Reducing laboratory costs through rational testing in suspected pre-eclampsia.

The current electronic laboratory order set at Epsom and St Helier University Hospitals NHS Trust for suspected pre-eclampsia includes a full blood count, urea and electrolytes, liver function, gamma-glutamyltransferase and uric acid. Local and national guidelines do not recommend the use of gamma-glutamyltransferase or uric acid for the investigation or monitoring of pre-eclampsia, as they are poor predictors of maternal and neonatal outcomes. We aimed to remove the automatic inclusion of gamma-glutamyltransferase and uric acid from the electronic laboratory order set for suspected pre-eclampsia. Stakeholders were approached to gain an understanding of whether gamma-glutamyltransferase and uric acid were being used in the clinical assessment of suspected pre-eclampsia. Obstetric consultants and maternity staff confirmed that they do not use uric acid in their clinical assessment, despite the laboratory phoning with abnormal results. In addition, an isolated gamma-glutamyltransferase rise is of no particular significance and is not part of the National Institute for Health and Care Excellence (NICE) diagnostic criteria for pre-eclampsia. The baseline number of gamma-glutamyltransferase and uric acid requests from the maternity department was identified over 2 months. The hospital information technology service was then asked to remove gamma-glutamyltransferase and uric acid from the electronic laboratory order set. The number of gamma-glutamyltransferase and uric acid requests from the maternity department following the intervention was identified over 2 months. A significant reduction in both gamma-glutamyltransferase and uric acid requests were noted. In addition, the midwives within the maternity assessment unit noted a significant reduction in phone calls from the laboratory to escalate abnormal blood results. This has saved the trust money and reduced staff time answering phone calls regarding abnormal blood results. A repeat assessment at 8 months following the removal of gamma-glutamyltransferase and uric acid demonstrated sustainability of the project.

Ticagrelor Removal by CytoSorb® in Patients Requiring Emergent or Urgent Cardiac Surgery: A UK-Based Cost-Utility Analysis.

BACKGROUND: Acute coronary syndrome patients receiving dual antiplatelet therapy who need emergent or urgent cardiac surgery are at high risk of major bleeding, which can impair postoperative outcomes. CytoSorb®, a blood purification technology based on adsorbent polymer, has been demonstrated to remove ticagrelor from blood during on-pump cardiac surgery. OBJECTIVE: The aim of this study was to evaluate the cost utility of intraoperative removal of ticagrelor using CytoSorb versus usual care among patients requiring emergent or urgent cardiac surgery in the UK. METHODS: A de novo decision analytic model, based on current treatment pathways, was developed to estimate the short- and long-term costs and outcomes. Results from randomised clinical trials and national standard sources such as National Health Service (NHS) reference costs were used to inform the model. Costs were estimated from the NHS and Personal Social Services perspective. Deterministic and probabilistic sensitivity analyses (PSAs) explored the uncertainty surrounding the input parameters. RESULTS: In emergent cardiac surgery, intraoperative removal of ticagrelor using CytoSorb was less costly (£12,933 vs. £16,874) and more effective (0.06201vs. 0.06091 quality-adjusted life-years) than cardiac surgery without physiologic clearance of ticagrelor over a 30-day time horizon. For urgent cardiac surgery, the use of CytoSorb was less costly than any of the three comparators-delaying surgery for natural washout without adjunctive therapy, adjunctive therapy with short-acting antiplatelet agents, or adjunctive therapy with low-molecular-weight heparin. Results from the PSAs showed that CytoSorb has a high probability of being cost saving (99% in emergent cardiac surgery and 53-77% in urgent cardiac surgery, depending on the comparators). Cost savings derive from fewer transfusions of blood products and re-thoracotomies, and shorter stay in the hospital/intensive care unit. CONCLUSIONS: The implementation of CytoSorb as an intraoperative intervention for patients receiving ticagrelor undergoing emergent or urgent cardiac surgery is a cost-saving strategy, yielding improvement in perioperative and postoperative outcomes and decreased health resource use.

Bariatric surgery versus conservative management for morbidly obese patients in Spain: a cost-effectiveness analysis.

