Sustainability Standards in Pediatric Anesthesia: Quality Initiative to Reduce Costly Environmentally Harmful Volatile Anesthetics.

Background: The emission and entrapment of greenhouse gases (GHG) inside the atmosphere is one of the leading causes of global warming. Commonly administered anesthetics have global warming potential up to 2,000 times greater than carbon dioxide. This Quality Improvement (QI) initiative aimed to develop a set of sustainability standards to reduce volatile anesthetic GHG emissions and costs at a children's hospital. Methods: In January 2020, the QI project team implemented education sessions for clinical staff on the environmental impact of volatile anesthetics, bedside clinical reminders, resource guides on sustainable anesthesia practices, preset low-flow gas levels on anesthesia machines, relocated and reduced the number of available vaporizers, and implemented policies to standardize clinical practice. Using hospital pharmacy purchase order data between 2018 and 2022, GHG emissions and costs from three commonly used volatile anesthetics (Isoflurane, Sevoflurane, and Desflurane) were compared using metric ton carbon dioxide equivalents. Results: During 3 years, GHG emissions from volatile anesthetics were significantly reduced by 77%, with most of the reduction attributed to the reduced use and eventual elimination of Desflurane. Purchase costs were also significantly reduced during this period by 41%. Conclusions: This QI project successfully decreased GHG emissions over 3 years by simultaneously reducing the use of costly and environmentally harmful volatile anesthetic, Desflurane, and increasing the use of low-flow anesthesia. This study addresses our anesthesia practices and healthcare system's impact on the pediatric population and proposes simple interventions to mitigate the negative consequences of current practices.

What are the clinical, quality-of-life, and cost consequences of 30 years of excellent vs. poor glycemic control in type 1 diabetes?

OBJECTIVE: The Diabetes Control and Complications Trial (DCCT) demonstrated that intensive therapy for type 1 diabetes delayed the development of microvascular and neuropathic complications compared to conventional therapy. At the end of DCCT, all participants were trained in intensive therapy, care was transferred to community providers, and the difference in HbA1c between treatment groups narrowed and disappeared. Our objective was to describe the outcomes and the quality-of-life and costs associated with those outcomes in participants who maintained excellent vs. poor glycemic control over 30 years. RESEARCH DESIGN AND METHODS: We assessed the incidence of retinopathy, nephropathy, neuropathy, cardiovascular disease, acute metabolic complications, death, quality-of-life, and costs in the tertile of DCCT intensive therapy participants who achieved a mean updated HbA1c of <7.2% (55 mmol/mol) and the tertile of DCCT conventional therapy participants (n = 240) who achieved a mean updated HbA1c of >8.8% (73 mmol/mol) over 30 years. RESULTS: Thirty years of excellent vs. poor glycemic control substantially reduced the incidence of retinopathy requiring laser therapy (5% vs. 45%), end-stage renal disease (0% vs. 5%), clinical neuropathy (15% vs. 50%), myocardial infarction (3% vs. 5%), stroke (0.4% vs. 2%), and death (6% vs. 20%). It also resulted in a gain of ~1.62 quality-adjusted life-years and averted ~$90,900 in costs of complications per participant. CONCLUSIONS: Thirty years of excellent vs. poor glycemic control for T1DM can substantially reduce the incidence of complications, comorbidities, and death, improve quality-of-life, and reduce costs. These estimates represent the benefits that may be achieved with excellent glycemic control.

The 30-year cost-effectiveness of alternative strategies to achieve excellent glycemic control in type 1 diabetes: An economic simulation informed by the results of the diabetes control and complications trial/epidemiology of diabetes interventions and complications (DCCT/EDIC).

