Incorporating Optical Coherence Tomography Macula Scans Enhances Cost-effectiveness of Fundus Photography-Based Screening for Diabetic Macular Edema.

OBJECTIVE: To compare four screening strategies for diabetic macular edema (DME). RESEARCH DESIGN AND METHODS: Patients attending diabetic retinopathy screening were recruited and received macular optical coherence tomography (OCT), in addition to visual acuity (VA) and fundus photography (FP) assessments, as part of the standard protocol. Two retina specialists provided the reference grading by independently assessing each subject's screened data for DME. The current standard protocol (strategy A) was compared for sensitivity, specificity, quality-adjusted life-year (QALY) gained, and incremental cost-effectiveness ratio (ICER) with three alternative candidate protocols using a simulation model with the same subjects. In strategy B, macular hemorrhage or microaneurysm on FP were removed as surrogate markers for possible DME. Strategy C used best-corrected instead of habitual/pinhole VA and added central subfield thickness (CST) >290 µm on OCT in suspected cases as a confirmation marker for possible DME. Strategy D used CST >290 µm OCT in all subjects as a surrogate marker for suspected DME. RESULTS: We recruited 2,277 subjects (mean age 62.80 ± 11.75 years, 43.7% male). The sensitivities and specificities were 40.95% and 86.60%, 22.86% and 95.63%, 32.38% and 100%, and 74.47% and 98.34% for strategies A, B, C, and D, respectively. The costs (in U.S. dollars) of each QALY gained for strategies A, B, C, and D were $7,447.50, $8,428.70, $5,992.30, and $4,113.50, respectively. CONCLUSIONS: The high false-positive rate of the current protocol generates unnecessary referrals, which are inconvenient for patients and costly for society. Incorporating universal OCT for screening DME can reduce false-positive results by eightfold, while improving sensitivity and long-term cost-effectiveness.

In Pursuit of the Most Cost-Effective Pediatric Laparoscopic Appendectomy: The Effect of Disposable Instrument Choice on Operative Time and Surgeon-Controllable Cost.

BACKGROUND: There is a movement toward cost savings in healthcare worldwide. Surgeons can affect two main cost variables in an operation (controllable cost): disposables and time. Our hypothesis is that increasing disposable costs do not change outcome or operative time, but simply increases controllable cost. METHODS: We retrospectively reviewed patients younger than the age of 18 years undergoing laparoscopic appendectomies for nonperforated appendicitis from January 2013 to November 2016. Data obtained included demographic information in addition to intraoperative details, including disposables used and associated cost, resident participation, operative time, and final pathology. Patients were excluded if perforation was present as confirmed by operative findings or pathology (Kansas City definition). Patients were also excluded if concurrent procedures were performed during the appendectomy. RESULTS: We reviewed 918 patients and excluded 288 for a total of 690. Disposable cost, operative time, and complications were compared between cases with a resident present and those without. Residents did not increase the use of disposables, but did increase operative time and therefore the total controllable cost. Transumbilical laparoscopic-assisted technique was significantly faster with lower controllable cost when compared with all other methods. Using disposable trocars with an endostapler was the second fastest and second lowest controllable cost and retained a significant difference when compared with most other methods. Endoloop methods did not show overall controllable cost savings versus the vast majority of methods. CONCLUSIONS: To maximize controllable cost savings, we recommend a transumbilical laparoscopic-assisted appendectomy or a standard three-port laparoscopic appendectomy, with disposable trocars and the endostapler.