Cost-effectiveness analysis of termination-of-resuscitation rules for patients with out-of-hospital cardiac arrest.

AIM: To evaluate the cost-effectiveness of practices with and without termination-of-resuscitation (TOR) rules for out-of-hospital cardiac arrest (OHCA), using an analytic model based on a nationwide population-based registry in Japan. METHODS: A combined model using a decision tree and Markov model was developed to compare costs and treatment effectiveness of three scenarios: basic life support (BLS) TOR rules (BLS-rule scenario), advanced life support (ALS) TOR rules (ALS-rule scenario), and no TOR rules (No-rule scenario). A nationwide population-based OHCA registry from January 1 to December 31, 2019 and published data were used. Analyses were performed from healthcare payers' perspectives. Life-time incremental cost-effectiveness ratio (ICER) was determined by the difference in cost between two scenarios, divided by the difference in quality adjusted life year (QALY). RESULTS: The OHCA registry included 126,271 patients (57.3% men; median age, 80 years). The BLS-rule scenario yielded lower cost and less QALY than the ALS-rule scenario and No-rule scenario. With reference to the BLS-rule scenario, the ICERs for the ALS-rule scenario and No-rule scenario were 81,000 and 98,762 USD per QALY, respectively. The BLS-rule scenario was cost-effective in 100% of simulations at the willingness-to-pay threshold in Japan (5 million JPY = 45,455 USD). The willingness-to-pay threshold higher than 80,000 and 204,000 USD were required for the ALS-rule scenario and No-rule scenarios, respectively, to be cost-effective. CONCLUSION: No-rule scenario was not cost-effective compared with BLS-rule scenario within acceptable willingness-to-pay thresholds. Further research on health economics of TOR rules is warranted to support constructive discussion on implementing TOR rules.

Urban-Rural Inequalities in Care and Outcomes of Severe Traumatic Brain Injury: A Nationwide Inpatient Database Analysis in Japan.

OBJECTIVE: This study aimed to investigate urban-rural inequalities in care and outcomes of severe traumatic brain injury (TBI). METHODS: This observational study identified patients with severe TBI from the Japanese Diagnosis Procedure Combination inpatient database from 1 July 2010 to 31 March 2020. The patients were dichotomized into rural and urban groups based on the geographical location of their residence, using the urban employment area scheme. The primary outcome measure was in-hospital mortality. Multivariable regression analyses adjusted for patient-level covariates were performed to compare the outcomes between the 2 groups. RESULTS: A total of 48,910 patients (rural group, n = 5423; urban group, n = 43,487) were evaluated. In-hospital mortality was significantly higher in the rural group than that in the urban group (49.9% vs. 45.1%; adjusted odds ratio [OR], 1.26; 95% confidence interval [CI], 1.18-1.35). The standardized in-hospital mortality of the rural group was consistently higher than that of the urban group in each fiscal year, and there was no significant trend for closing the gap (P for trend = 0.95). Patients in the rural group were less likely to undergo craniotomy/craniectomy (adjusted OR, 0.83; 95% CI, 0.77-0.89) and intracranial pressure monitoring (adjusted OR, 0.53; 95% CI, 0.46-0.61) and achieve independent activities of daily living at discharge (8.2% vs. 10.5%, adjusted OR, 0.85; 95% CI, 0.76-0.96). CONCLUSIONS: There are significant urban-rural inequalities in TBI in Japan, and the gap in in-hospital mortality has not improved over the last 10 years. Improving TBI care in rural communities may be a target for reducing disparities in health care.

A new screening model for quantitative risk assessment of blunt thoracic aortic injury.

PURPOSE: Early identification of blunt thoracic aortic injury is vital for preventing subsequent aortic rupture. However, risk factors for blunt thoracic aortic injury remain unclear, and a prediction rule remains to be established. We developed and internally validated a new nomogram-based screening model that allows clinicians to quantify blunt thoracic aortic injury risk. METHODS: Adult patients (age ≥ 18 years) with blunt injury were selected from a nationwide Japanese database (January 2004-May 2019). Patients were randomly divided into training and test cohorts. A new nomogram-based blunt thoracic aortic injury-screening model was constructed using multivariate logistic regression analysis to quantify the association of potential predictive factors with blunt thoracic aortic injury in the training cohort. RESULTS: Overall, 305,141 patients (training cohort, n = 152,570; test cohort, n = 152,571) were eligible for analysis. Median patient age was 65 years, and 60.9% were men. Multivariate analysis in the training cohort revealed that 13 factors (positive association: age ≥ 55 years, male sex, high-energy impact, hypotension on hospital arrival, Glasgow Coma Scale score < 9 on hospital arrival, diaphragmatic injuries, hepatic injuries, pulmonary injuries, cardiac injuries, renal injuries, sternum fractures, multiple rib fractures, and pelvic fractures) were significantly associated with blunt thoracic aortic injury and included in the screening model. In the test cohort, the new screening model had an area under the curve of 0.87. CONCLUSIONS: Our novel nomogram-based screening model aids in the quantitative assessment of blunt thoracic aortic injury risk. This model may improve tailored decision-making for each patient.

Epidemiological state, predictive model for mortality, and optimal management strategy for pancreatic injury: A multicentre nationwide cohort study.

BACKGROUND: Data for establishing the optimal management modalities for pancreatic injury are lacking. Herein, we aimed to describe the epidemiology, identify mortality predictors, and determine the optimal management strategy for pancreatic injury. METHODS: We identified patients with pancreatic injury between 2004 and 2017 recorded in the Japan Trauma Data Bank. The primary outcome was mortality. Multivariable logistic regression analyses were used to identify factors significantly associated with mortality and to develop a predictive model. Patients were also classified according to the Organ Injury Scaling of the American Association for the Surgery of Trauma (AAST grade I/II or III/IV). Outcomes were compared based on significant confounder-adjusted treatment strategy. RESULTS: Overall, 743 (0.25%) patients had pancreatic injury. Traffic accident was the most common aetiology. The overall mortality rate was 17.5%, while it was 4.7% for isolated pancreatic injury. AAST grade, Revised Trauma Scale score on arrival, age, and coexistence of severe abdominal injury aside from pancreatic injury were independently associated with mortality. A predictive model for mortality comprising these four variables showed excellent performance, with an area under the receiver operating characteristic curve of 0.89 (95% confidence interval [CI], 0.85-0.93). The in-hospital mortality was higher in patients who underwent celiotomy than in those who did not among those with AAST grade I/II (15.1% vs. 5.3%) and III/IV (13.8% vs. 12.3%). After adjusting for confounders, these differences were not significant with the adjusted odds ratios of 1.41 (95% CI, 0.55-3.60) and 0.54 (95% CI, 0.17-1.67) for AAST grade I/II and III/IV, respectively. CONCLUSIONS: AAST grade, Revised Trauma Scale score on arrival, age, and coexistence of severe abdominal injury aside from pancreatic injury were prognostic factors of mortality after pancreatic injury. Confounder-adjusted analysis did not show that operative management was superior to non-operative management for survival. Non-operative management may be a reasonable strategy for select pancreatic injury patients, especially in institutions where expertise in interventional endoscopy is available.