analgesic outcomes, physical function scores, and patient satisfaction up to 3 months postoperatively. Total hospital cost of care was 15% lower in the expedited care pathway group. CONCLUSION: The results suggest that an expedited care pathway with early hospital discharge followed by ambulatory brachial plexus analgesia and continuous passive motion at home is a cost-effective alternative to 72 h of hospital admission after complex arthroscopic elbow surgery.
Assuntos
Analgésicos/administração & dosagem , Artroscopia , Plexo Braquial/efeitos dos fármacos , Cotovelo/cirurgia , Bombas de Infusão , Dor Pós-Operatória/tratamento farmacológico , Acetaminofen/administração & dosagem , Acetaminofen/economia , Acetaminofen/uso terapêutico , Adulto , Analgesia/economia , Analgesia/métodos , Analgésicos/economia , Analgésicos/uso terapêutico , Analgésicos não Narcóticos/administração & dosagem , Analgésicos não Narcóticos/economia , Analgésicos não Narcóticos/uso terapêutico , Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/economia , Analgésicos Opioides/uso terapêutico , Análise de Variância , Anti-Inflamatórios não Esteroides/administração & dosagem , Anti-Inflamatórios não Esteroides/economia , Anti-Inflamatórios não Esteroides/uso terapêutico , Análise Custo-Benefício , Equipamentos Descartáveis , Feminino , Seguimentos , Humanos , Indometacina/administração & dosagem , Indometacina/economia , Indometacina/uso terapêutico , Pacientes Internados , Tempo de Internação/estatística & dados numéricos , Masculino , Oxicodona/administração & dosagem , Oxicodona/economia , Oxicodona/uso terapêutico , Satisfação do Paciente/estatística & dados numéricos , Amplitude de Movimento Articular , Método Simples-CegoRESUMO
Since being reported in 2008, high volume local infiltration analgesia (HVLIA) has rapidly gained popularity for patients undergoing hip and knee replacement. We undertook this review to investigate whether there was evidence for equivalence of HVLIA compared to peripheral nerve block techniques with respect to early postoperative analgesia and functional recovery, or for other outcomes such as cost and process efficiency, persistent postsurgical pain and arthroplasty revision rate. We found that despite the popularity of HVLIA, supporting evidence for its use is currently limited. HVLIA certainly provides postoperative analgesia, but it is not clear whether it is equivalent to contemporary peripheral nerve block techniques in terms of either analgesia or early or later functional outcome in the context of a modern, comprehensive enhanced recovery program. Nor is it possible to state whether HVLIA provides benefits in terms of persistent postsurgical pain or cost and process efficiency. Well designed trials directly comparing peripheral nerve block with a standardised HVLIA technique are urgently required.
Assuntos
Analgesia/métodos , Anestesia Local/métodos , Artroplastia de Quadril/métodos , Artroplastia do Joelho/métodos , Bloqueio Nervoso/métodos , Nervos Periféricos , Amidas , Analgesia/economia , Anestesia Local/economia , Anestésicos Locais , Anti-Inflamatórios não Esteroides , Artroplastia de Quadril/economia , Artroplastia do Joelho/economia , Custos e Análise de Custo , Medicina Baseada em Evidências , Humanos , Cetorolaco , Dor Pós-Operatória/epidemiologia , Reoperação/estatística & dados numéricos , Ropivacaina , Resultado do TratamentoAssuntos
Analgesia/veterinária , Analgésicos/administração & dosagem , Dor/veterinária , Medicina Veterinária/ética , Analgesia/economia , Analgésicos/economia , Animais , Ética Profissional , Humanos , Dor/tratamento farmacológico , Dor/prevenção & controle , Medicina Veterinária/economia , Medicina Veterinária/normasRESUMO
