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1.
JAMA ; 330(23): 2245-2246, 2023 12 19.
Artigo em Inglês | MEDLINE | ID: mdl-37983061

RESUMO

This Viewpoint argues for an expansion of paid family leave policies to include eldercare as a way to support the well-being of faculty members, retain physicians, and promote gender equity in academic medicine.


Assuntos
Docentes de Medicina , Equidade de Gênero , Médicas , Idoso , Feminino , Humanos , Masculino , Centros Médicos Acadêmicos , Cuidadores , Liderança
4.
Surgery ; 171(1): 96-103, 2022 01.
Artigo em Inglês | MEDLINE | ID: mdl-34238603

RESUMO

BACKGROUND: Guidelines recommend screening for primary aldosteronism in patients diagnosed with hypertension and obstructive sleep apnea. Recent studies have shown that adherence to these recommendations is extremely low. It has been suggested that cost is a barrier to implementation. No analysis has been done to rigorously evaluate the cost-effectiveness of widespread implementation of these guidelines. METHODS: We constructed a decision-analytic model to evaluate screening of the hypertensive obstructive sleep apnea population for primary aldosteronism as per guideline recommendations in comparison with current rates of screening. Probabilities, utility values, and costs were identified in the literature. Threshold and sensitivity analyses assessed robustness of the model. Costs were represented in 2020 US dollars and health outcomes in quality-adjusted life-years. The model assumed a societal perspective with a lifetime time horizon. RESULTS: Screening per guideline recommendations had an expected cost of $47,016 and 35.27 quality-adjusted life-years. Continuing at current rates of screening had an expected cost of $48,350 and 34.86 quality-adjusted life-years. Screening was dominant, as it was both less costly and more effective. These results were robust to sensitivity analysis of disease prevalence, test sensitivity, patient age, and expected outcome of medical or surgical treatment of primary aldosteronism. The screening strategy remained cost-effective even if screening were conservatively presumed to identify only 3% of new primary aldosteronism cases. CONCLUSIONS: For patients with hypertension and obstructive sleep apnea, rigorous screening for primary aldosteronism is cost-saving due to cardiovascular risk averted. Cost should not be a barrier to improving primary aldosteronism screening adherence.


Assuntos
Redução de Custos/estatística & dados numéricos , Hiperaldosteronismo/diagnóstico , Hipertensão/etiologia , Programas de Rastreamento/economia , Apneia Obstrutiva do Sono/etiologia , Adulto , Idoso , Análise Custo-Benefício , Feminino , Humanos , Hiperaldosteronismo/complicações , Hiperaldosteronismo/economia , Hiperaldosteronismo/terapia , Hipertensão/economia , Hipertensão/terapia , Masculino , Cadeias de Markov , Programas de Rastreamento/normas , Pessoa de Meia-Idade , Modelos Econômicos , Guias de Prática Clínica como Assunto , Anos de Vida Ajustados por Qualidade de Vida , Apneia Obstrutiva do Sono/economia , Apneia Obstrutiva do Sono/terapia
5.
JMIR Form Res ; 5(7): e27484, 2021 Jul 16.
Artigo em Inglês | MEDLINE | ID: mdl-34269691

RESUMO

BACKGROUND: In cancers with a chronic phase, patients and family caregivers face difficult decisions such as whether to start a novel therapy, whether to enroll in a clinical trial, and when to stop treatment. These decisions are complex, require an understanding of uncertainty, and necessitate the consideration of patients' informed preferences. For some cancers, such as medullary thyroid carcinoma, these decisions may also involve significant out-of-pocket costs and effects on family members. Providers have expressed a need for web-based interventions that can be delivered between consultations to provide education and prepare patients and families to discuss these decisions. To ensure that these tools are effective, usable, and understandable, studies are needed to identify patients', families', and providers' decision-making needs and optimal design strategies for a web-based patient decision aid. OBJECTIVE: Following the international guidelines for the development of a web-based patient decision aid, the objectives of this study are to engage potential users to guide development; review the existing literature and available tools; assess users' decision-making experiences, needs, and design recommendations; and identify shared decision-making approaches to address each need. METHODS: This study used the decisional needs assessment approach, which included creating a stakeholder advisory panel, mapping decision pathways, conducting an environmental scan of existing materials, and administering a decisional needs assessment questionnaire. Thematic analyses identified current decision-making pathways, unmet decision-making needs, and decision support strategies for meeting each need. RESULTS: The stakeholders reported wide heterogeneity in decision timing and pathways. Relevant existing materials included 2 systematic reviews, 9 additional papers, and multiple educational websites, but none of these met the criteria for a patient decision aid. Patients and family members (n=54) emphasized the need for plain language (46/54, 85%), shared decision making (45/54, 83%), and help with family discussions (39/54, 72%). Additional needs included information about uncertainty, lived experience, and costs. Providers (n=10) reported needing interventions that address misinformation (9/10, 90%), foster realistic expectations (9/10, 90%), and address mistrust in clinical trials (5/10, 50%). Additional needs included provider tools that support shared decision making. Both groups recommended designing a web-based patient decision aid that can be tailored to (64/64, 100%) and delivered on a hospital website (53/64, 83%), focuses on quality of life (45/64, 70%), and provides step-by-step guidance (43/64, 67%). The study team identified best practices to meet each need, which are presented in the proposed decision support design guide. CONCLUSIONS: Patients, families, and providers report multifaceted decision support needs during the chronic phase of cancer. Web-based patient decision aids that provide tailored support over time and explicitly address uncertainty, quality of life, realistic expectations, and effects on families are needed.

