RESUMO
PURPOSE: The objective of this study is to compare the operative time, intraoperative complications, length of stay, readmission rates, overall complications, mortality, and cost associated with Robotic Surgery (RS) and Laparascopic Surgery (LS) in anti-reflux and hiatal hernia surgery. METHODS: A comprehensive literature search was conducted using MEDLINE (via PubMed), Web of Science and Scopus databases. Studies comparing short-term outcomes and cost between RS and LS in patients with anti-reflux and hiatal hernia were included. Data on operative time, complications, length of stay, readmission rates, overall complications, mortality, and cost were extracted. Quality assessment of the included studies was performed using the MINORS scale. RESULTS: Fourteen retrospective observational studies involving a total of 555,368 participants were included in the meta-analysis. The results showed no statistically significant difference in operative time, intraoperative complications, length of stay, readmission rates, overall complications, and mortality between RS and LS. However, LS was associated with lower costs compared to RS. CONCLUSION: This systematic review and meta-analysis demonstrates that RS has non-inferior short-term outcomes in anti-reflux and hiatal hernia surgery, compared to LS. LS is more cost-effective, but RS offers potential benefits such as improved visualization and enhanced surgical techniques. Further research, including randomized controlled trials and long-term outcome studies, is needed to validate and refine these findings.
Assuntos
Refluxo Gastroesofágico , Hérnia Hiatal , Laparoscopia , Procedimentos Cirúrgicos Robóticos , Humanos , Hérnia Hiatal/cirurgia , Hérnia Hiatal/economia , Procedimentos Cirúrgicos Robóticos/economia , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Laparoscopia/economia , Laparoscopia/efeitos adversos , Refluxo Gastroesofágico/cirurgia , Refluxo Gastroesofágico/economia , Duração da Cirurgia , Herniorrafia/economia , Herniorrafia/métodos , Herniorrafia/efeitos adversos , Resultado do Tratamento , Tempo de Internação/economia , Fundoplicatura/economia , Fundoplicatura/métodos , Readmissão do Paciente/economia , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/economiaRESUMO
BACKGROUND: Wide area transepithelial sampling with three-dimensional computer-assisted analysis (WATS3D) is an adjunct to the standard random 4-quadrant forceps biopsies (FB, "Seattle protocol") that significantly increases the detection of Barrett's esophagus (BE) and associated neoplasia in patients undergoing screening or surveillance. AIMS: To examine the cost-effectiveness of adding WATS3D to the Seattle protocol in screening patients for BE. METHODS: A decision analytic model was used to compare the effectiveness and cost-effectiveness of two alternative BE screening strategies in chronic gastroesophageal reflux disease patients: FB with and without WATS3D. The reference case was a 60-year-old white male with gastroesophageal reflux disease (GERD). Effectiveness was measured by the number needed to screen to avert one cancer and one cancer-related death, and quality-adjusted life years (QALYs). Cost was measured in 2019 US$, and the incremental cost-effectiveness ratio (ICER) was measured in $/QALY using thresholds for cost-effectiveness of $100,000/QALY and $150,000/QALY. Cost was measured in 2019 US$. Cost and QALYs were discounted at 3% per year. RESULTS: Between 320 and 337 people would need to be screened with WATS3D in addition to FB to avert one additional cancer, and 328-367 people to avert one cancer-related death. Screening with WATS3D costs an additional $1219 and produced an additional 0.017 QALYs, for an ICER of $71,395/QALY. All one-way sensitivity analyses resulted in ICERs under $84,000/QALY. CONCLUSIONS: Screening for BE in 60-year-old white male GERD patients is more cost-effective when WATS3D is used adjunctively to the Seattle protocol than with the Seattle protocol alone.
Assuntos
Esôfago de Barrett/patologia , Diagnóstico por Computador/economia , Detecção Precoce de Câncer/economia , Células Epiteliais/patologia , Mucosa Esofágica/patologia , Neoplasias Esofágicas/patologia , Refluxo Gastroesofágico/patologia , Custos de Cuidados de Saúde , Esôfago de Barrett/economia , Esôfago de Barrett/mortalidade , Esôfago de Barrett/terapia , Biópsia/economia , Simulação por Computador , Análise Custo-Benefício , Técnicas de Apoio para a Decisão , Neoplasias Esofágicas/economia , Neoplasias Esofágicas/mortalidade , Neoplasias Esofágicas/terapia , Refluxo Gastroesofágico/economia , Refluxo Gastroesofágico/mortalidade , Refluxo Gastroesofágico/terapia , Humanos , Imageamento Tridimensional/economia , Masculino , Pessoa de Meia-Idade , Modelos Econômicos , Valor Preditivo dos Testes , Anos de Vida Ajustados por Qualidade de Vida , Fatores de Risco , Resultado do TratamentoRESUMO
BACKGROUND: We compared the cost-effectiveness of the common surgical strategies for the management of infants with feeding difficulty. METHODS: Infants with feeding difficulty undergoing gastrostomy alone (GT), GT and fundoplication, or gastrojejunostomy (GJ) tube were enrolled between 2/2017 and 2/2018. A validated GERD symptom severity questionnaire (GSQ) and visual analog scale (VAS) to assess quality of life (QOL) were administered at baseline, 1â¯month, and every 6â¯months. Data collected included demographics, resource utilization, diagnostic studies, and costs. VAS scores were converted to quality adjusted life months (QALMs), and costs per QALM were compared using a decision tree model. RESULTS: Fifty patients initially had a GT alone (71% laparoscopically), and one had a primary GJ. Median age was 4â¯months (IQR 3-8â¯months). Median follow-up was 11â¯months (IQR 5-13â¯months). Forty-three did well with GT alone. Six (12%) required conversion from GT to GJ tube, and one required a fundoplication. Of those with GT alone, six (14%) improved significantly so that their GT was removed after a mean of 7⯱â¯3â¯months. Overall, the median GSQ score improved from 173 at baseline to 18 after 1â¯year (pâ¯<â¯0.001). VAS scores also improved from 70/100 at baseline to 85/100 at 1â¯year (pâ¯<â¯0.001). ED visits (59%), readmissions (47%), and clinic visits (88%) cost $58,091, $1,442,139, and $216,739, respectively. GJ tube had significantly higher costs for diagnostic testing compared to GT (median $8768 vs. $1007, pâ¯<â¯0.001). Conversion to GJ tube resulted in costs of $68,241 per QALM gained compared to GT only. CONCLUSIONS: Most patients improved with GT alone without needing GJ tube or fundoplication. GT and GJ tube were associated with improvement in symptoms and QOL. GJ tube patients reported greater gains in QALMS but incurred higher costs. Further analysis of willingness to pay for each additional QALM will help determine the value of care. STUDY AND LEVEL OF EVIDENCE: Cost-effectiveness study, Level II.