BACKGROUND: Infantile hypertrophic pyloric stenosis can be corrected by either open (OP) or laparoscopic pyloromyotomy (LP). LP may provide clinical benefits of reduced time to postoperative full feeds and reduced postoperative inpatient stay, but the cost effectiveness is not known. Our aim was to compare the cost effectiveness of laparoscopic and open pyloromyotomy. METHODS: OP and LP were compared in a multicenter randomized double-blind controlled trial, for which the primary outcomes were time to full feeds and time to discharge. In order to undertake a detailed cost analysis, we assigned costs, calculated on an individual patient basis, to laboratory costs, imaging, medical staff, medication, ward, operative, and outpatient appointments for 74 patients recruited from one of the participating centers. Data (mean ± SEM) were compared using linear regression analysis, adjusting for the minimization criteria used in the trial. RESULTS: Operation costs were similar between the two groups ($3,276 ± $244 LP versus $3,535 ± $152 OP). A shorter time to full feeds and shorter hospital stay in LP versus OP patients resulted in a highly significant difference in ward costs ($2,650 ± $126 LP versus $3,398 ± $126 OP; P = .001) and a small difference in other costs. Overall, LP patients were $1,263 (95% confidence interval $395-$2,130; P = .005) less expensive to treat than OP patients. Sensitivity analyses of laparoscopic hardware usage and of incomplete pyloromyotomy indicated that LP was consistently less expensive than OP. CONCLUSIONS: LP is a cost-effective alternative to OP as it delivers improved clinical outcome at a lower price.
Assuntos
Laparoscopia/economia , Tempo de Internação/economia , Avaliação de Resultados em Cuidados de Saúde/economia , Estenose Pilórica Hipertrófica/economia , Estenose Pilórica Hipertrófica/cirurgia , Analgesia/economia , Análise Custo-Benefício , Custos Hospitalares , Humanos , Lactente , Recém-Nascido , Laboratórios Hospitalares/economia , Laparoscopia/métodos , Ambulatório Hospitalar/economia , Estudos ProspectivosRESUMO
BACKGROUND: Intensive care units (ICUs) account for considerable health care costs. Adequate pain and sedation management is important to clinical care. OBJECTIVE: To determine whether implementing a protocol for management of analgesia, sedation, and delirium in the ICU would save costs. METHODS: With data from the I-SAVE (Impact of Sedation, Analgesia and Delirium Protocols Evaluated in the Intensive Care Unit: an Economic Evaluation) study, a prospective pre- and postprotocol design was used. Between the 2 periods, protocols for systematic management of sedation, analgesia, and delirium were implemented. Cost-effectiveness was calculated by associating the variation of cost and effectiveness measures (proportion of patients within targeted pain, sedation, and delirium goals). Total costs (in 2004 Canadian dollars), by patient, consisted of the sum of sedation, analgesia, and delirium drug acquisition costs during the ICU stay and the cost of the ICU stay. RESULTS: A total of 1214 patients, 604 in the preprotocol group and 610 in the postprotocol group, were included. The mean (SD) ICU length of stay and the duration of mechanical ventilation were shorter among patients of the postprotocol group compared with those of the preprotocol group (5.43 [6.43] and 6.39 [8.05] days, respectively; p = 0.004 and 5.95 [6.80] and 7.27 [9.09] days, respectively; p < 0.009). The incidence of delirium remained the same. The proportion of patients with Richmond Agitation and Sedation (RASS) scores between -1 and +1 increased from 57.0% to 66.2% (p = 0.001), whereas the proportion of patients with a numeric rating scale (NRS) score of 1 or less increased from 56.3% to 66.6% (p < 0.001). The mean total cost of ICU hospitalization decreased from $6212.64 (7846.86) in the preprotocol group to $5279.90 (6263.91) in the postprotocol group (p = 0.022). The cost analyses for pain and agitation management improved; the proportion of patients with RASS scores between -1 and +1 or NRS scores of 1 or less increased significantly in the postprotocol group while costing, on average, $932.74 less per hospitalization. CONCLUSIONS: Establishing protocols for patient-driven management of sedation, analgesia, and delirium is a cost-effective practice and allows savings of nearly $1000 per hospitalization.