6.
J Vasc Surg ; 74(4): 1343-1353.e2, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-33887430

RESUMO

OBJECTIVE: Vascular surgery patients are highly complex, second only to patients undergoing cardiac procedures. However, unlike cardiac surgery, work relative value units (wRVU) for vascular surgery were undervalued based on an overall patient complexity score. This study assesses the correlation of patient complexity with wRVUs for the most commonly performed inpatient vascular surgery procedures. METHODS: The 2014 to 2017 National Surgical Quality Improvement Program Participant Use Data Files were queried for inpatient cases performed by vascular surgeons. A previously developed patient complexity score using perioperative domains was calculated based on patient age, American Society of Anesthesiologists class of ≥4, major comorbidities, emergent status, concurrent procedures, additional procedures, hospital length of stay, nonhome discharge, and 30-day major complications, readmissions, and mortality. Procedures were assigned points based on their relative rank and then an overall score was created by summing the total points. An observed to expected ratio (O/E) was calculated using open ruptured abdominal aortic aneurysm repair (rOAAA) as the referent and then applied to an adjusted median wRVU per operative minute. RESULTS: Among 164,370 cases, patient complexity was greatest for rOAAA (complexity score = 128) and the least for carotid endarterectomy (CEA) (complexity score = 29). Patients undergoing rOAAA repair had the greatest proportion of American Society of Anesthesiologists class of ≥IV (84.8%; 95% confidence interval [CI], 82.6%-86.8%), highest mortality (35.5%; 95% CI, 32.8%-38.3%), and major complication rate (87.1%; 95% CI, 85.1%-89.0%). Patients undergoing CEA had the lowest mortality (0.7%; 95% CI, 0.7%-0.8%), major complication rate (8.2%; 95% 95% CI, 8.0%-8.5%), and shortest length of stay (2.7 days; 95% CI, 2.7-2.7). The median wRVU ranged from 10.0 to 42.1 and only weakly correlated with overall complexity (Spearman's ρ = 0.11; P < .01). The median wRVU per operative minute was greatest for thoracic endovascular aortic repair (0.25) and lowest for both axillary-femoral artery bypass (0.12) and open femoral endarterectomy, thromboembolectomy, or reconstruction (0.12). After adjusting for patient complexity, CEA (O/E = 3.8) and transcarotid artery revascularization (O/E = 2.8) had greater than expected O/E. In contrast, lower extremity bypass (O/E = 0.77), lower extremity embolectomy (O/E = 0.79), and open abdominal aortic repair (O/E = 0.80) had a lower than expected O/E. CONCLUSIONS: Patient complexity varies substantially across vascular procedures and is not captured effectively by wRVUs. Increased operative time for open procedures is not adequately accounted for by wRVUs, which may unfairly penalize surgeons who perform complex open operations.


Assuntos
Custos de Cuidados de Saúde , Escalas de Valor Relativo , Doenças Vasculares/economia , Doenças Vasculares/cirurgia , Procedimentos Cirúrgicos Vasculares/economia , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Bases de Dados Factuais , Feminino , Humanos , Pacientes Internados , Tempo de Internação/economia , Masculino , Pessoa de Meia-Idade , Alta do Paciente/economia , Readmissão do Paciente/economia , Sistema de Registros , Reembolso de Incentivo/economia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , Doenças Vasculares/diagnóstico , Doenças Vasculares/mortalidade , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Procedimentos Cirúrgicos Vasculares/mortalidade , Adulto Jovem
7.
Surgery ; 168(3): 371-378, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32336468

