RESUMO
OBJECTIVES: Gastrointestinal (GI) bleeding is a common medical emergency associated with significant mortality. Transcatheter arterial embolization first was introduced by Rosch et al as an alternative to surgery for upper GI bleeding. The clinical success in patients with GI bleeding treated with transcatheter arterial embolization previously has been reported. However, there are no cost-effectiveness analyses reported to date. Here we report cost-effectiveness analysis of N-butyl 2-cyanoacrylate glue (NBCA) and ethylene-vinyl alcohol copolymer (Onyx) versus coil (gold standard) for treatment of GI bleeding from a healthcare payer perspective. METHODS: Fixed-effects modeling with a generalized linear mixed method was used in NBCA and coil intervention arms to determine the pooled probabilities of clinical success and mortality with complications with their confidence intervals, while the Clopper-Pearson model was used for Onyx to determine the same parameters. Models were provided by the "Meta-Analysis with R" software package. A decision tree was built for cost-effectiveness analysis, and Microsoft Excel was used for probabilistic sensitivity analysis. The cost-effective option was determined based on the incremental cost-effectiveness ratio and scatter plots of incremental cost versus incremental quality-adjusted life-years. RESULTS: Comparing scatter plots and incremental cost-effectiveness ratio results, -$1024 and -$1349 per quality-adjusted life-year for Onyx and N-butyl 2-cyanoacrylate glue, respectively, Onyx was the least expensive and most effective intervention. CONCLUSION: Onyx was the dominant strategy regardless of threshold values. Our analyses provide a framework for researchers to predict the target clinical effectiveness for early-stage TAE interventions and guide resource allocation decisions.
Assuntos
Embolização Terapêutica/economia , Embolização Terapêutica/métodos , Embucrilato/economia , Hemorragia Gastrointestinal/economia , Hemorragia Gastrointestinal/terapia , Polivinil/economia , Artérias/cirurgia , Cateterismo/economia , Cateterismo/métodos , Análise Custo-Benefício , Árvores de Decisões , Embucrilato/uso terapêutico , Hemorragia Gastrointestinal/mortalidade , Humanos , Método de Monte Carlo , Polivinil/uso terapêuticoRESUMO
BACKGROUND: Gastrointestinal hemorrhage (GIH) has been reported as one of the most common GI complications in patients with pulmonary hypertension (PH). There is paucity of data on the national burden of GIH in patients with PH. We aimed to assess the prevalence, trends and outcomes of endoscopic interventions in patients with PH who were admitted with GIH. METHOD: We queried National Inpatient Sample (NIS) database from 2005 to 2014 and identified the patients hospitalized with primary or secondary discharge diagnosis of PH (ICD 9 CM Code: 416.0, 416.8, and 416.9). Using Clinical Classification Software Coding system (153) patients with concurrent diagnosis of GIH were then identified. We studied the prevalence and trends of GIH in PH, factors associated with GIH, use of endoscopy, factors associated with utilization of endoscopic interventions, endoscopy outcomes including mortality, and overall healthcare burden. RESULTS: Out of 7,586,973 PH hospitalizations 3.2% (N = 246,358) had concurrent GIH, with a rising prevalence of GIH in PH patients during the last decade. Clinical predictors for GIH in PH included older age, congestive heart failure, anticoagulation therapy and concurrent alcohol abuse. Mean length of stay (LOS) in PH patients hospitalized with GIH was significantly higher than without GIH (8.6 vs. 6.4 days, p < 0.01) along with a significant increase in hospitalization cost ($20,189 vs. $14,807, p < 0.01). Similarly, odds of in-hospital mortality increase by ~ 1.5 times in PH patients with GIH than those without it (adjusted odds ratio [aOR: 1.45, 95%CI: 1.43-1.47]). Endoscopic interventions were performed in 48.6% of patients with PH and GIH during their hospitalization. Older patients were more likely to undergo endoscopy, as well as the patients who received blood transfusion, and those with hypovolemic shock. Patients with acute respiratory failure and acute renal failure were less likely to get endoscopy. Mean LOS in patients undergoing endoscopic intervention was significantly higher than those who did not receive any intervention (8.7 vs. 8.4 days, p < 0.01), without a substantial increase in hospitalization cost ($20,344 vs. $20,041, p < 0.01). Also, there was a significant decrease in in-hospital mortality in patients undergoing endoscopic interventions. CONCLUSION: Concurrent GIH in patients with PH increases length of stay; healthcare costs and increases in-hospital mortality. Use of endoscopic interventions in these patients is associated with reduced length of stay, in-hospital mortality without significantly increasing the overall health care burden and should be considered in hospitalized patients with PH who are admitted with GIH. Future studies comparing GIH patients with and without PH should be done to assess if PH is a risk factor for worse outcomes. CLINICAL TRIAL REGISTRATION NUMBER: No IRB required due to use of national de-identified data.