OBJECTIVE: To simulate the cost-effectiveness of historical and modern treatment scenarios that achieve excellent vs. poor glycemic control in type 1 diabetes (T1DM). RESEARCH DESIGN AND METHODS: We describe and compare the costs of intensive and conventional therapies for T1DM as performed during DCCT, and modern intensive and basic therapy scenarios using insulin analogs, pens, pumps, and continuous glucose monitoring (CGM) to achieve excellent or poor glycemic control. We then assess the differences in treatment costs and the costs of outcomes over 30 years and report incremental cost-effectiveness ratios. RESULTS: Over 30 years, DCCT intensive therapy cost $127,500 to $181,600 more per participant than DCCT conventional therapy, and modern intensive therapy cost $87,700 to $409,000 more per individual than modern basic therapy. Excellent glycemic control averted as much as $90,900 in costs from complications and added ~1.62 quality-adjusted life-years (QALYs) per participant over 30 years. When costs and QALYs were discounted at 3% annually, DCCT intensive therapy and modern intensive therapies that use multiple daily injections (MDI) or pumps are cost-saving or cost-effective (<$100,000/QALY-gained). If applied to all patients with T1DM, modern intensive therapy using pumps and CGM is not cost-effective (>$250,000/QALY-gained) but would be more cost-effective if associated with less hypoglycemia, better glycemic control, fewer complications, or improved health-related quality-of-life. CONCLUSIONS: Use of the least expensive intensive therapy needed to safely achieve treatment goals for patients with T1DM represents a good value for money. TRIAL REGISTRATION: clinicaltrials.govNCT00360815 and NCT00360893.

Burden of Urological Complications in Men and Women With Long-standing Type 1 Diabetes in the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Cohort.

OBJECTIVE: Type 1 diabetes has been associated with high rates of urinary and sexual problems, but the cumulative burden and overlap of these complications are unknown. We sought to determine prevalence of urological complications in persons with type 1 diabetes, associations with clinical and diabetes-related factors, and rates of emergence, persistence, and remission. RESEARCH DESIGN AND METHODS: This ancillary longitudinal study among participants in the Diabetes Control and Complications Trial (DCCT) and observational follow-up study Epidemiology of Diabetes Interventions and Complications (EDIC) (652 women and 713 men) was conducted in 2003 and 2010/2011. Urinary incontinence (UI), lower urinary tract symptoms, urinary tract infection, female sexual dysfunction, erectile dysfunction, low male sexual desire, and orgasmic dysfunction were measured with validated instruments. Logistic regression determined association of complications with demographics and clinical characteristics. RESULTS: Of sexually active women completing the 2010/2011 survey, 35% reported no complications, 39% had one, 19% two, 5% three, and 2% four. In men, 31% had no complications, 36% had one, 22% two, 9% three, and 3% four. Sexual dysfunction was most prevalent (42% women and 45% men) followed by UI in women (31%) and low sexual desire in men (40%). Urological complications were associated with age, BMI, and HbA1c. Remission rates ranged from 4 to 12% over the 7-year interval between surveys. CONCLUSIONS: Urological complications are prevalent and frequently co-occur in persons with type 1 diabetes. Remission rates in a minority subset indicate a rationale for future studies to mitigate the onset or impact of urological complications of diabetes.

Relationship of urologic complications with health-related quality of life and perceived value of health in men and women with type 1 diabetes: the Diabetes Control and Complications Trial/Epidemiology of Interventions and Complications (DCCT/EDIC) cohort.

OBJECTIVE: Limited information exists about the influence of urologic complications on health-related quality of life (HRQOL) in patients with type 1 diabetes. RESEARCH DESIGN AND METHODS: We studied 664 men and 580 women from the Diabetes Control and Complications Trial/Epidemiology of Interventions and Complications Study: mean ages were 51.6 ± 6.6 and 50.6 ± 7.2 years and duration of diabetes was 29.5 ± 4.8 and 29.8 ± 5.1 years, respectively. We assessed associations of sexual dysfunction, lower urinary tract symptoms (LUTS), and, in women, urinary incontinence (UI) with general quality of life (SF-36), perceived value of health (EuroQol-5), diabetes-related quality of life (Diabetes Quality of Life Scale [DQOL]), and psychiatric symptoms (Symptom Checklist 90-R). RESULTS: In both men and women, urologic complications adversely affected HRQOL and psychiatric symptoms, even after accounting for history of depression leading to treatment. Multivariable analyses accounting for the presence of diabetic retinopathy, neuropathy, and nephropathy also revealed substantial independent effects. In men, for example, the odds (95% CI) of a low DQOL score (≤25th percentile) were 3.01 (1.90-4.75) times greater with erectile dysfunction and 2.65 (1.68-4.18) times greater with LUTS and in women, 2.04 (1.25-3.35) times greater with sexual dysfunction and 2.71 (1.72-4.27) times greater with UI/LUTS combined compared with men and women without such complications. Similar effects were observed for the other measures. CONCLUSIONS: Sexual dysfunction and urinary complications with type 1 diabetes are associated with decreased quality of life and perceived value of health and with higher levels of psychiatric symptoms, even after accounting for other diabetes complications and depression treatment.