Assuntos
Transtornos da Alimentação e da Ingestão de Alimentos/economia , Transtornos da Alimentação e da Ingestão de Alimentos/cirurgia , Fundoplicatura/economia , Derivação Gástrica/economia , Refluxo Gastroesofágico/cirurgia , Gastrostomia/economia , Análise Custo-Benefício , Serviço Hospitalar de Emergência/economia , Nutrição Enteral/economia , Transtornos da Alimentação e da Ingestão de Alimentos/etiologia , Feminino , Seguimentos , Refluxo Gastroesofágico/complicações , Refluxo Gastroesofágico/economia , Humanos , Lactente , Intubação Gastrointestinal/economia , Masculino , Visita a Consultório Médico/economia , Readmissão do Paciente/economia , Qualidade de Vida , Reoperação , Estudos Retrospectivos , Índice de Gravidade de Doença , Inquéritos e QuestionáriosRESUMO
BACKGROUND: Functional and motility disorders (FMDs) are common conditions that cause significant morbidity and economic loss. A comprehensive analysis of these disorders and their impact has not been done in an inpatient setting. AIMS: We seek to evaluate adult hospitalization trends for FMDs in the USA. METHODS: The National Inpatient Sample between 2005 and 2014 was analyzed. Poisson regression was used to assess hospitalization trends for FMDs referenced to non-FMD hospitalizations. Linear regression was used to assess cost per hospitalization and length of stay (LOS). All models were adjusted for age, sex, primary insurance, and Charlson comorbidity index. RESULTS: Hospitalizations with FMDs as the primary diagnosis fell by an adjusted 2.46%/year over the study period (p < 0.001). The entirety of this reduction was explained by falling admissions for gastroesophageal reflux (adjusted reduction of 7.04%/year, p < 0.001). The hospitalization rate for all other FMDs (excluding gastroesophageal reflux) minimally increased by 0.75%/year (p = 0.001). Total cost of care for FMD hospitalizations remained relatively stable ($3.17 billion in 2014), while increasing for all other hospitalizations. Mean LOS for FMD hospitalization increased by an adjusted 0.025 days/year, but decreased by 0.038 days/year for all other hospitalizations (p < 0.001). CONCLUSIONS: The hospitalization rate for gastroesophageal reflux fell between 2005 and 2014, but remained relatively stable to increase for all other FMDs. These trends may be due to increased proton pump inhibitor use, better patient/provider education, emphasis on outpatient management, and/or coding bias.
Assuntos
Refluxo Gastroesofágico/economia , Refluxo Gastroesofágico/epidemiologia , Custos Hospitalares/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Hospitalização/tendências , Custos Hospitalares/tendências , Humanos , Tempo de Internação , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: While clinical outcomes have been reported for anti-reflux surgery (ARS), there are limited data on post-operative encounters, including readmission, and their associated costs. This study evaluates healthcare utilization during the 90-day post-operative period following ARS including fundoplication and/or paraesophageal hernia (PEH) repair. METHODS: Data were analyzed from the Truven Health MarketScan® Databases. Patients older than 16 years with an ICD-9 procedure code or Common Procedural Terminology (CPT) code for ARS and a primary diagnosis of GERD during 2012-2014 were selected. Healthcare spending and utilization on emergency department (ED) visits, performance of outpatient endoscopy, and readmission were examined. Reasons for readmission were classified based on ICD-9 code. RESULTS: A total of 40,853 patients were included in the cohort with a mean age of 49 years and females comprising 76.0%. Mean length of stay was 1.4 days, and 93.0% of patients underwent a laparoscopic approach. The mean cost of the index surgical admission was $24,034. Readmission occurred in 4.2% of patients, and of those, 26.3% required a surgical intervention. Patients requiring one or more related readmissions accrued additional costs of $29,513. Some of the most common reasons for readmission were related to nutritional, metabolic, and fluid and electrolyte disorders. Presentation to the ED occurred in 14.0% of patients, and outpatient upper endoscopy was required in 1.5% of patients, but with much lower associated costs as compared to readmission ($1175). CONCLUSION: The majority of patients undergoing ARS do not require additional care within 90 days of surgery. Patients who are readmitted accrue costs that almost double the overall cost of care compared to the initial hospitalization. Measures to attenuate potentially preventable readmissions after ARS may reduce healthcare utilization in this patient population.