Assuntos
Endoscopia Gastrointestinal/tendências , Hemorragia Gastrointestinal/terapia , Hemostase Endoscópica/tendências , Hipertensão Pulmonar/terapia , Adolescente , Adulto , Idoso , Bases de Dados Factuais , Endoscopia Gastrointestinal/efeitos adversos , Endoscopia Gastrointestinal/economia , Endoscopia Gastrointestinal/mortalidade , Feminino , Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/economia , Hemorragia Gastrointestinal/mortalidade , Custos de Cuidados de Saúde/tendências , Hemostase Endoscópica/efeitos adversos , Hemostase Endoscópica/economia , Hemostase Endoscópica/mortalidade , Mortalidade Hospitalar/tendências , Humanos , Hipertensão Pulmonar/diagnóstico , Hipertensão Pulmonar/economia , Hipertensão Pulmonar/mortalidade , Pacientes Internados , Tempo de Internação/tendências , Masculino , Pessoa de Meia-Idade , Prevalência , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , Adulto JovemRESUMO
BACKGROUND AND AIMS: Gastrointestinal (GI) bleeding is one most common complications of acute myocardial infarction (AMI). We aimed to determine the incidence, in-hospital outcomes, associated healthcare burden and predictors of GI bleeding within 30 days after AMI. METHODS: Data were extracted from Nationwide Readmission Database 2010-2014. Patients were included if they had a primary diagnosis of ST or non-ST elevation myocardial infarction. Exclusion criteria were admissioned in December, aged less than 18 years and a diagnosis of type-2 MI. The primary outcome was 30-day readmission with upper or lower GI bleeding. Secondary outcomes were in-hospital mortality, etiology of bleeding, in-hospital complications, procedures, length of stay, and total hospitalization charges. Independent predictors of readmission were identified using multivariate logistic regression analysis. RESULTS: Out of the 3,520,241 patients discharged with ACS, 10,018 (0.3%) were readmitted with GI bleeding within 30 days of discharge. 60% had lower GI bleeding. Most common sources suspected were GI cancers in 17% and hemorrhoidal bleeding in 10%. In hospital mortality rate for readmission was 3.6%. Independent predictors of readmission were age, Charlson comorbidity score, history of chronic kidney disease, GI tumor, inflammatory bowel disease and artificial heart valve. Type of treatment for AMI had no impact on readmission. Patients readmitted had higher rates of shock (adjusted odds ratio, 1.48, 95% CI 1.01-3.72). CONCLUSIONS: In the first nationwide study, 30-day incidence of GI bleeding after AMI is 0.3%. GI bleeding complicating AMI carries a substantial in-hospital mortality and cost of care.
Assuntos
Hemorragia Gastrointestinal/epidemiologia , Infarto do Miocárdio/complicações , Readmissão do Paciente/estatística & dados numéricos , Idoso , Comorbidade , Bases de Dados Factuais , Feminino , Hemorragia Gastrointestinal/economia , Hemorragia Gastrointestinal/etiologia , Custos de Cuidados de Saúde/estatística & dados numéricos , Mortalidade Hospitalar , Humanos , Incidência , Seguro Saúde/estatística & dados numéricos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Modelos Logísticos , Masculino , Infarto do Miocárdio/economia , Readmissão do Paciente/economia , Fatores de Risco , Estados Unidos/epidemiologiaAssuntos
Pólipos do Colo/cirurgia , Hemorragia Gastrointestinal/prevenção & controle , Hemorragia Pós-Operatória/prevenção & controle , Procedimentos Cirúrgicos Profiláticos/economia , Instrumentos Cirúrgicos/economia , Idoso , Idoso de 80 Anos ou mais , Colonoscopia/efeitos adversos , Redução de Custos , Ressecção Endoscópica de Mucosa/efeitos adversos , Feminino , Hemorragia Gastrointestinal/economia , Hemorragia Gastrointestinal/etiologia , Humanos , Masculino , Medicare , Hemorragia Pós-Operatória/economia , Hemorragia Pós-Operatória/etiologia , Procedimentos Cirúrgicos Profiláticos/instrumentação , Procedimentos Cirúrgicos Profiláticos/métodos , Estados UnidosRESUMO
Aim: To estimate the healthcare costs attributable to gastrointestinal (GI) bleeds in nonvalvular atrial fibrillation (NVAF) patients. Material & methods: A difference-in-differences approach was used in which NVAF patients suffering a (GI) bleed were propensity score matched to those not suffering a GI bleed, and the difference in healthcare costs in the year prior to the GI bleed and the subsequent 3 years was compared between the two groups. Results: The mean cost attributable to GI bleeds was £3989 (p < 0.0001) in the year of the bleed and £1816 (p = 0.001) in the subsequent year. Attributable costs arose primarily from inpatient visits. Conclusion: GI bleeds among NVAF patients are associated with significant healthcare costs up to 2 years following the bleed.
Assuntos
Anticoagulantes/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Efeitos Psicossociais da Doença , Hemorragia Gastrointestinal/economia , Pontuação de Propensão , Sistema de Registros , Acidente Vascular Cerebral/prevenção & controle , Idoso , Anticoagulantes/efeitos adversos , Fibrilação Atrial/complicações , Feminino , Seguimentos , Hemorragia Gastrointestinal/induzido quimicamente , Hemorragia Gastrointestinal/epidemiologia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/economia , Reino Unido/epidemiologiaRESUMO
Gastrointestinal bleeding (GIB) complicating ST-elevation myocardial infarction (STEMI) poses significant management challenges and may be associated with poor outcomes. We sought to evaluate the incidence and outcomes of GIB in STEMI patients using a nationwide database. We identified adults admitted with STEMI between in the National Inpatient Sample (2003 to 2016), and compared the morbidity, mortality, resource utilization, and cost in patients with and without GIB. We assessed rates of endoscopy referral and its associated with mortality. Among 1,450,696 weighted STEMI hospitalizations, 32,624 (2.2%) were complicated with GIB. Patients with GIB were older, and had distinctive characteristics compared to those without GIB. Older age, cardiogenic shock; history of peptic ulcer disease, cirrhosis, anemia, or alcohol use disorder were the strongest predictors of GIB during STEMI hospitalizations. In-hospital mortality was higher in the GIB group (28.2% vs 11.1%, p <0.001). The excess mortality associated with GIB persisted after propensity-score matching, and in sensitivity analyses excluding patients who underwent coronary intervention >24-hours after admission, and those transferred to another hospital. Post-STEMI GIB was associated with more strokes and acute kidney injury, longer hospitalizations, and higher cost. In a logistic regression analysis, GIB was independently associated with mortality (odds ratios [OR] 1.91, 95% confidence interval [CI] 1.85 to 1.97, p <0.001). There was a correlation between undergoing endoscopy and lower in-hospital mortality (unadjusted OR 0.27; 95% CI, 0.24 to 0.29; adjusted-OR 0.30; 95% CI, 0.27 to 0.33; p <0.001). In conclusion, GIB complicating STEMI is uncommon but is associated with excess morbidity, mortality, resource utilization and cost. Referral to endoscopy in this cohort may be associated with reduced in-hospital mortality.