RESUMO

BACKGROUND: Understanding the differences in how patient complexity varies across surgical specialties can inform policy decisions about appropriate resource allocation and reimbursement. This study evaluated variation in patient complexity across surgical specialties and the correlation between complexity and work relative value units. STUDY DESIGN: The 2017 American College of Surgeons National Surgical Quality Improvement Program was queried for cases involving otolaryngology and general, neurologic, vascular, cardiac, thoracic, urologic, orthopedic, and plastic surgery. A total of 10 domains of patient complexity were measured: American Society of Anesthesiologists class ≥4, number of major comorbidities, emergency operation, major complications, concurrent procedures, additional procedures, length of stay, non-home discharge, readmission, and mortality. Specialties were ranked by their complexity domains and the domains summed to create an overall complexity score. Patient complexity then was evaluated for correlation with work relative value units. RESULTS: Overall, 936,496 cases were identified. Cardiac surgery had the greatest total complexity score and was most complex across 4 domains: American Society of Anesthesiologists class ≥4 (78.5%), 30-day mortality (3.4%), major complications (56.9%), and mean length of stay (9.8 days). Vascular surgery had the second greatest complexity score and ranked the greatest on the domains of major comorbidities (2.7 comorbidities) and 30-day readmissions (10.1%). The work relative value units did not correlate with overall complexity score (Spearman's ρ = 0.07; P < .01). Although vascular surgery had the second most complex patients, it ranked fifth greatest in median work relative value units. Similarly, general surgery was the fifth most complex but had the second-least median work relative value units. CONCLUSION: Substantial differences exist between patient complexity across specialties, which do not correlate with work relative value units. Physician effort is determined largely by patient complexity, which is not captured appropriately by the current work relative value units.


Assuntos
Eficiência , Escalas de Valor Relativo , Especialidades Cirúrgicas/estatística & dados numéricos , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Adulto , Idoso , Comorbidade , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Transferência de Pacientes/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Melhoria de Qualidade , Estudos Retrospectivos , Risco Ajustado/estatística & dados numéricos , Fatores de Risco , Especialidades Cirúrgicas/organização & administração , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Fatores de Tempo
8.
Am J Surg ; 220(4): 813-820, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32115176

RESUMO

BACKGROUND: This study analyzed independent factors associated with post-thyroidectomy Emergency Room (ER) visits and Hospital Readmissions (HR). METHODS: This is a retrospective review from the CESQIP registry of 8381 thyroidectomy patients by 173 surgeons at 46 institutions. A total of 7142 ER visits and 7265 HR were analyzed. Multivariable logistic regression analysis was performed to determine the risk factors for an ER visit or HR. RESULTS: Within 30-days of surgery, rates of all ER visits were 3.4% (n = 250) and all HR were 2.3% (n = 170). Hypocalcemia was the reason for 21.9% of ER encounters and 36.4% of HR. BMI >40 kg/m2 was a risk factor for both ER visit (OR1.86) and HR (OR1.94). Surgical duration >3 h (OR2.63), and transection of recurrent laryngeal nerve (OR4.58) were risk factors for HR. CONCLUSIONS: Strategies to decrease hypocalcemia and improve perioperative care of patients with BMI >40 kg/m2 may improve post-thyroidectomy outcome.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Utilização de Instalações e Serviços/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Tireoidectomia , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Melhoria de Qualidade , Estudos Retrospectivos , Fatores de Risco , Estados Unidos
9.
Endocr Pract ; 25(1): 31-42, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30383499

RESUMO

OBJECTIVE: Recombinant human thyroid-stimulating hormone (rhTSH) has been approved for diagnostic (1998) and therapeutic (2008) indications in conjunction with radioactive iodine (RAI) administration post-thyroidectomy. Potential benefits of rhTSH, including avoidance of hypothyroidism side effects and shorter, less costly hospital stays, have not been assessed at the population level within the United States. In this study we quantify utilization, outcomes, and associated costs of rhTSH within the nationally representative Surveillance, Epidemiology, and End Results (SEER)-Medicare patient population. METHODS: We conducted a retrospective analysis of beneficiaries aged >65 years diagnosed within the SEER-Medicare data with differentiated thyroid cancer. Endpoints examined included ( 1) rhTSH utilization in the 2 years post-thyroidectomy (patients diagnosed 1996-2011 [utilization cohort]) and ( 2) comparison of resource utilization and costs as a function of rhTSH receipt in the 30 days prior to and 1 year following therapeutic RAI administration (patients diagnosed 2008-2011 [resource use cohort]). All costs were adjusted to reflect 2013 dollars. RESULTS: A total of 6,482 patients met inclusion criteria, of which, 1,363 (21.0%) received rhTSH. Receipt varied by region and was higher in the South (18%), Northeast (28%), and West (44%) compared to the Midwest (10%), and lower in census tracts in the bottom quartile of high school education rates (odds ratio 0.68, 95% confidence interval [CI] 0.55-0.83). rhTSH receipt was not associated with patient sex, age, comorbidities, or stage. Post-therapeutic RAI, 1,444 patients were assessed for resource utilization (2008-2011). The average cost of rhTSH was $905 per patient, with $2,483 being spent on average among patients who received rhTSH in association with therapeutic RAI. rhTSH receipt was not significantly associated with total inpatient days or number of outpatient and emergency department visits. Multivariable analyses showed similar overall costs among patients who did versus did not receive rhTSH (cost ratio [CR] 0.96, 95% CI 0.86-1.09), partially due to increased mean outpatient costs ($5,213 vs. $4,190) being offset by lower inpatient costs ($3,493 vs. $6,143). Overall costs were significantly higher in multivariable analyses among patients with distant metastatic disease (CR 1.92, 95% CI 1.58-2.32) and multiple comorbidities (CR 2.15, 95% CI 1.83-2.53). CONCLUSION: rhTSH recipients had higher outpatient, lower inpatient, and similar total Medicare payments as those not receiving rhTSH in conjunction with RAI, lending support to the use of rhTSH as a cost-neutral treatment option from the payer perspective. ABBREVIATIONS: CI = confidence interval; CMS = Centers for Medicare & Medicaid Services; CR = cost ratio; HCPCS = Healthcare Common Procedure Coding System; IQR = interquartile range; mCi = millicurie; OR = odds ratio; PET = positron emission tomography; RAI = radioactive iodine; rhTSH = recombinant human thyroid-stimulating hormone; RR = risk ratio; SEER = Surveillance, Epidemiology, and End Results.