Assuntos
Utilização de Instalações e Serviços/economia , Fundoplicatura/economia , Refluxo Gastroesofágico/cirurgia , Custos de Cuidados de Saúde/estatística & dados numéricos , Hérnia Hiatal/cirurgia , Herniorrafia/economia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Assistência Ambulatorial/economia , Assistência Ambulatorial/estatística & dados numéricos , Bases de Dados Factuais , Serviço Hospitalar de Emergência/economia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Endoscopia/economia , Utilização de Instalações e Serviços/estatística & dados numéricos , Feminino , Seguimentos , Refluxo Gastroesofágico/economia , Hérnia Hiatal/economia , Humanos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/economia , Readmissão do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Estados Unidos , Adulto JovemRESUMO
BACKGROUND: Medication-refractory gastroesophageal reflux disease (GERD) is sometimes treated with laparoscopic Nissen fundoplication (LNF); however, this is a non-reversible procedure associated with important side effects and the need for repeat surgery. Removable magnetic sphincter augmentation (MSA) devices are an alternative, effective, and safe treatment option for such patients who have some lower esophageal sphincter function. The objective of this study was to assess the economic impact of introducing MSA technology (i.e., LINX Reflux Management System) into current practice from a US-payer perspective. METHODS: An economic budget impact model was developed over a 1-year time horizon that compared current treatment of GERD patients who are medically managed (but refractory) or receiving LNF to future treatment of GERD patients that included a mix of patients treated with medical management only, LNF, or MSA. Resources included within the analyses were index procedures (inpatient and outpatient use), reoperations (revisions and removals), readmissions, healthcare visits, diagnostic tests, procedures, and medications. Medicare payment rates were typically used to inform unit costs. RESULTS: Assuming a hypothetical commercial insurance population of 1 million members, the base-case analysis estimated a net cost savings of $111,367 with introduction of the MSA. This translates to a savings of $0.01 per member per month. Results were largely driven by avoided inpatient procedures with use of the MSA device. Alternative analyses exploring the potential impact of increasing surgical volumes predicted that results would remain cost saving if the proportion of MSA market share taken from LNF was ≥ 90%. CONCLUSIONS: This study predicts that the introduction of the MSA device would lead to favorable budget impact results for the treatment of medication-refractory mechanical GERD for commercial payers. Future analyses will benefit from inclusion of middle-ground treatments as well as longer time horizons.
Assuntos
Orçamentos/estatística & dados numéricos , Esofagoplastia/instrumentação , Refluxo Gastroesofágico/cirurgia , Seguro Saúde/estatística & dados numéricos , Imãs/economia , Idoso , Idoso de 80 Anos ou mais , Esfíncter Esofágico Inferior/cirurgia , Esofagoplastia/economia , Esofagoplastia/métodos , Feminino , Refluxo Gastroesofágico/economia , Humanos , Masculino , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Modelos Econômicos , Resultado do Tratamento , Estados UnidosRESUMO
BACKGROUND: Gastroesophageal reflux disease (GERD) can be treated using a vonoprazan-first strategy (first-line treatment with vonoprazan), or esomeprazole-first/rabeprazole-first strategies (first-line treatment with proton-pump inhibitors [PPIs], esomeprazole/rabeprazole, followed by a switch to vonoprazan). This cost-utility analysis used long-term simulation modeling to evaluate the cost-effectiveness of a vonoprazan-first strategy compared with the esomeprazole-first and rabeprazole-first strategies. METHODS: A Markov simulation model was developed to evaluate the cost-effectiveness of vonoprazan-first, esomeprazole-first, and rabeprazole-first strategies, comprising healing and maintenance therapies, over 5 years (4-week cycles). Healing therapy began with the administration of a normal dose of drug per real-world practice. If patients were not healed endoscopically, either a longer duration of healing therapy was provided (vonoprazan), the dose was increased (rabeprazole), or patients were switched to vonoprazan (immediately for esomeprazole, and after dose-escalation for rabeprazole, respectively). Healed patients received maintenance (lower/same dose as healing therapy). Recurrence resulted in re-challenge with healing therapy. Transition probabilities were derived from the results of indirect comparisons (network meta-analysis) and costs calculated from the Japanese payer perspective. Outcomes were defined as quality-adjusted life years (QALYs), with utilities based on published values. RESULTS: Expected costs of the vonoprazan-, esomeprazole-, and rabeprazole-first strategies were ¥36,194, ¥76,719, and ¥41,105, respectively, over 5 years. QALY gains for vonoprazan-first strategy versus the esomeprazole- and rabeprazole-first strategies were 0.014 and 0.003, respectively. Both estimated incremental cost-effectiveness ratios were dominant and robust to two sensitivity analyses. CONCLUSIONS: Vonoprazan-first strategy increased QALYs and appeared to be cost-effective for GERD patients compared with the esomeprazole- or rabeprazole-first strategies.