Assuntos
Analgesia/economia , Protocolos Clínicos , Cuidados Críticos/economia , Sedação Profunda/economia , Delírio/economia , APACHE , Analgesia/métodos , Analgésicos/administração & dosagem , Analgésicos/economia , Análise Custo-Benefício , Cuidados Críticos/métodos , Sedação Profunda/métodos , Delírio/epidemiologia , Delírio/etiologia , Humanos , Hipnóticos e Sedativos/administração & dosagem , Hipnóticos e Sedativos/economia , Unidades de Terapia Intensiva/economia , Unidades de Terapia Intensiva/normas , Tempo de Internação/economia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Respiração Artificial/economiaAssuntos
Analgesia/normas , Analgesia/tendências , Medicina Baseada em Evidências/normas , Medicina Baseada em Evidências/tendências , Dor/tratamento farmacológico , Padrões de Prática Médica/normas , Padrões de Prática Médica/tendências , Analgesia/economia , Conflito de Interesses/legislação & jurisprudência , Indústria Farmacêutica/ética , Indústria Farmacêutica/legislação & jurisprudência , Medicina Baseada em Evidências/legislação & jurisprudência , Humanos , Padrões de Prática Médica/legislação & jurisprudênciaRESUMO
Xenon is widely used for maintenance of anesthesia, however the analgesic effect of this noble gas brings to an idea of its use in analgesic schemes. The first time antinociceptive features of Xe were described by B. Lachman and colleagues in 1988. It is well known that Xe realises its analgesic potential through powerful non-competitive blockade of NMDA-glutamate receptors, by that suppressing the development of hyperalgesia process in neurons of posterior horns of spinal cord, which take part in the process of pain transmission and forming of central sensitization and becoming the actual "gates of pain". In the given review the literature data on mechanisms, effectiveness, safety and farmacoeconomic justification of the use of Xe as an analgesic in clinical practice are brought up.
Assuntos
Analgesia/métodos , Analgésicos/uso terapêutico , Dor Pós-Operatória/prevenção & controle , Xenônio/uso terapêutico , Analgesia/economia , Analgésicos/administração & dosagem , Analgésicos/efeitos adversos , Analgésicos/economia , Humanos , Xenônio/administração & dosagem , Xenônio/efeitos adversos , Xenônio/economiaRESUMO
The practice of pain medicine is often considered a fledgling field, as are the economic, business, and related ethical issues associated with providing these services. This article first traces the history of pain care and its relationships to industry and business, as well as the impact of government regulations over the ages. The authors challenge the view that the commonly discussed health care issues facing pain medicine are new by tracing the business and regulatory-related antecedents of pain care practice from the first through 21st century. The controversies associated with the practice of delivering pain-related health care services in an ethical manner are discussed with specific reference to the early work of clinicians, health care activists, and policy makers. The early activities of noteworthy individuals such as Pliny the Great, Hua T'o, John Locke, Benjamin Franklin, Oliver Wendell Holmes Sr., William Morton, Henry and William James, Heinrick Dresser, and other recent health care activists are reviewed. Issues of practitioner liability and regulatory restrictions on practice are also discussed in a historical context. The authors conclude that familiar ethical dilemmas commonly arose in past centuries, and history may be repeating itself with respect to the concerns now being discussed within our field. These arguments are reflected against the pain medicine Ethics Charters of the American Academy of Pain Medicine throughout the document. Finally, we outline the challenges for the present and future. With an understanding of these eight historical events as a backdrop, we may be at an opportune time to better address these issues in a manner that could provide the most effective pain care in our society.