Assuntos
Neoplasias da Glândula Tireoide , Tireoidectomia , Idoso , Humanos , Radioisótopos do Iodo , Medicare , Proteínas Recombinantes , Estudos Retrospectivos , Tireotropina , Estados Unidos
10.
Ann Surg Oncol ; 25(4): 949-956, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29417402

RESUMO

BACKGROUND: Some surgeons perform flexible fiberoptic laryngoscopy (FFL) in all patients prior to thyroid cancer operations. Given the low likelihood of recurrent laryngeal nerve (RLN) or aerodigestive invasion in clinically low-risk thyroid cancers, the value of routine FFL in this group is controversial. We hypothesized that routine preoperative FFL would not be cost effective in low-risk differentiated thyroid cancer (DTC). METHODS: A decision model was constructed comparing preoperative FFL versus surgery without FFL in a clinical stage T2 N0 DTC patient without voice symptoms. Total thyroidectomy and definitive hemithyroidectomy were both modeled as possible initial surgical approaches. Outcome probabilities and their corresponding utilities were estimated via literature review, and costs were estimated using Medicare reimbursement data. Sensitivity analysis was conducted to examine the uncertainty of cost, probability, and utility estimates in the model. RESULTS: When the initial surgical strategy was total thyroidectomy, routine preoperative FFL produced an incremental cost of $183 and an incremental effectiveness of 0.000126 quality-adjusted life-years (QALYs). The incremental cost-effectiveness ratio (ICER) for routine FFL prior to total thyroidectomy was $1.45 million/QALY, exceeding the $100,000/QALY threshold for cost effectiveness. Routine FFL became cost effective if the preoperative probability of asymptomatic vocal cord paralysis increased from 1.0% to 4.9%, or if the cost of preoperative FFL decreased from $128 to $27. Changing the extent of initial surgery to hemithyroidectomy produced a higher ICER for routine FFL of $1.7 million/QALY. CONCLUSION: Routine preoperative FFL is not cost effective in asymptomatic patients with sonographically low-risk DTC, regardless of the initial planned extent of surgery.


Assuntos
Laringoscopia/economia , Neoplasias da Glândula Tireoide/economia , Tireoidectomia/economia , Análise Custo-Benefício , Árvores de Decisões , Humanos , Laringoscopia/estatística & dados numéricos , Cadeias de Markov , Prognóstico , Anos de Vida Ajustados por Qualidade de Vida , Neoplasias da Glândula Tireoide/patologia , Neoplasias da Glândula Tireoide/cirurgia , Tireoidectomia/estatística & dados numéricos
11.
J Oncol Pract ; 13(4): e283-e290, 2017 04.
Artigo em Inglês | MEDLINE | ID: mdl-28291382

RESUMO

INTRODUCTION: Breast cancer treatment costs are rising, and identification of high-value oncology treatment strategies is increasingly needed. We sought to determine the potential cost savings associated with an evidence-based radiation treatment (RT) approach among women with early-stage breast cancer treated in the United States. PATIENTS AND METHODS: Using the National Cancer Database, we identified women with T1-T2 N0 invasive breast cancers treated with lumpectomy during 2011. Adjuvant RT regimens were categorized as conventionally fractionated whole-breast irradiation, hypofractionated whole-breast irradiation, and omission of RT. National RT patterns were determined, and RT costs were estimated using the Medicare Physician Fee Schedule. RESULTS: Within the 43,247 patient cohort, 64% (n = 27,697) received conventional RT, 13.3% (n = 5,724) received hypofractionated RT, 1.1% (n = 477) received accelerated partial-breast irradiation, and 21.6% (n = 9,349) received no RT. Among patients who were eligible for shorter RT or omission of RT, 57% underwent treatment with longer, more costly regimens. Estimated RT expenditures of the national cohort approximated $420.2 million during 2011, compared with $256.2 million had women been treated with the least expensive regimens for which they were safely eligible. This demonstrated a potential annual savings of $164.0 million, a 39% reduction in associated treatment costs. CONCLUSION: Among women with early-stage breast cancer after lumpectomy, use of an evidence-based approach illustrates an example of high-value care within oncology. Identification of high-value cancer treatment strategies is critically important to maintaining excellence in cancer care while reducing health care expenditures.