Assuntos
Esomeprazol/administração & dosagem , Refluxo Gastroesofágico/tratamento farmacológico , Pirróis/administração & dosagem , Rabeprazol/administração & dosagem , Sulfonamidas/administração & dosagem , Simulação por Computador , Análise Custo-Benefício , Esomeprazol/economia , Refluxo Gastroesofágico/economia , Humanos , Japão , Cadeias de Markov , Inibidores da Bomba de Prótons/administração & dosagem , Inibidores da Bomba de Prótons/economia , Pirróis/economia , Anos de Vida Ajustados por Qualidade de Vida , Rabeprazol/economia , Recidiva , Sulfonamidas/economia , Fatores de Tempo , Resultado do TratamentoRESUMO
INTRODUCTION: Evidence about the economic burden related to interstitial lung diseases (ILDs) and the cost-driving factors is sparse. In the knowledge that distinct comorbidities affect the clinical course of ILDs, our study investigates their impact on costs of care within first year after diagnosis. METHODS: Using claims data of individuals diagnosed with Idiopathic Interstitial Pneumonia (IIP) (nâ¯=â¯14â¯453) or sarcoidosis (nâ¯=â¯9106) between 2010 and 2013, we calculated total and ILD-associated mean annual per capita costs adjusted by age, sex and comorbidity burden via Generalized Linear Gamma models. Then, we assessed the cost impact of chronic obstructive pulmonary disease (COPD), diabetes, coronary artery disease, depression, gastro-esophageal reflux disease, pulmonary hypertension (PH), obstructive sleep apnoea syndrome (OSAS) and lung cancer using the model-based parameter estimates. RESULTS: Total mean annual per capita costs were 11 131 in the pooled cohort, 12 111 in IIP and 8793 in sarcoidosis, each with a 1/3 share of ILD-associated cost. Most comorbidities had a significant cost-driving effect, which was most pronounced for lung cancer in total (1.989 pooled, 2.491 sarcoidosis, 1.696 IIP) and for PH in ILD-associated costs (2.606 pooled, 2.347 IIP, 3.648 sarcoidosis). The lung-associated comorbidities COPD, PH, OSAS more strongly affected ILD-associated than total costs. CONCLUSION: Comorbidities increase the already substantial costs of care in ILDs. To support patient-centred ILD care, not only highly cost-driving conditions that are inherent with high mortality themselves require systematic management. Moreover, conditions that are more rather restricting the patient's activities of daily living should be addressed - despite a low-cost impact.
Assuntos
Comorbidade/tendências , Efeitos Psicossociais da Doença , Doenças Pulmonares Intersticiais/economia , Sarcoidose/economia , Atividades Cotidianas/psicologia , Idoso , Idoso de 80 Anos ou mais , Doença da Artéria Coronariana/economia , Doença da Artéria Coronariana/epidemiologia , Depressão/economia , Depressão/epidemiologia , Diabetes Mellitus/economia , Diabetes Mellitus/epidemiologia , Feminino , Refluxo Gastroesofágico/economia , Refluxo Gastroesofágico/epidemiologia , Humanos , Hipertensão Pulmonar/economia , Hipertensão Pulmonar/epidemiologia , Revisão da Utilização de Seguros/economia , Doenças Pulmonares Intersticiais/diagnóstico , Doenças Pulmonares Intersticiais/epidemiologia , Doenças Pulmonares Intersticiais/mortalidade , Neoplasias Pulmonares/economia , Neoplasias Pulmonares/epidemiologia , Masculino , Pessoa de Meia-Idade , Assistência Centrada no Paciente/economia , Doença Pulmonar Obstrutiva Crônica/economia , Estudos Retrospectivos , Sarcoidose/diagnóstico , Sarcoidose/epidemiologia , Apneia Obstrutiva do Sono/economia , Apneia Obstrutiva do Sono/epidemiologiaRESUMO
OBJECTIVES: Numerous risk factors have been characterized for acquired subglottic stenosis (ASGS) in the pediatric population. This analysis explores the comorbidities of hospitalized ASGS patients in the United States and associated costs and length of stay (LOS). METHODS: A retrospective analysis of the Kids' Inpatient Database (KID) from 2009 to 2012 for inpatientsâ¯≤â¯20 years of age who were diagnosed with ASGS. International Classification of Diseases, Clinical Modification, Version 9 diagnosis codes were used to extract diagnoses of interest from 14, 045, 425 weighted discharges across 4179 hospitals in the United States. An algorithm was created to identify the most common co-diagnoses and subsequently evaluated for total charges and LOS. RESULTS: ASGS was found in 7981 (0.06%) of total discharges. The mean LOS in discharges with ASGS is 13.11 days while the mean total charge in discharges with ASGS is $114,625; these values are significantly greater in discharges with ASGS than discharges without ASGS. Patients with ASGS have greater odds of being co-diagnosed with gastroesophageal reflux, Trisomy 21, other upper airway anomalies and asthma, while they have lower odds of being diagnosed with prematurity and dehydration. Aside from Trisomy 21 and asthma, hospitalizations of ASGS patients with the aforementioned comorbidities incurred a greater LOS and mean total charge. CONCLUSION: Our analysis identifies numerous comorbidities in children with ASGS that are associated with increased resource utilization amongst US hospitalizations. The practicing otolaryngologist should continue to advocate interdisciplinary care and be aware of the need for future controlled studies that investigate the management of such comorbidities.