Assuntos
Hemorragia Gastrointestinal/epidemiologia , Infarto do Miocárdio com Supradesnível do Segmento ST/epidemiologia , Injúria Renal Aguda/epidemiologia , Fatores Etários , Idoso , Alcoolismo/epidemiologia , Anemia/epidemiologia , Bases de Dados Factuais , Endoscopia Gastrointestinal/estatística & dados numéricos , Feminino , Hemorragia Gastrointestinal/economia , Mortalidade Hospitalar , Hospitalização/economia , Humanos , Incidência , Tempo de Internação/estatística & dados numéricos , Cirrose Hepática/epidemiologia , Masculino , Úlcera Péptica/epidemiologia , Encaminhamento e Consulta/estatística & dados numéricos , Choque Cardiogênico/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Estados Unidos/epidemiologiaRESUMO
OBJECTIVE: Acute cholangitis (AC) and upper gastrointestinal hemorrhage (UGIH) are common emergencies encountered by gastroenterologists. We aimed to evaluate the impact of UGIH on in-hospital mortality, morbidity and resource utilization among patients with AC. PATIENTS AND METHODS: Adult admissions with a principal diagnosis of AC were selected from the National Inpatient Sample 2010-2014. The exposure of interest was significant UGIH (requiring red blood cell transfusion). The primary outcome was in-hospital mortality. Secondary outcomes were significant UGIH's incidence, morbidity (shock, prolonged mechanical ventilation and total parenteral nutrition), and resource utilization (length of hospital stay and total hospitalization charges and costs). Confounders were adjusted for using propensity matching and multivariate regression analysis. RESULTS: A total of 50 375 admissions were included in the analysis, 747 of whom developed significant UGIH. After adjusting for confounders, the adjusted odds ratio (aOR) of in-hospital mortality for patients who developed UGIH was 7.1 (95% confidence interval: 2.1-23.9, P<0.01) compared with those who did not. Significant UGIH was associated with substantial increase in morbidity [shock: aOR: 4.1 (2.1-9.3), P<0.01, prolonged mechanical ventilation: aOR: 5.8 (2.2-12.4), P<0.01, total parenteral nutrition: aOR: 4.7 (1.9-10.7), P<0.01], and resource utilization [mean adjusted difference in: length of hospital stay: 7.01 (4.72-9.29), P<0.01 and total hospitalization charges: $81 818 ($58 109-$105 527), P<0.01 and costs: $25 230 ($17 805-$32 653), P<0.01]. Similar results were obtained using multivariate regression analysis. CONCLUSION: Onset of significant UGIH among patients hospitalized with AC has a detrimental effect on in-hospital mortality, morbidity and resource utilization.
Assuntos
Colangite/terapia , Hemorragia Gastrointestinal/terapia , Doença Aguda , Colangite/diagnóstico , Colangite/economia , Colangite/mortalidade , Bases de Dados Factuais , Feminino , Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/economia , Hemorragia Gastrointestinal/mortalidade , Preços Hospitalares , Custos Hospitalares , Mortalidade Hospitalar , Humanos , Incidência , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/terapia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Gastrointestinal hemorrhage (GIH) is reported to occur in 1-8% of patients admitted with acute ischemic stroke (AIS). AIS is considered to be a relative contraindication to GIE. AIMS: Evaluate the outcomes of gastrointestinal endoscopy (GIE) in patients hospitalized with AIS and GIH. METHODS: Patients hospitalized with AIS and GIH were included from the National Inpatient Sample 2005-2014. Primary outcome measure was in-hospital mortality in patients with AIS and GIH who underwent gastrointestinal endoscopy. Secondary outcomes were (1) resource utilization as measured by length of stay (LOS) and total hospitalization costs and (2) to identify independent predictors of undergoing GIE in patients with AIS and GIH. Confounders were adjusted for by using multivariable regression analysis. RESULTS: A total of 75,756 hospitalizations were included in the analysis. Using a multivariate analysis, the in-hospital mortality was significantly lower in patients who underwent GIE as compared to those who did not [aOR: 0.4, P < 0.001]. Patients who underwent GIE also had significantly shorter adjusted mean LOS [adjusted mean difference in LOS: 0.587 days, P < 0.001]. Patients with AIS and GIH who did not undergo GIE had significantly higher adjusted total hospitalization costs. [Mean adjusted difference in total hospitalization costs was $5801 (P < 0.001).] Independent predictors of undergoing GIE in this population were male gender, age > 65 years, Asian or Pacific race, hypovolemic shock, need for blood transfusion and admission to urban non-teaching hospital. CONCLUSIONS: Gastrointestinal endoscopy can be safely performed in a substantial number of patients with AIS and GIH.