Assuntos
Neoplasias da Mama/epidemiologia , Prática Clínica Baseada em Evidências/economia , Custos de Cuidados de Saúde , Radioterapia Adjuvante/economia , Adulto , Idoso , Idoso de 80 Anos ou mais , Biomarcadores Tumorais , Neoplasias da Mama/diagnóstico , Neoplasias da Mama/radioterapia , Neoplasias da Mama/cirurgia , Custos e Análise de Custo , Fracionamento da Dose de Radiação , Prática Clínica Baseada em Evidências/métodos , Feminino , Humanos , Mastectomia Segmentar , Pessoa de Meia-Idade , Gradação de Tumores , Estadiamento de Neoplasias , Cuidados Pós-Operatórios , Dosagem Radioterapêutica , Carga Tumoral , Adulto Jovem
13.
PLoS Curr ; 52013 Feb 11.
Artigo em Inglês | MEDLINE | ID: mdl-23437421

RESUMO

Ruling out malignancy in thyroid nodules historically depended on thyroid resection and histopathological evaluation until fine needle aspiration (FNA) biopsy was introduced into the United States in the 1970's. Thyroid FNA biopsy identified a majority of thyroid nodules as benign, obviating the need for surgery in over half of the patients. However, 15%-30% of thyroid FNAs have indeterminate cytology that still requires operation, even though most of these operated nodules prove to be benign post-operatively. In order to predict which cytologically indeterminate thyroid nodules are benign and to potentially avoid surgery on these nodules, a recently described commercially available Gene Expression Classifier (GEC) test (Afirma®, Veracyte, Inc., South San Francisco, CA) has been developed that can be run on the FNA sample. This paper reviews the published literature and technology assessments/guidelines by independent parties and professional groups regarding the clinical utility as well as the analytic and clinical validity of the Afirma GEC.

14.
J Vasc Surg ; 57(5): 1325-30, 2013 May.
Artigo em Inglês | MEDLINE | ID: mdl-23375438

RESUMO

OBJECTIVE: Racial disparities in the outcomes of patients undergoing carotid endarterectomy (CEA) have been reported. We sought to examine the contemporary relationship between race and outcomes and to report postdischarge events after CEA. METHODS: The American College of Surgeons National Surgical Quality Improvement Program Participant Use Data Files were reviewed to identify all CEAs performed from 2005 to 2010 by vascular surgeons. The influence of race on outcomes was examined. Multivariate analysis was performed using variables found to be significant on bivariate analysis. The primary outcomes were stroke and mortality. Secondary outcomes were other 30-day complications, including postdischarge events. RESULTS: CEA was performed on 29,114 white patients (95.7%) and on 1316 black patients (4.3%); the overall stroke and mortality rates were 1.65% and 0.7%, respectively. The stroke rate was 1.6% for whites and 2.5% blacks (P = .009). The 30-day mortality rate was 0.7% for whites and 1.4% for blacks (P = .002). There was a longer operating time (P < .001) and total length of stay (P < .001), more postoperative pneumonias (P = .049), unplanned intubations (P < .001), ventilator dependence (P < .001), cardiac arrests (P < .001), bleeding requiring transfusions (P = .024), and reoperations within 30 days (P = .021) among black patients. Multivariate logistic regression modeling identified black race as an independent risk factor for 30-day mortality (odds ratio, 1.9; P = .007). Black patients also had a greater proportion of in-hospital deaths than white patients (73.7% vs 43.1%; P = .01). There was no between-group difference in the rate of postdischarge strokes. Thirty-six percent of all strokes occurred after discharge at a mean of 8.3 days, and 54.3% of deaths occurred after discharge at a mean of 11 days. CONCLUSIONS: Black race is an independent risk factor for 30-day mortality after CEA. A significant proportion of strokes and deaths occur after discharge in both racial groups evaluated.