Assuntos
Refluxo Gastroesofágico/epidemiologia , Preços Hospitalares/estatística & dados numéricos , Laringoestenose/epidemiologia , Tempo de Internação/estatística & dados numéricos , Adolescente , Asma/economia , Asma/epidemiologia , Criança , Pré-Escolar , Comorbidade , Bases de Dados Factuais , Desidratação/economia , Desidratação/epidemiologia , Síndrome de Down/economia , Síndrome de Down/epidemiologia , Refluxo Gastroesofágico/economia , Humanos , Lactente , Recém-Nascido , Classificação Internacional de Doenças , Laringoestenose/economia , Tempo de Internação/economia , Nascimento Prematuro/economia , Nascimento Prematuro/epidemiologia , Anormalidades do Sistema Respiratório/economia , Anormalidades do Sistema Respiratório/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Estados Unidos/epidemiologia , Adulto JovemRESUMO
INTRODUCTION: Laparoscopic antireflux surgery and medical therapy with proton pump inhibitors are gold standards of gastroesophageal reflux treatment. On account of limited resources and increasing healthcare needs and costs, in this analysis, not only optimal medical results, but also superiority in health economics of these 2 methods are evaluated. METHODS: We performed an electronic literature survey in MEDLINE, PubMed, Cochrane Library, ISRCTN (International Standard Randomization Controlled Trial Number) as well as in the NHS Economic Evaluation Database, including studies published until 1/2017. Only studies considering the effect size of QALY (Quality-Adjusted Life Years) (with respect to different quality of life-scores) as primary outcome comparing laparoscopic fundoplication and medical therapy were included. Criteria of comparison were ICER (Incremental Cost-Effectiveness Ratio) and ICUR (Incremental Cost-Utility Ratio). Superiority of the respective treatment option for each publication was worked out. RESULTS: In total, 18 comparative studies were identified in the current literature with respect to above-mentioned search terms, qualifying for the defined inclusion criteria. Six studies were finally selected for analyses. Out of 6 publications, 3 showed superiority of laparoscopic fundoplication over long-term medical management based on current cost-effectiveness data. Limitations were related to different time intervals, levels of evidence of studies and underlying resources/costs of analyses, healthcare systems and applied quality of life instruments. CONCLUSION: Future prospective, randomized trials should examine this comparison in greater detail. Additionally, there is a large potential for further research in the health economics assessment of early diagnosis and prevention measures of reflux disease and Barrett's esophagus/carcinoma.
Assuntos
Refluxo Gastroesofágico , Custos de Cuidados de Saúde , Qualidade de Vida , Análise Custo-Benefício , Refluxo Gastroesofágico/economia , Alemanha , Humanos , Anos de Vida Ajustados por Qualidade de VidaAssuntos
Cuidados Críticos/métodos , Fundoplicatura/métodos , Refluxo Gastroesofágico/cirurgia , Medicare/economia , Cirurgia Endoscópica por Orifício Natural/métodos , Idoso , Idoso de 80 Anos ou mais , Cuidados Críticos/economia , Feminino , Seguimentos , Refluxo Gastroesofágico/economia , Humanos , Masculino , Cirurgia Endoscópica por Orifício Natural/economia , Estudos Retrospectivos , Estados UnidosRESUMO
BACKGROUND: Proton pump inhibitors (PPIs) remain one of the world's most frequently prescribed medications and there is a growing number of publications on correct versus incorrect use of PPIs worldwide. The objective of this observational retrospective study was to assess changes in PPI prescribing trends over the past decade and pharmacists' effect on optimizing PPI prescribing practice at a tertiary hospital in China. METHODS: We collected the prescriptions of PPIs in our hospital from January 2007 to December 2016. Then the rate of PPI prescribing, the defined daily doses (DDDs) and expenditures were calculated and plotted to show the change in utilization of and expenditure on PPIs. Reasons behind this change and effect of pharmacists' intervention were evaluated by investigating the rationality of PPI use through sample surveys of patients of pre-intervention (Jul.-Dec. 2015) and post-intervention (Jul.-Dec. 2016). RESULTS: In outpatient settings, the rate of PPI prescribing remained almost constant, utilization (from 135,808 DDDs to 722,943 DDDs) and expenditure (from 1.85 million CNY to 7.96 million CNY) increased for the past ten years, dominated by oral formulations and rabeprazole. In contrast, in inpatient settings, the rate of PPI prescribing (from 20.41 to 37.21%), utilization (from 132,329 DDDs to 827,747 DDDs) and expenditure (from 3.15 million CNY to 25.29 million CNY) increased from 2007 to 2015 and then decreased, dominated by injection formulations and omeprazole. Pharmacist interventions could significantly promote the rational use of PPIs (44.00% versus 26.67%), decrease PPI use and reduce patients' charges (P < 0.05). CONCLUSIONS: The utilization of and expenditure on PPIs grew due to the increase of patients and irrational use of PPI. Pharmacist interventions help to reduce PPI utilization and expenditure and enhance rationality for inpatients, but much work should be done to regulate injection and originator formulas, and improve the rationality in the future.