Assuntos
Isquemia Encefálica/epidemiologia , Endoscopia Gastrointestinal , Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/terapia , Hemostase Endoscópica , Acidente Vascular Cerebral/epidemiologia , Adolescente , Adulto , Idoso , Isquemia Encefálica/economia , Isquemia Encefálica/mortalidade , Isquemia Encefálica/terapia , Tomada de Decisão Clínica , Bases de Dados Factuais , Endoscopia Gastrointestinal/efeitos adversos , Endoscopia Gastrointestinal/economia , Endoscopia Gastrointestinal/mortalidade , Feminino , Hemorragia Gastrointestinal/economia , Hemorragia Gastrointestinal/mortalidade , Hemostase Endoscópica/efeitos adversos , Hemostase Endoscópica/economia , Hemostase Endoscópica/mortalidade , Mortalidade Hospitalar , Hospitalização , Humanos , Pacientes Internados , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Valor Preditivo dos Testes , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/economia , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/terapia , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , Adulto JovemRESUMO
BACKGROUND AND GOALS: We examined the interaction between race, insurance, and important outcomes in nonvariceal upper gastrointestinal hemorrhage (NVUGIH). STUDY: Adults with NVUGIH were selected from the National Inpatient Sample. PRIMARY OUTCOME: in-hospital mortality. SECONDARY OUTCOMES: treatment modalities [esophagogastroduodenoscopy (EGD), early EGD, and endoscopic or radiologic therapy], and resource utilization (length of hospital stay and total hospitalization charges). RESULTS: Mortality was similar for Medicare and private insurance [adjusted odds ratios (aOR): 1.15 95% confidence interval (CI) 0.90 to 1.47), P=0.24], but higher for under/uninsured patients [aOR: 1.84 (CI: 1.42 to 2.40), P<0.01]. Compared with Medicare, patients with private insurance had more EGDs [aOR: 1.35 (CI: 1.23 to 1.48), P<0.01], early EGDs [aOR: 1.29 (CI: 1.21 to 1.38), P<0.01], and endoscopic [aOR: 1.19 (CI: 1.11 to 1.27), P<0.01], or radiologic therapy [aOR:1.35 (CI: 1.06 to 1.71), P=0.01]. Patients who were under/uninsured had less EGDs [aOR: 0.84 (CI: 0.76 to 0.91), P<0.01] or endoscopic therapy [aOR: 0.74 (CI: 0.68 to 0.81), P<0.01], but similar odds of early EGD [aOR: 0.95 (CI: 0.88 to 1.02), P=0.13] or radiologic therapy [aOR: 1.01 (CI: 0.75 to 1.37), P=0.75]. Compared with whites, blacks had lower [aOR: 0.73 (CI: 0.58 to 0.93), P=0.01] and Native Americans higher mortality [aOR: 2.60 (CI: 1.57 to 4.13), P<0.01]. Blacks were less likely [aOR: 0.86 (CI: 0.79 to 0.94), P<0.01] and Asians more likely [aOR: 1.24 (CI: 1.05 to 1.47), P=0.01] to have EGDs. Both blacks and Hispanics had lower, whereas Asians had higher early EGD rates. Patients with private insurance had lower total charges [adjusted mean difference: -$2761 (CI: -$4617 to -$906), P<0.01]. CONCLUSIONS: Insurance and race have independent effects on NVUGIH mortality, therapeutic modalities used, and resource utilization. Black and under/uninsured patients have the worst outcomes.
Assuntos
Hemorragia Gastrointestinal/terapia , Hospitalização/estatística & dados numéricos , Cobertura do Seguro/estatística & dados numéricos , Grupos Raciais/estatística & dados numéricos , Adulto , Idoso , Estudos de Coortes , Endoscopia do Sistema Digestório/métodos , Feminino , Hemorragia Gastrointestinal/economia , Hemorragia Gastrointestinal/epidemiologia , Preços Hospitalares/estatística & dados numéricos , Mortalidade Hospitalar , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Estudos Retrospectivos , Estados UnidosRESUMO
BACKGROUND: Non-variceal upper gastrointestinal bleeding (NVUGIB) is still a common and life-threatening disease, thus it would have a big impact on medical care cost. However, little is known about risk factors for increased medical care cost in NVUGIB patients. AIM: The purpose of the study was to clarify predictor of requiring high medical care cost in NVUGIB patients. Patients who underwent endoscopic hemostasis due to NVUGIB between April 2012 and March 2015 were included in this retrospective study. We analyzed the association between patients' background including activity of daily livings (ADL) and high medical care cost using logistic regression model. Medical care cost was calculated in reference to the "Diagnosis Procedure Combination" which is diagnosis-dominant case-mix system in Japan. The cutoff value of high medical care cost was defined as its first quartile. ADL was assessed according to Katz-6 score. We defined impaired ADL patient who revealed Katz-6 score more than 1. RESULTS: A total of 128 consecutive patients were included in this study. Median medical care cost was 5323 USD (IQR 3661-8172 USD). There were 13 patients (10%) in impaired ADL group. In univariate analysis, age and impaired ADL before admission revealed significant association with high cost. Of these, impaired ADL was an only independent risk factor [odds ratio 15.3 (95% CI 2.49-183)] in multivariate analysis. CONCLUSION: Impairment in ADL before admission was an independent predictor for high medical care cost with NVUGIB patients.