Assuntos
Negro ou Afro-Americano , Doenças das Artérias Carótidas/cirurgia , Endarterectomia das Carótidas/efeitos adversos , Endarterectomia das Carótidas/mortalidade , Disparidades nos Níveis de Saúde , Acidente Vascular Cerebral/etnologia , Acidente Vascular Cerebral/mortalidade , População Branca , Idoso , Idoso de 80 Anos ou mais , Transfusão de Sangue , Doenças das Artérias Carótidas/etnologia , Doenças das Artérias Carótidas/mortalidade , Distribuição de Qui-Quadrado , Feminino , Parada Cardíaca/etnologia , Parada Cardíaca/mortalidade , Humanos , Intubação Intratraqueal , Tempo de Internação , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Alta do Paciente , Pneumonia/etnologia , Pneumonia/mortalidade , Hemorragia Pós-Operatória/etnologia , Hemorragia Pós-Operatória/mortalidade , Hemorragia Pós-Operatória/terapia , Respiração Artificial , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia
15.
Am J Surg ; 201(6): 789-96, 2011 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-21741511

RESUMO

BACKGROUND: Gallstone disease increases with age. The aims of this study were to measure short-term outcomes from cholecystectomy in hospitalized elderly patients, assess the effect of age, and identify predictors of outcomes. METHODS: This was a cross-sectional analysis, using the Health Care Utilization Project Nationwide Inpatient Sample (1999-2006), of elderly patients (aged 65-79 and ≥80 years) and a comparison group (aged 50-64 years) hospitalized for cholecystectomy. Linear and logistic regression models were used to evaluate age and outcome relationships. Main outcomes were in-hospital mortality, complications, discharge disposition, mean length of stay, and cost. RESULTS: A total of 149,855 patients aged 65 to 79 years, 62,561 patients aged ≥ 80 years, and 145,675 subjects aged 50 to 64 years were included. Elderly patients had multiple biliary diagnoses and longer times to surgery from admission and underwent more open procedures. Patients aged 65 to 79 years and those aged ≥80 years had higher adjusted odds of mortality (odds ratios [ORs], 2.36 and 5.91, respectively), complications (ORs, 1.57 and 2.39), nonroutine discharge (ORs, 3.02 and 10.76), longer length of stay (ORs, 1.11 and 1.31), and higher cost (ORs, 1.09 and 1.22) than younger patients. CONCLUSIONS: Elderly patients undergoing inpatient cholecystectomy have complex disease, with worse outcomes. Longer time from admission to surgery predicts poor outcome.


Assuntos
Colecistectomia/economia , Efeitos Psicossociais da Doença , Doenças da Vesícula Biliar/cirurgia , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Feminino , Seguimentos , Doenças da Vesícula Biliar/economia , Doenças da Vesícula Biliar/mortalidade , Mortalidade Hospitalar/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Estados Unidos/epidemiologia
16.
Ann Surg Oncol ; 18(5): 1293-9, 2011 May.
Artigo em Inglês | MEDLINE | ID: mdl-21088914

RESUMO

BACKGROUND: Postoperative hypocalcemia is the most common complication after thyroidectomy; prevention and treatment remain areas of ongoing debate. The purpose of this study was to determine the incremental cost utility of routine versus selective calcium and vitamin D supplementation after total or completion thyroidectomy. METHODS: A cost-utility analysis using a Markov decision model was performed for a hypothetical cohort of adult patients after thyroidectomy. Routine or selective supplementation of oral calcium carbonate, vitamin D (calcitriol), and intravenous calcium gluconate, when required, was used. Selective supplementation was determined by serum intact parathyroid hormone levels. The incremental cost utility, measured in U.S. dollars per quality-adjusted life-year (QALY), was calculated. RESULTS: In the base-case analysis, the cost of routine supplementation was $102 versus $164 for selective supplementation. Patients in the routine arm gained 0.002 QALYs compared to patients in the selective arm (0.95936 QALYs vs. 0.95725 QALYs). At the population level, this translates into a savings of $29,365/QALY (95% confidence interval, -$66,650 to -$1,772) for routine supplementation. Sensitivity analyses demonstrated that the model was most sensitive to the utility of the hypocalcemic state, postoperative rates of hypocalcemia, and cost of serum parathyroid hormone testing. CONCLUSIONS: Routine oral calcium and calcitriol supplementation in patients after thyroidectomy seems to be less expensive and results in higher patient utility than selective supplementation. Surgeons who have very low rates of hypocalcemia in their patients may benefit less from routine supplementation.