Assuntos
Prescrições de Medicamentos/economia , Refluxo Gastroesofágico/tratamento farmacológico , Farmacêuticos , Padrões de Prática Médica/tendências , Inibidores da Bomba de Prótons/uso terapêutico , Centros de Atenção Terciária , China , Uso de Medicamentos , Refluxo Gastroesofágico/economia , Humanos , Pacientes Internados , Pacientes Ambulatoriais , Padrões de Prática Médica/estatística & dados numéricos , Inibidores da Bomba de Prótons/economia , Estudos RetrospectivosRESUMO
In the past decade, the introduction of high-resolution manometry and the classification of achalasia into subtypes has made possible to accurately diagnose the disease and predict the response to treatment for its different subtypes. However, even to date, in an era of exponential medical progress and increased insight in disease mechanisms, treatment of patients with achalasia is still rather simplistic and mostly confined to mechanical disruption of the lower esophageal sphincter by different means. In addition, there is partial consensus on what is the best form of available treatments for patients with achalasia. Herein, we provide a comprehensive outlook to a general approach to the patient with suspected achalasia by: 1) defining the modern evaluation process; 2) describing the diagnostic value of high-resolution manometry and the Chicago Classification in predicting treatment outcomes and 3) discussing the available treatment options, considering the patient conditions, alternatives available to both the surgeon and the gastroenterologist, and the burden to the health care system. It is our hope that such discussion will contribute to value-based management of achalasia through promoting a leaner clinical flow of patients at all points of care.
Assuntos
Acalasia Esofágica/terapia , Refluxo Gastroesofágico/terapia , Comunicação Interdisciplinar , Equipe de Assistência ao Paciente/normas , Bloqueadores dos Canais de Cálcio/economia , Bloqueadores dos Canais de Cálcio/uso terapêutico , Consenso , Dilatação/efeitos adversos , Dilatação/economia , Dilatação/instrumentação , Dilatação/métodos , Acalasia Esofágica/diagnóstico , Acalasia Esofágica/economia , Acalasia Esofágica/fisiopatologia , Esfíncter Esofágico Inferior/fisiopatologia , Esfíncter Esofágico Inferior/cirurgia , Esofagoscopia/efeitos adversos , Esofagoscopia/economia , Esofagoscopia/instrumentação , Esofagoscopia/métodos , Fundoplicatura/efeitos adversos , Fundoplicatura/economia , Fundoplicatura/instrumentação , Fundoplicatura/métodos , Refluxo Gastroesofágico/economia , Refluxo Gastroesofágico/fisiopatologia , Reforma dos Serviços de Saúde , Miotomia de Heller/efeitos adversos , Miotomia de Heller/economia , Miotomia de Heller/instrumentação , Miotomia de Heller/métodos , Humanos , Manometria/métodos , Valor Preditivo dos Testes , Prognóstico , Resultado do Tratamento , Estados UnidosRESUMO
Introduction: Gastroesophageal reflux (GER) is a common disease usually limited to the oesophagus. Laryngopharyngeal reflux (LPR) is an inflammatory reaction of the mucosa of pharynx, larynx, and other associated upper respiratory organs, caused by a reflux of stomach contents outside the oesophagus. LPR is considered to be a relatively new clinical entity with a vast number of clinical manifestations which are treated sometimes empirically and without a correct diagnosis. However, there is disagreement between specialists about its definition and management: gastroenterologists consider LPR to be a substantially rare manifestation of gastroesophageal reflux disease (GERD), whereas otolaryngologists believe that LPR is an independent, but common in their practice, disorder. Patients suffering from LPR firstly consult their general practitioners, but a multidisciplinary approach may be fruitful to define a unified strategy based on specific medications and behavioural changes. The present Supplement would review the topic, considering LPR and GER characteristics, pathophysiology, diagnostic work-up, and new therapeutic strategies also comparing different specialist points of view and patient populations. In particular, new insights derive from an interesting gel compound, containing magnesium alginate and E-Gastryal® (hyaluronic acid, hydrolysed keratin, Tara gum, and Xantana gum). In particular, two very large Italian surveys were conducted in real-world setting, such as outpatient clinics. The most relevant outcomes are presented and discussed in the current Issue. Actually, laryngopharyngeal reflux (LPR) is considered an extraesophageal manifestation of the gastroesophageal reflux disease (GERD). Both GERD and its extraesophageal manifestation are very common in clinical practice. Both disorders have a relevant burden for the society: about this topic most of pharmaco-economic studies were conducted in the United States. In population-based studies, 19.8% of North Americans complain of typical symptoms of GERD (heartburn and regurgitation) at least weekly (1). Also in the late 1990s, GERD accounted for $9.3 to $12.1 billion in direct annual healthcare costs in the United States, higher than any other digestive disease. As a result, acid-suppressive agents were the leading pharmaceutical expenditure in the United States. The prevalence of GERD in the primary care setting becomes even more evident when one considers that, in the United States, 4.6 million office encounters annually are primarily for GERD, whereas 9.1 million encounters include GERD in the top 3 diagnoses for the encounter. GERD is also the most frequently first-listed gastrointestinal diagnosis in ambulatory care visits (2, 3) Extraesophageal manifestations of reflux, including LPR, asthma, and chronic cough, have been estimated to cost $5438 per patient in direct medical expenses in the first year after presentation and $13,700 for 5 years.