Assuntos
Avaliação da Deficiência , Pessoas com Deficiência , Hemorragia Gastrointestinal/economia , Hemorragia Gastrointestinal/cirurgia , Atividades Cotidianas , Idoso , Estudos de Coortes , Feminino , Hemostase Endoscópica , Humanos , Japão , Masculino , Estudos Retrospectivos , Fatores de RiscoRESUMO
BACKGROUND AND AIM: Endoscopic treatment is widely accepted as the first-line therapy selection for esophageal variceal bleeding. Nevertheless, endoscopic injection sclerotherapy requires experienced endoscopists and is associated with a high risk of bleeding. Our study evaluates the feasibility and efficacy of transparent cap-assisted endoscopic sclerotherapy in the management of esophageal varices. PATIENTS AND METHODS: A randomized-controlled trial was conducted in a tertiary referral center from April 2015 to May 2016. Patients who received endoscopic sclerotherapy were randomized in a blinded manner into two groups: the transparent cap-assisted group (n=59) and the control group (n=61). RESULTS: The average injection sites were reduced in the transparent cap-assisted group compared with the control group (1.2±0.4 vs. 1.4±0.05, P=0.000), whereas no difference was observed in the dosage of lauromacrogol (16.97±4.91 vs. 16.85±4.57, P=0.662) and the hemorrhage that occurred during injection made no difference (50.8 vs. 61.0%, P=0.276); yet, salvage hemostasis methods were used in only nine patients in the transparent cap-assisted group compared with 17 patients in the control group (25.0 vs. 38.7%, P=0.0936). The cost of each procedure in the cap-assisted group was ¥2578 (1878-4202), whereas it was ¥3691 for the control group (2506-5791) (P=0.023). Moreover, in both groups, no esophageal constriction was observed during the 6-month follow-up period, whereas the rebleeding rate between two groups showed no statistical significance in 6 months (89.8 vs. 93.4%, P=0.563). CONCLUSION: Transparent cap-assisted sclerotherapy provided a clear field of vision and helped to fix the targeted veins, thus significantly reducing the use of the salvage hemostasis method during sclerotherapy injection hemorrhage. It is also associated with reduced injection sites and endoscopic therapy cost.
Assuntos
Varizes Esofágicas e Gástricas/terapia , Esofagoscópios , Esofagoscopia/instrumentação , Hemorragia Gastrointestinal/terapia , Hemostase Endoscópica/instrumentação , Polietilenoglicóis/administração & dosagem , Soluções Esclerosantes/administração & dosagem , Escleroterapia/instrumentação , China , Análise Custo-Benefício , Desenho de Equipamento , Varizes Esofágicas e Gástricas/diagnóstico , Varizes Esofágicas e Gástricas/economia , Esofagoscópios/economia , Esofagoscopia/efeitos adversos , Esofagoscopia/economia , Estudos de Viabilidade , Feminino , Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/economia , Custos de Cuidados de Saúde , Hemostase Endoscópica/efeitos adversos , Hemostase Endoscópica/economia , Humanos , Masculino , Pessoa de Meia-Idade , Polidocanol , Polietilenoglicóis/efeitos adversos , Polietilenoglicóis/economia , Estudos Prospectivos , Recidiva , Soluções Esclerosantes/efeitos adversos , Soluções Esclerosantes/economia , Escleroterapia/efeitos adversos , Escleroterapia/economia , Centros de Atenção Terciária , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND & AIMS: We aimed to determine the rate of hospital readmission within 30 days of non-variceal upper gastrointestinal hemorrhage and its impact on mortality, morbidity, and health care use in the United States. METHODS: We performed a retrospective study using the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project Nationwide Readmission Database for the year 2014 (data on 14.9 million hospital stays at 2048 hospitals in 22 states). We collected data on hospital readmissions of 203,220 adults who were hospitalized for urgent non-variceal upper gastrointestinal hemorrhage and discharged. The primary outcome was rate of all-cause readmission within 30 days of discharge. Secondary outcomes were reasons for readmission, readmission mortality rate, morbidity (shock and prolonged mechanical ventilation) and resource use (length of stay and total hospitalization costs and charges). Independent risk factors for readmission were identified using Cox regression analysis. RESULTS: The 30-day rate of readmission was 13%. Only 18% of readmissions were due to recurrent non-variceal upper gastrointestinal bleeding. The rate of death among patients readmitted to the hospital (4.7%) was higher than that for index admissions (1.9%) (P < .01). A higher proportion of readmitted patients had morbidities requiring prolonged mechanical ventilation (1.5%) compared with index admissions (0.8%) (P < .01). A total of 133,368 hospital days was associated with readmission, and the total health care in-hospital economic burden was $30.3 million (in costs) and $108 million (in charges). Independent predictors of readmission were Medicaid insurance, higher Charlson comorbidity score, lower income, residence in a metropolitan area, hemorrhagic shock, and longer stays in the hospital. Older age, private or no insurance, upper endoscopy, and prolonged mechanical ventilation were associated with lower odds for readmission. CONCLUSIONS: In a retrospective study of patients hospitalized for non-variceal upper gastrointestinal hemorrhage, 13% are readmitted to the hospital within 30 days of discharge. Readmission is associated with higher mortality, morbidity, and resource use. Most readmissions are not for recurrent gastrointestinal bleeding.
Assuntos
Doenças do Esôfago/epidemiologia , Hemorragia Gastrointestinal/epidemiologia , Mortalidade Hospitalar , Tempo de Internação/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Respiração Artificial/estatística & dados numéricos , Choque Hemorrágico/epidemiologia , Gastropatias/epidemiologia , Adulto , Fatores Etários , Idoso , Bases de Dados Factuais , Endoscopia do Sistema Digestório , Feminino , Hemorragia Gastrointestinal/economia , Custos de Cuidados de Saúde , Recursos em Saúde/economia , Recursos em Saúde/estatística & dados numéricos , Humanos , Renda/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Tempo de Internação/economia , Masculino , Medicaid/estatística & dados numéricos , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Readmissão do Paciente/economia , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Estados Unidos/epidemiologia , População UrbanaRESUMO
BACKGROUND: Gastrointestinal bleeding (GIB) is a frequent cause of re-admission in patients with continuous-flow left ventricular assist devices (CF-LVADs) and is associated with multiple endoscopic procedures and high resource utilization. Our aim was to determine the diagnostic and therapeutic yield of endoscopy and to develop a more cost-effective approach for the management of GIB in CF-LVAD recipients. METHODS: We retrospectively reviewed 428 patients implanted with a CF-LVAD between 2009 and 2016 at the Columbia University Medical Center and identified those hospitalized for GIB. Patients were categorized into upper GIB (UGIB), lower GIB (LGIB) and occult GIB (OGIB), based on clinical presentation. RESULTS: Eighty-seven CF-LVAD patients underwent a total of 164 GIBs, resulting in 239 endoscopies. Index presentation was consistent with UGIB in 30 (34.5%), LGIB in 19 (21.8%) and OGIB in 38 (43.7%) patients. On the first GIB, 147 endoscopies localized a bleeding source in 49 (30%), resulting in 24 (16.3%) endoscopic interventions. Of 45 lesions identified, arteriovenous malformations (AVMs) were the most common (22, 48.9%). A gastric or small bowel source (HR 2.8, p = 0.003) and an endoscopic intervention (HR 1.9, p = 0.04) predicted recurrent GIB. The proposed algorithm may reduce the number of endoscopic procedures by 45% and costs by 35%. CONCLUSIONS: Occult GIB is the most common presentation in CF-LVAD patients and carries the lowest diagnostic and therapeutic yield of endoscopy. Performing an intervention was among the strongest predictors of recurrent GIB. Our proposed algorithm may decrease the number of low-yield procedures and improve resource utilization.