Assuntos
Cálcio/administração & dosagem , Complicações Pós-Operatórias , Tireoidectomia/economia , Vitamina D/administração & dosagem , Adulto , Cálcio/sangue , Custos e Análise de Custo , Suplementos Nutricionais , Humanos , Hipocalcemia/etiologia , Hipocalcemia/prevenção & controle , Hipocalcemia/cirurgia , Cadeias de Markov , Hormônio Paratireóideo/sangue , Prognóstico , Tireoidectomia/efeitos adversos , Vitamina D/sangue
17.
Ann Surg Oncol ; 17(11): 2816-23, 2010 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-20552406

RESUMO

BACKGROUND: Thyroid cancer increases in incidence and aggressiveness with age. The elderly are the fastest growing segment of the U.S. population. Reducing rates of rehospitalization would lower cost and improve quality of care. This is the first study to report population-level information characterizing rehospitalization after thyroidectomy among the elderly. METHODS: The Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database was used to identify patients older than aged 65 years with thyroid cancer who underwent thyroidectomy from 1997-2002. Patient and hospital characteristics were studied to predict the risk of rehospitalization. Outcomes were 30-day unplanned rehospitalization rate, cost, and length of stay (LOS) of readmission. RESULTS: Of 2,127 patients identified, 69% were women, 84% had differentiated thyroid cancer, and 52% underwent total thyroidectomy. Mean age was 74 years. A total of 171 patients (8%) underwent 30-day unplanned rehospitalization. Rehospitalization was associated with increased comorbidity, advanced stage, number of lymph nodes examined, increased LOS of index admission, and small hospital size (all P < 0.05). Patients with a complication during index hospital stay were more likely to be readmitted (P < 0.001), whereas patients who saw an outpatient medical provider after index discharge returned less frequently (P < 0.001). Forty-seven percent of readmissions were for endocrine-related causes. Mean LOS and cost of rehospitalization were 3.5 days and $5,921, respectively. Unplanned rehospitalization was associated with death at 1 year compared with nonrehospitalized patients (18% vs. 6%; P < 0.001). DISCUSSION: Rehospitalization among Medicare beneficiaries with thyroid cancer after thyroidectomy is prevalent and costly. Further study of predictors could identify high-risk patients for whom enhanced preoperative triage, improved discharge planning, and increased outpatient support might prove cost-effective.


Assuntos
Readmissão do Paciente , Programa de SEER , Neoplasias da Glândula Tireoide/cirurgia , Tireoidectomia/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Tempo de Internação , Masculino , Medicare , Prevalência , Estados Unidos
18.
Arch Surg ; 145(4): 356-62; discussion 362, 2010 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-20404286

RESUMO

BACKGROUND: Efforts to maximize kidney transplantation are tempered by concern for the live donor's safety. Case series and center surveys exist, but national aggregate data are lacking. We sought to determine predictors of early clinical and economic outcomes following living donor nephrectomy. DESIGN: A retrospective cross-sectional analysis using 1999-2005 discharge data from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample was performed. Cases were identified by International Classification of Diseases, Ninth Revision (ICD-9), codes. Clinical and economic outcomes were analyzed with regard to patient and provider characteristics using bivariate and multivariate regression analyses. SETTING: Healthcare Cost and Utilization Project Nationwide Inpatient Sample. PATIENTS: Patients undergoing living donor nephrectomy, identified by the ICD-9 codes. INTERVENTIONS: Clinical and economic outcomes were analyzed with regard to patient and provider characteristics using bivariate and multivariate regression analyses. MAIN OUTCOME MEASURES: In-hospital complications, mortality, mean length of stay (LOS), and mean total hospital costs. RESULTS: A total of 6320 cases were identified with 0% mortality and a complication rate of 18.4%. The mean (SD) LOS was 3.3 (0.3) days, and the mean inpatient cost was $10 708 ($505). Independent predictors of donor complications included older age (odds ratio [OR], 1.01), male sex (OR, 1.19), Charlson Comorbidity Index of at least 1 (OR, 1.49), obesity (OR, 1.76), medium-size hospitals (OR, 1.88), and low-volume hospitals (OR, 1.37). Predictors of longer LOS included older age, female sex, Charlson score of at least 1, lower household income, low-volume and urban hospitals, and low-volume surgeons. CONCLUSIONS: Kidney donation is associated with a low mortality rate but an 18% complication rate. Donation by those with advanced age or obesity is associated with higher risks. Informed consent should include discussion of these risks.


Assuntos
Doadores Vivos , Nefrectomia/estatística & dados numéricos , Adulto , Comorbidade , Efeitos Psicossociais da Doença , Bases de Dados Factuais , Feminino , Custos Hospitalares , Hospitais de Ensino/estatística & dados numéricos , Humanos , Falência Renal Crônica/epidemiologia , Falência Renal Crônica/cirurgia , Transplante de Rim/economia , Transplante de Rim/estatística & dados numéricos , Masculino , Análise Multivariada , Nefrectomia/economia , Razão de Chances , Estados Unidos
19.
J Clin Endocrinol Metab ; 95(4): 1672-80, 2010 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-20139234