Assuntos
Refluxo Gastroesofágico , Refluxo Laringofaríngeo , Refluxo Gastroesofágico/economia , Refluxo Gastroesofágico/epidemiologia , Refluxo Gastroesofágico/terapia , Humanos , Refluxo Laringofaríngeo/economia , Refluxo Laringofaríngeo/epidemiologia , Refluxo Laringofaríngeo/terapia , Prevalência , Inquéritos e QuestionáriosRESUMO
Management of gastroesophageal reflux disease (GERD) commonly starts with an empiric trial of proton pump inhibitor (PPI) therapy and complementary lifestyle measures, for patients without alarm symptoms. Optimization of therapy (improving compliance and timing of PPI doses), or increasing PPI dosage to twice daily in select circumstances, can reduce persistent symptoms. Patients with continued symptoms can be evaluated with endoscopy and tests of esophageal physiology, to better determine their disease phenotype and optimize treatment. Laparoscopic fundoplication, magnetic sphincter augmentation, and endoscopic therapies can benefit patients with well-characterized GERD. Patients with functional diseases that overlap with or mimic GERD can also be treated with neuromodulators (primarily antidepressants), or psychological interventions (psychotherapy, hypnotherapy, cognitive and behavioral therapy). Future approaches to treatment of GERD include potassium-competitive acid blockers, reflux-reducing agents, bile acid binders, injection of inert substances into the esophagogastric junction, and electrical stimulation of the lower esophageal sphincter.
Assuntos
Esofagoscopia/métodos , Fundoplicatura/métodos , Refluxo Gastroesofágico/terapia , Laparoscopia/métodos , Inibidores da Bomba de Prótons/uso terapêutico , Antiácidos/uso terapêutico , Biópsia , Efeitos Psicossociais da Doença , Resistência a Medicamentos , Terapia por Estimulação Elétrica/métodos , Esofagite Eosinofílica/diagnóstico , Esofagite Eosinofílica/patologia , Esfíncter Esofágico Inferior/inervação , Esfíncter Esofágico Inferior/patologia , Esfíncter Esofágico Inferior/fisiopatologia , Esfíncter Esofágico Inferior/cirurgia , Monitoramento do pH Esofágico , Derivação Gástrica , Refluxo Gastroesofágico/diagnóstico , Refluxo Gastroesofágico/economia , Refluxo Gastroesofágico/epidemiologia , Antagonistas dos Receptores H2 da Histamina/uso terapêutico , Humanos , Neurotransmissores/uso terapêutico , Prevalência , Inibidores da Bomba de Prótons/economia , Inibidores da Bomba de Prótons/farmacologia , Comportamento de Redução do Risco , Resultado do TratamentoRESUMO
BACKGROUND: We previously reported on the outcomes of laparoscopic and open reoperative antireflux surgery. The aim of this study was to compare the costs of these procedures. STUDY DESIGN: We performed a retrospective review. Financial and procedure coding data were obtained using a cost accounting system. There were 49 procedures in 46 patients (36 female and 10 male). There were 38 laparoscopic (including 4 conversions) and 11 open procedures (7 transabdominal repairs and 4 gastric-preserving Roux-en-Y esophagojejunostomy). Values are median and interquartile range (IQR) and mean costs. RESULTS: Median age was 54 years (IQR 49 to 67 years) for the laparoscopic group vs 56 years (IQR 50 to 65 years) for the open group (p = 0.675). Mean direct costs per case for the laparoscopic group vs open group were $12,655 vs $24,636 (p < 0.002); operating room costs: $3,788 vs $5,547 (p = 0.011); hospital room costs: $1,948 vs $6,438 (p < 0.005); and supply costs: $4,386 vs $5,386 (p = 0.077). Median duration of the operation for the laparoscopic group was 185 minutes (IQR 147 to 254 minutes) vs 308 minutes (IQR 259 to 416 minutes) for the open group (p < 0.002). Median length of stay for the laparoscopic group was 3 days (IQR 2 to 4 days) vs 9 days (IQR 8 to 14 days) for the open group (p < 0.001). There was no 30-day or in-hospital mortality. Excluding the 4 Roux-en-Y procedures, direct costs for the laparoscopic group (n = 38) were $12,655 vs $23,678 for the transabdominal group (n = 7) (p = 0.035); duration of operation: 185 minutes (IQR 147 to 254 minutes) vs 292 minutes (IQR 218 to 309 minutes) (p = 0.003); and length of stay: 3 days (IQR 2 to 4 days) vs 9 days (IQR 7 to 15 days) (p = 0.017). There were 3 recurrences in the laparoscopic group. Two were repaired laparoscopically and 1 required a gastric-preserving Roux-en-Y esophagojejunostomy because the patient had undergone 2 earlier failed repairs. Including the cumulative costs of 3 recurrent hiatal hernia repairs, the driving force to reduce costs remained length of stay, manifested by the costs of the hospital rooms. CONCLUSIONS: Laparoscopic reoperative antireflux surgery is more cost-effective than open repair. The laparoscopic approach, when feasible, should be considered the surgical option for treatment of recurrent hiatal hernia in specialized esophageal centers with highly experienced surgical teams.