Assuntos
Endoscopia Gastrointestinal , Hemorragia Gastrointestinal/diagnóstico , Coração Auxiliar , Complicações Pós-Operatórias/diagnóstico , Análise Custo-Benefício , Endoscopia Gastrointestinal/economia , Feminino , Hemorragia Gastrointestinal/economia , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/economia , Estudos RetrospectivosRESUMO
Background and Aims: Acute upper gastrointestinal bleeding (AUGIB) is a lethal complication of liver cirrhosis. We aimed to compare the outcomes of patients with liver cirrhosis and AUGIB who were admitted to hospital on regular hours and off-hours. Methods: This retrospective study screened all cirrhotic patients with AUGIB who were admitted to our hospital from January 2010 to June 2014 for the test cohort and from December 2014 to March 2018 for the validation cohort. A 1:1 propensity score matching analysis was performed to adjust the Child-Pugh and MELD scores. In-hospital mortality, 5-day rebleeding rate, length of stay, and total payment were primary outcomes. Results: Overall, 826 and 173 patients with liver cirrhosis and AUGIB were included in the test and validation cohorts, respectively. After propensity score matching, 226 and 40 patients were included in the test and validation cohorts, respectively. The overall analysis of the test cohort found significantly higher Child-Pugh score (P=0.006), 5-day rebleeding rate (18.69% versus 10.72%, P=0.001), and total payment (¥25,906.83 versus ¥22,017.42, P<0.001) in patients admitted on off-hours. By contrast, the overall analysis of the validation cohort did not find any difference in Child-Pugh score, 5-day rebleeding, in-hospital mortality, length of stay, or hospital payment between patients admitted on regular hours and off-hours. Similarly, the propensity score matching analyses of both test and validation cohorts found no difference in these primary outcomes between the two groups. Conclusions: Off-hours admission might not be negatively associated with the outcomes of patients with liver cirrhosis and AUGIB.
Assuntos
Plantão Médico/estatística & dados numéricos , Hemorragia Gastrointestinal/mortalidade , Cirrose Hepática/mortalidade , Admissão do Paciente/estatística & dados numéricos , Fatores de Tempo , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Feminino , Hemorragia Gastrointestinal/economia , Hemorragia Gastrointestinal/etiologia , Custos Hospitalares/estatística & dados numéricos , Mortalidade Hospitalar , Humanos , Tempo de Internação/estatística & dados numéricos , Cirrose Hepática/complicações , Cirrose Hepática/economia , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Pontuação de Propensão , Recidiva , Estudos Retrospectivos , Índice de Gravidade de DoençaRESUMO
OBJECTIVES: The economic impact of therapeutic innovations on the hospital patient management cannot be easily estimated. The objective of this study is to illustrate the use of a Delphi survey as a support tool to identify the changes following the use of idarucizumab in dabigatran-treated patients with uncontrolled/life-threatening bleeding or who required emergency surgery/urgent procedures. METHODS: The Delphi questionnaires have been administrated to 8 emergency physicians or anesthetists from 6 different hospital centers. Following the answers, an economic valorization has been carried out on every parameter on which a consensus was reached (at least 4 answers showing an identical trend). A mean management cost for each etiology with and without the use of idarucizumab has thus been identified. RESULTS: For gastro-intestinal and other life-threatening bleedings (excepted intracranial bleedings), the total management cost of the hospital stay was respectively 6058 (-35%) and 6219 (-34%) following the use of the reversal agent. The hospital management cost for intracranial bleeding is slightly increasing to 9790 (+3%). The cost of a stay for emergency surgery decreases to 6962 (-2%). CONCLUSIONS: This study shows a positive economic impact following the use of the dabigatran-specific reversal agent for patients with uncontrolled/life-threatening bleeding excepted in the case of intracranial bleeding. Moreover, it points out that a Delphi survey is an easy way to predict the hospital economic impact of a therapeutic innovation when no other evaluation is possible.