Assuntos
Analgesia/história , Atenção à Saúde/história , Dor/tratamento farmacológico , Analgesia/economia , Analgesia/métodos , Atenção à Saúde/legislação & jurisprudência , Indústria Farmacêutica , Ética Médica , Medicina Baseada em Evidências , Regulamentação Governamental , História do Século XVIII , História do Século XIX , História do Século XX , História do Século XXI , História Antiga , História Medieval , HumanosRESUMO
INTRODUCTION: Today local anesthetic wound infiltration is widely recognized as a useful adjunct in a multimodality approach to postoperative pain management. The effectiveness of continuous wound infusion of ropivacaine for postoperative pain relief after laparoscopic living donor nephrectomy was analyzed in this retrospective, comparative analysis. METHODS: Twenty patients undergoing living donor nephrectomy were divided into two groups: standard analgesic therapy (n=10) and ropivacaine continuous infusion group (n = 10). RESULTS: We observed a significant difference in term of visual analogue scale scores, use of morphine, hospital stay, and bowel recovery in favor of the ropivacaine group. The cost analysis demonstrated an overall savings of 985 Euros/patient. DISCUSSION: Surgical wound infusion with ropivacaine was safe and seemed to improve pain relief and accelerate recovery and discharge, reducing the overall costs of care. Postoperative pain control in the donor is of primary importance for better patient compliance and greater perceived quality of health care service.
Assuntos
Amidas/administração & dosagem , Analgesia/métodos , Anestésicos Locais/administração & dosagem , Transplante de Rim , Laparoscopia , Doadores Vivos , Nefrectomia , Dor Pós-Operatória/prevenção & controle , Amidas/economia , Analgesia/economia , Anestésicos Locais/economia , Estudos de Casos e Controles , Análise Custo-Benefício , Defecação/efeitos dos fármacos , Custos de Medicamentos , França , Custos Hospitalares , Humanos , Infusões Intralesionais , Itália , Transplante de Rim/efeitos adversos , Transplante de Rim/economia , Laparoscopia/efeitos adversos , Laparoscopia/economia , Tempo de Internação , Morfina/administração & dosagem , Entorpecentes/administração & dosagem , Nefrectomia/efeitos adversos , Nefrectomia/economia , Medição da Dor , Dor Pós-Operatória/economia , Dor Pós-Operatória/etiologia , Recuperação de Função Fisiológica , Estudos Retrospectivos , Ropivacaina , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVE: To evaluate treatment patterns and costs among patients with painful diabetic peripheral neuropathy (pDPN) newly prescribed pregabalin or duloxetine in usual care settings. METHODS: Using the PharMetrics® Database, patients with pDPN (ICD-9-CM codes 357.2 or 250.6x) newly prescribed pregabalin or duloxetine were identified. Patients initiated on duloxetine (n=713; mean age 55.4 ± 9.5 years) were propensity score-matched with patients initiated on pregabalin (n=713; mean age 56.3 ± 9.3 years). Prevalence of comorbidities, pain-related pharmacotherapy and healthcare resource use/costs (pharmacy, outpatient, inpatient, total) were examined during the 12 months preceding (pre-index) and following (follow-up) the date of the first pregabalin or duloxetine prescription. RESULTS: Both cohorts had multiple comorbidities and a substantial pain medication burden. Among pregabalin patients, use of other anticonvulsants (35.6% vs. 24.7%) and tricyclic antidepressants significantly decreased (18.2% vs. 13.7%) and serotonin-norepinephrine reuptake inhibitors (SNRIs) increased (7.9 % vs. 12.9%) in the follow-up period; all P values <0.05. Among duloxetine patients, use of other SNRIs (8.7% vs. 5.2%) and selective serotonin reuptake inhibitors decreased significantly (32.1% vs. 18.9%) in the follow-up period, but there were increases for anticonvulsants (42.1% vs. 48.4%), benzodiazepines (25.5% vs. 32%), and sedative/hypnotics (22.6% vs. 25.8%); all P values <0.05. Among pregabalin and duloxetine patients there were increases (P<0.05) in pharmacy, outpatient, and total healthcare costs from the pre-index to the follow-up period. Total medication costs in the follow-up period were significantly higher for duloxetine (median $6,763 [IQR $3,970-$10,914]) relative to pregabalin (median $6,059 [IQR $3,277-$9,865]); P=0.0017. CONCLUSIONS: Patients with pDPN prescribed pregabalin and duloxetine were characterized by a substantial comorbidity and pain medication burden. Although there were no differences in total healthcare costs, medication costs were significantly higher in the duloxetine cohort relative to the pregabalin cohort.