RESUMO

CONTEXT: Use of recombinant human TSH (rhTSH) prior to radioactive iodine remnant ablation for patients with differentiated thyroid cancer avoids the hypothyroid state and improves quality of life. European studies have shown that use of rhTSH vs. thyroid hormone withdrawal is a cost-effective method for preparing patients for ablation. OBJECTIVE: The objective of the study was to determine the cost-utility of rhTSH prior to ablation in the United States. DESIGN/SETTING/SUBJECTS: A Markov decision model was developed for a hypothetical group of adult patients with low-risk differentiated thyroid cancer who were prepared for ablation by either rhTSH or thyroid hormone withdrawal. Patients entered the model after initial thyroidectomy; follow-up was in accordance with current American Thyroid Association guidelines. Input data were obtained from the literature, Medicare reimbursement schedule, and U.S. Bureau of Labor Statistics. Sensitivity analyses were performed for all clinically relevant inputs. MAIN OUTCOME MEASURES: Cost-utility, measured in U.S. dollars per quality-adjusted life-year ($/QALY), was measured. RESULTS: Use of rhTSH yielded an incremental cost-utility of $52,554/QALY (95% confidence interval $52,058-53,050/QALY) (incremental societal cost of $1,365/patient; incremental benefit of 0.026 QALY/patient). The majority of cost and benefit occurs during the preablation, ablation, and postablation period; differences in cost are due to cost of rhTSH and differences in productivity loss (days off work). The model was most sensitive to changes in time off work, cost of rhTSH, and differences in utilities of health states. CONCLUSIONS: In the United States, the cost-effectiveness of rhTSH for ablation in patients with low-risk differentiated thyroid cancer is highly dependent on potential variations in cost of rhTSH, rates of remnant ablation, time off work, and quality of life.


Assuntos
Neoplasias da Glândula Tireoide/radioterapia , Tireotropina/uso terapêutico , Tiroxina/uso terapêutico , Adulto , Análise Custo-Benefício , Custos e Análise de Custo , Técnicas de Apoio para a Decisão , Árvores de Decisões , Feminino , Humanos , Radioisótopos do Iodo/uso terapêutico , Masculino , Cadeias de Markov , Recidiva Local de Neoplasia/epidemiologia , Anos de Vida Ajustados por Qualidade de Vida , Proteínas Recombinantes/uso terapêutico , Neoplasias da Glândula Tireoide/economia , Neoplasias da Glândula Tireoide/cirurgia , Tireoidectomia , Estados Unidos
20.
Arch Surg ; 144(11): 1060-7, 2009 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-19917944

RESUMO

OBJECTIVE: To assess the effect of surgeon volume and specialty on clinical and economic outcomes after adrenalectomy. DESIGN: Population-based retrospective cohort analysis. SETTING: Healthcare Cost and Utilization Project Nationwide Inpatient Sample. PARTICIPANTS: Adults (>or=18 years) undergoing adrenalectomy in the United States (1999-2005). Patient demographic and clinical characteristics, surgeon specialty (general vs urologist), surgeon adrenalectomy volume, and hospital factors were assessed. MAIN OUTCOME MEASURES: The chi(2) test, analysis of variance, and multivariate linear and logistic regression were used to assess in-hospital complications, mean hospital length of stay (LOS), and total inpatient hospital costs. RESULTS: A total of 3144 adrenalectomies were included. Mean patient age was 53.7 years; 58.8% were women and 77.4% white. A higher proportion of general surgeons were high-volume surgeons compared with urologists (34.1% vs 18.2%, P < .001). Low-volume surgeons had more complications (18.2% vs 11.3%, P < .001) and their patients had longer LOS (5.5 vs 3.9 days, P < .001) than did high-volume surgeons; urologists had more complications (18.4% vs 15.2%, P = .03) and higher costs ($13,168 vs $11,732, P = .02) than did general surgeons. After adjustment for patient and provider characteristics in multivariate analyses, surgeon volume, but not specialty, was an independent predictor of complications (odds ratio = 1.5, P < .002) and LOS (1.0-day difference, P < .001). Hospital volume was associated only with LOS (0.8-day difference, P < .007). Surgeon volume, specialty, and hospital volume were not predictors of costs. CONCLUSION: To optimize outcomes, patients with adrenal disease should be referred to surgeons based on adrenal volume and laparoscopic expertise irrespective of specialty practice.


Assuntos
Adrenalectomia/mortalidade , Adrenalectomia/estatística & dados numéricos , Avaliação de Resultados em Cuidados de Saúde , Padrões de Prática Médica/normas , Carga de Trabalho/estatística & dados numéricos , Neoplasias das Glândulas Suprarrenais/diagnóstico , Neoplasias das Glândulas Suprarrenais/mortalidade , Neoplasias das Glândulas Suprarrenais/cirurgia , Adrenalectomia/economia , Adulto , Idoso , Competência Clínica , Estudos de Coortes , Feminino , Seguimentos , Custos Hospitalares , Mortalidade Hospitalar/tendências , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Padrões de Prática Médica/economia , Probabilidade , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Especialização , Taxa de Sobrevida , Resultado do Tratamento , Estados Unidos , Carga de Trabalho/economia
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