Assuntos
Anticorpos Monoclonais Humanizados/economia , Anticorpos Monoclonais Humanizados/uso terapêutico , Antitrombinas/farmacologia , Dabigatrana/antagonistas & inibidores , Economia Hospitalar/tendências , Hemorragia/tratamento farmacológico , Hemorragia/economia , Antitrombinas/economia , Dabigatrana/economia , Dabigatrana/farmacologia , Técnica Delphi , Custos de Medicamentos , França , Hemorragia Gastrointestinal/induzido quimicamente , Hemorragia Gastrointestinal/tratamento farmacológico , Hemorragia Gastrointestinal/economia , Hemorragia/induzido quimicamente , Humanos , Inquéritos e QuestionáriosRESUMO
BACKGROUND: Bleeding from a colonic diverticulum is serious in aged patients. The aim of this study was to determine the risk factors for high-cost hospitalization of colonic diverticular bleeding using the diagnosis procedure combination (DPC) data. METHODS: From January 2009 to December 2015, 78 patients with colonic diverticular bleeding were identified by DPC data in Saga Medical School Hospital. All patients underwent colonic endoscopy within 3 days. The patients were divided into 2 groups: the low-cost group (DPC cost of <500,000 yen) and the high-cost group (DPC cost of >500,000 yen). RESULTS: Univariate analysis revealed that aging, hypertension, rebleeding, a low hemoglobin concentration at admission, and blood transfusion were risk factors for high hospitalization cost. Multivariate analysis revealed that rebleeding (OR 5.3; 95% CI 1.3-21.3; p = 0.017) and blood transfusion (OR 3.8; 95% CI 1.01-14.2; p = 0.048) were definite risk factors for high hospitalization cost. CONCLUSION: Rebleeding and blood transfusion were related to high hospitalization cost for colonic diverticular bleeding.
Assuntos
Colonoscopia/economia , Divertículo do Colo/economia , Hemorragia Gastrointestinal/economia , Custos de Cuidados de Saúde/estatística & dados numéricos , Hospitalização/economia , Idoso , Idoso de 80 Anos ou mais , Transfusão de Sangue/economia , Transfusão de Sangue/estatística & dados numéricos , Colo/diagnóstico por imagem , Colo/patologia , Colonoscopia/estatística & dados numéricos , Divertículo do Colo/complicações , Divertículo do Colo/diagnóstico , Divertículo do Colo/terapia , Feminino , Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/etiologia , Hemorragia Gastrointestinal/terapia , Hemoglobinas/análise , Hospitalização/estatística & dados numéricos , Humanos , Japão , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de RiscoRESUMO
BACKGROUND: Use of oral anticoagulation therapy in patients with atrial fibrillation (AF) involves a trade-off between a reduced risk of ischemic stroke and an increased risk of bleeding events. Different anticoagulation therapies have different safety profiles and data on the societal costs of both ischemic stroke and bleeding events are necessary for assessing the cost-effectiveness and budgetary impact of different treatment options. To our knowledge, no previous studies have estimated the societal costs of bleeding events in patients with AF. The objective of this study was to estimate the 3-years societal costs of first-incident intracranial, gastrointestinal and other major bleeding events in Danish patients with AF. METHODS: The study was an incidence-based cost-of-illness study carried out from a societal perspective and based on data from national Danish registries covering the period 2002-2012. Costs were estimated using a propensity score matching and multivariable regression analysis (first difference OLS) in a cohort design. RESULTS: Average 3-years societal costs attributable to intracranial, gastrointestinal and other major bleeding events were 27,627, 17,868, and 12,384 EUR per patient, respectively (2015 prices). Existing evidence shows that the corresponding costs of ischemic stroke were 24,084 EUR per patient (2012 prices). The average costs of bleeding events did not differ between patients with AF who were on oral anticoagulation therapy prior to the event and patients who were not. CONCLUSIONS: The societal costs attributable to major bleeding events in patients with AF are significant. Intracranial haemorrhages are most costly to society with average costs of similar magnitude as the costs of ischemic stroke. The average costs of gastrointestinal and other major bleeding events are lower than the costs of intracranial haemorrhages, but still substantial. Knowledge about the relative size of the costs of bleeding events compared to ischemic stroke in patients with AF constitutes valuable evidence for decisions-makers in Denmark as well as in other countries.
Assuntos
Fibrilação Atrial/economia , Hemorragia Gastrointestinal/economia , Acidente Vascular Cerebral/economia , Idoso , Anticoagulantes/economia , Anticoagulantes/uso terapêutico , Estudos de Coortes , Análise Custo-Benefício , Custos e Análise de Custo , Dinamarca , Feminino , Hemorragia/tratamento farmacológico , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Análise de Regressão , Fatores de RiscoRESUMO
BACKGROUND: Transjugular intrahepatic portosystemic shunt (TIPS) and open splenectomy and esophagogastric devascularization (OSED) are widely used to treat patients with portal hypertension and recurrent variceal bleeding (PHRVB). This study aimed to compare the effectiveness between TIPS and OSED for the treatment of PHRVB. METHODS: The data were retrospectively retrieved from 479 cirrhotic patients (Child-Pugh A or B class) with PHRVB, who had undergone TIPS (TIPS group) or OSED (OSED group) between January 1, 2010 and October 31, 2014. RESULTS: A total of 196 patients received TIPS, whereas 283 underwent OSED. Within one month after TIPS and OSED, the rebleeding rates were 6.1% and 3.2%, respectively (P=0.122). Significantly lower incidence of pleural effusion, splenic vein thrombosis, and pulmonary infection, as well as higher hepatic encephalopathy rate, shorter postoperative length of hospital stay, and higher hospital costs were observed in the TIPS group than those in the OSED group. During the follow-up periods (29 months), significantly higher incidences of rebleeding (15.3% vs 4.6%, P=0.001) and hepatic encephalopathy (17.3% vs 3.9%, P=0.001) were observed in the TIPS group than in the OSED group. The incidence of in-stent stenosis was 18.9%. The survival rates were 91.3% in the TIPS group and 95.1% in the OSED group. The long-term liver function did not worsen after either TIPS or OSED. CONCLUSION: For the patients with liver function in the Child-Pugh A or B class, TIPS is not superior over OSED in terms of PHRVB treatment and rebleeding prevention.