BACKGROUND: We assessed the cost-effectiveness of bariatric surgery (BS) versus conservative management (CM) for treating morbid obesity in Spain. METHODS: We developed a probabilistic Markov model to estimate health outcomes, quality-adjusted life years (QALY), life years gained (LYG), and costs over lifetime and 10-year horizons. Combined common BS procedures were compared with CM. Clinical and utility inputs were obtained from the literature and resource use and costs from local sources (€2017). RESULTS: Over the 10-year horizon, BS led to a cost increment of €9,386 and 1.6 additional QALY (€5,966/QALY). Leading to 0.6 LYG and 4.4 QALY gains and €300/patient average cost savings over lifetime, BS could potentially significantly reduce diabetes and cardiovascular disease risk over the considered horizons. Despite short-term cost reductions, surgery delay may lead to significant clinical benefits loss. CONCLUSIONS: Compared to CM, BS is a more effective and less costly alternative for treating morbid obesity in Spain.

Cost-Utility Analysis of Bariatric Surgery in Italy: Results of Decision-Analytic Modelling.

OBJECTIVE: To evaluate the cost-effectiveness of bariatric surgery in Italy from a third-party payer perspective over a medium-term (10 years) and a long-term (lifetime) horizon. METHODS: A state-transition Markov model was developed, in which patients may experience surgery, post-surgery complications, diabetes mellitus type 2, cardiovascular diseases or die. Transition probabilities, costs, and utilities were obtained from the Italian and international literature. Three types of surgeries were considered: gastric bypass, sleeve gastrectomy, and adjustable gastric banding. A base-case analysis was performed for the population, the characteristics of which were obtained from surgery candidates in Italy. RESULTS: In the base-case analysis, over 10 years, bariatric surgery led to cost increment of EUR 2,661 and generated additional 1.1 quality-adjusted life years (QALYs). Over a lifetime, surgery led to savings of EUR 8,649, additional 0.5 life years and 3.2 QALYs. Bariatric surgery was cost-effective at 10 years with an incremental cost-effectiveness ratio of EUR 2,412/QALY and dominant over conservative management over a lifetime. CONCLUSION: In a comprehensive decision analytic model, a current mix of surgical methods for bariatric surgery was cost-effective at 10 years and cost-saving over the lifetime of the Italian patient cohort considered in this analysis.

Radiographic assessment of the postoperative knee.

Radiologists often encounter postoperative knee radiographs lacking any adjunct clinical data which might hinder accurate image interpretation. Surgical techniques are constantly evolving with new devices being used which make it sometimes challenging for the radiologist to deduce the performed procedure and to look for associated complications. This article reviews commonly performed surgical procedures of the knee, highlights their expected postoperative radiographic appearance and describes the appearance of certain postoperative complications.

Bariatric Surgery can Lead to Net Cost Savings to Health Care Systems: Results from a Comprehensive European Decision Analytic Model.

BACKGROUND: The objective of the present study was to evaluate the cost-utility of bariatric surgery in a lifetime horizon from a Swedish health care payer perspective. METHODS: A decision analytic model using the Markov process was developed covering cardiovascular diseases, type 2 diabetes, and surgical complications. Clinical effectiveness and safety were based on the literature and data from the Scandinavian Obesity Surgery Registry. Gastric bypass, sleeve gastrectomy, and gastric banding were included in the analysis. Cost data were obtained from Swedish sources. RESULTS: Bariatric surgery was cost saving in comparison with conservative management. It also led to a substantial reduction in lifetime risk of events: from a 16 % reduction in the risk of transient ischaemic attacks to a 62 % reduction in the incidence of type 2 diabetes. Over a lifetime, surgery led to savings of euro 8408 and generated an additional 0.8 years of life and 4.1 quality-adjusted life years (QALYs) per patient, which translates into gains of 32,390 quality-adjusted person-years and savings of euro 66 million for the cohort, operated in 2012. Analysis of the consequences of a 3-year delay in surgery provision showed that the overall lifetime cost of treatment may be increased in patients with diabetes or a body mass index >40 kg/m(2). Delays in surgery may also lead to a loss of clinical benefits: up to 0.6 life years and 1.2 QALYs per patient over a lifetime. CONCLUSION: Bariatric surgery, over a lifetime horizon, may lead to significant cost savings to health care systems in addition to the known clinical benefits.