Assuntos
Análise Custo-Benefício , Refluxo Gastroesofágico/economia , Refluxo Gastroesofágico/cirurgia , Laparoscopia/economia , Reoperação/economia , Idoso , Procedimentos Cirúrgicos do Sistema Digestório/economia , Procedimentos Cirúrgicos do Sistema Digestório/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
OBJECTIVES: To compare the cost-effectiveness of therapy of gastroesophageal reflux disease with esomeprazole and other proton pump inhibitors (PPIs) in Poland. MATERIALS & METHODS: Studies comparing esomeprazole with other PPIs in the treatment of erosive esophagitis, non-erosive reflux disease and gastroesophageal reflux disease maintenance therapy were systematically reviewed. 9 randomized clinical trials were selected, meta-analyses were conducted. Cost data derived from Polish Ministry of Health and Pharmacies in Wroclaw. RESULTS: In the treatment of erosive esophagitis esomeprazole was significantly more effective than other PPIs. Both for 4- and 8-week therapy respective incremental cost-effectiveness ratio values were acceptably low. Differences in effectiveness of non-erosive reflux disease therapy were not significant. The replacement of pantoprazole 20 mg with more effective esomeprazole 20 mg in the 6-month maintenance therapy was associated with a substantially high incremental cost-effectiveness ratio.
Assuntos
Análise Custo-Benefício/estatística & dados numéricos , Esomeprazol/economia , Esomeprazol/uso terapêutico , Refluxo Gastroesofágico/tratamento farmacológico , 2-Piridinilmetilsulfinilbenzimidazóis/economia , 2-Piridinilmetilsulfinilbenzimidazóis/uso terapêutico , Refluxo Gastroesofágico/economia , Humanos , Pantoprazol , Polônia , Inibidores da Bomba de Prótons/economia , Inibidores da Bomba de Prótons/uso terapêutico , Resultado do TratamentoAssuntos
Esôfago de Barrett/economia , Prestação Integrada de Cuidados de Saúde/economia , Cuidado Periódico , Esofagoscopia/economia , Gastroenterologia/economia , Refluxo Gastroesofágico/economia , Custos de Cuidados de Saúde , Seguro Saúde/economia , Esôfago de Barrett/diagnóstico , Esôfago de Barrett/terapia , Procedimentos Clínicos/economia , Prestação Integrada de Cuidados de Saúde/normas , Esofagoscopia/normas , Honorários e Preços , Gastroenterologia/normas , Refluxo Gastroesofágico/diagnóstico , Refluxo Gastroesofágico/terapia , Custos de Cuidados de Saúde/normas , Reforma dos Serviços de Saúde/economia , Gastos em Saúde , Humanos , Seguro Saúde/normas , Pacotes de Assistência ao Paciente/economia , Equipe de Assistência ao Paciente/economia , Guias de Prática Clínica como Assunto , Sistema de Pagamento Prospectivo/economia , Melhoria de Qualidade/economia , Indicadores de Qualidade em Assistência à Saúde/economia , Fatores de Tempo , Resultado do Tratamento , Aquisição Baseada em Valor/economiaAssuntos
Esôfago de Barrett/economia , Prestação Integrada de Cuidados de Saúde/economia , Cuidado Periódico , Esofagoscopia/economia , Gastroenterologia/economia , Refluxo Gastroesofágico/economia , Custos de Cuidados de Saúde , Seguro Saúde/economia , Esôfago de Barrett/diagnóstico , Esôfago de Barrett/terapia , Procedimentos Clínicos/economia , Prestação Integrada de Cuidados de Saúde/normas , Esofagoscopia/normas , Honorários e Preços , Gastroenterologia/normas , Refluxo Gastroesofágico/diagnóstico , Refluxo Gastroesofágico/terapia , Custos de Cuidados de Saúde/normas , Reforma dos Serviços de Saúde/economia , Gastos em Saúde , Humanos , Seguro Saúde/normas , Pacotes de Assistência ao Paciente/economia , Equipe de Assistência ao Paciente/economia , Guias de Prática Clínica como Assunto , Sistema de Pagamento Prospectivo/economia , Melhoria de Qualidade/economia , Indicadores de Qualidade em Assistência à Saúde/economia , Fatores de Tempo , Resultado do Tratamento , Aquisição Baseada em Valor/economiaRESUMO
UNLABELLED: Background /Aim: Narrow band imaging (NBI) is a novel, innovative high-resolution endoscopic technique, which utilizes spectral narrow band filter for the visualization of mucosal patterns and microvasculature. Nonerosive reflux disease (NERD) is a type of gastroesophageal reflux disease (GERD) and it is characterized by reflux symptoms without mucosal breaks on white light endoscopy (WLE). Biopsies from distal esophagus of GERD patients show group of histologic features such as basal cell hyperplasia, elongation of lamina propria papillae, and inflammatory cells. The present study was undertaken to evaluate diagnostic utility of NBI endoscopy and biopsy study in NERD patients and also to correlate NBI endoscopy findings with histologic features of GERD. PATIENTS AND METHODS: A total of 71 cases of NERD having symptom score more than 10 and those not having erosion on WLE were recruited prospectively and underwent NBI endoscopic examination. Two mucosal biopsies were taken at 3 cm above the squamocolumnar junction. RESULTS: Histologic features of GERD were seen in 50 (70.4%) out of 71 cases. No significant correlation between NBI endoscopic findings with histologic features of GERD was found. CONCLUSION: The present study showed that histopathologic evaluation of distal esophageal mucosa has promising diagnostic value over NBI endoscopy in NERD patients. Use of newly introduced NBI technique requires tremendous familiarity for the detection of the cases of NERD, which show histologic features of GERD.