Assuntos
Varizes Esofágicas e Gástricas/cirurgia , Esôfago/irrigação sanguínea , Hemorragia Gastrointestinal/cirurgia , Hipertensão Portal/cirurgia , Cirrose Hepática/complicações , Derivação Portossistêmica Transjugular Intra-Hepática , Esplenectomia , Procedimentos Cirúrgicos Vasculares/métodos , Adulto , Análise Custo-Benefício , Varizes Esofágicas e Gástricas/diagnóstico , Varizes Esofágicas e Gástricas/economia , Varizes Esofágicas e Gástricas/etiologia , Feminino , Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/economia , Hemorragia Gastrointestinal/etiologia , Custos Hospitalares , Humanos , Hipertensão Portal/diagnóstico , Hipertensão Portal/economia , Hipertensão Portal/etiologia , Tempo de Internação , Cirrose Hepática/diagnóstico , Cirrose Hepática/economia , Testes de Função Hepática , Masculino , Pessoa de Meia-Idade , Derivação Portossistêmica Transjugular Intra-Hepática/efeitos adversos , Derivação Portossistêmica Transjugular Intra-Hepática/economia , Complicações Pós-Operatórias/etiologia , Recidiva , Estudos Retrospectivos , Fatores de Risco , Esplenectomia/efeitos adversos , Esplenectomia/economia , Fatores de Tempo , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Procedimentos Cirúrgicos Vasculares/economiaRESUMO
PURPOSE: The present study aimed to assess the cost effectiveness of concomitant proton pump inhibitor (PPI) treatment in low-dose acetylsalicylic acid (LDASA) users at risk of upper gastrointestinal (UGI) adverse effects as compared with no PPI co-medication with attention to the age-dependent influence of PPI-induced adverse effects. METHODS: We used a Markov model to compare the strategy of PPI co-medication with no PPI co-medication in older LDASA users at risk of UGI adverse effects. As PPIs reduce the risk of UGI bleeding and dyspepsia, these risk factors were modelled together with PPI adverse effects for LDASA users 60-69, 70-79 (base case) and 80 years and older. Incremental cost-utility ratios (ICURs) were calculated as cost per quality-adjusted life-year (QALY) gained per age category. Furthermore, a budget impact analysis assessed the expected changes in expenditure of the Dutch healthcare system following the adoption of PPI co-treatment in all LDASA users potentially at risk of UGI adverse effects. RESULTS: PPI co-treatment of 70- to 79-year-old LDASA users, as compared with no PPI, resulted in incremental costs of 100.51 at incremental effects of 0.007 QALYs with an ICUR of 14,671/QALY. ICURs for 60- to 69-year-old LDASA users were 13,264/QALY and 64,121/QALY for patients 80 years and older. Initiation of PPI co-treatment for all Dutch LDASA users of 60 years and older at risk of UGI adverse effects but not prescribed a PPI (19%) would have cost 1,280,478 in the first year (year 2013 values). CONCLUSIONS: PPI co-medication in LDASA users at risk of UGI adverse effects is generally cost effective. However, this strategy becomes less cost effective with higher age, particularly in patients aged 80 years and older, mainly due to the increased risks of PPI-induced adverse effects.
Assuntos
Aspirina/efeitos adversos , Hemorragia Gastrointestinal/prevenção & controle , Inibidores da Bomba de Prótons/economia , Idoso , Envelhecimento/efeitos dos fármacos , Aspirina/administração & dosagem , Análise Custo-Benefício , Relação Dose-Resposta a Droga , Hemorragia Gastrointestinal/induzido quimicamente , Hemorragia Gastrointestinal/economia , Humanos , Masculino , Cadeias de Markov , Pessoa de Meia-Idade , Países Baixos , Inibidores da Bomba de Prótons/administração & dosagem , Inibidores da Bomba de Prótons/efeitos adversos , Inibidores da Bomba de Prótons/uso terapêutico , Anos de Vida Ajustados por Qualidade de Vida , Fatores de Risco , Trato Gastrointestinal SuperiorRESUMO
BACKGROUND: Left ventricular assist devices (LVADs) are being utilized for management of end-stage heart failure and require systemic anticoagulation. Gastrointestinal bleeding (GIB) is one of the most common adverse events following LVAD implantation. AIM: To investigate the impact of continuous-flow (CF) LVAD implants on outcomes of patients admitted with GIB. METHODS: This is a cross-sectional study utilizing the Nationwide Inpatient Sample in the CF-LVAD era from 2010 to 2012. All adult admissions with a primary diagnosis of GIB were included. Among hospitalizations with GIB, patients with (cases) and without (controls) CF-LVAD implants were compared using univariate and multivariate analyses. The main outcome measurements were in-hospital mortality, length of stay, and hospitalization costs. RESULTS: Among 1,002,299 hospitalizations for GIB, 1112 (0.11%) patients had CF-LVADs. Bleeding angiodysplasia accounted for a majority of GIB in CF-LVAD patients (35.4% of 1112). Multivariate analysis adjusting for demographic, hospital and etiological differences, site of GIB, and patient comorbidities revealed that CF-LVADs were not adversely associated with mortality in GIB (OR 0.53, 95% CI 0.07-4.15). However, CF-LVADs independently accounted for prolonged hospitalization (3.5 days, 95% CI 2.6-4.6) and higher hospital charges ($37,032, 95% CI $7991-$66,074). CONCLUSIONS: In patients admitted with GIB, CF-LVAD implantation accounts for higher healthcare utilization, but is not adversely associated with mortality despite therapeutic anticoagulation, increased comorbidities, and comparatively delayed endoscopy. These findings are relevant as CF-LVADs are the dominant type of LVAD and are associated with increased risk of GIB compared to their predecessors.