Challenges and strategies for contraceptive care in independent abortion clinics in the United States, 2017.

OBJECTIVE: Many patients may wish to receive contraceptive counseling and services during an abortion visit, but a 2009 study documented challenges faced by abortion clinics, especially independent ones, in providing contraceptive care. Since then, the Affordable Care Act (ACA) has made contraception more accessible by expanding coverage to millions of individuals and by eliminating out of pocket costs. This paper aims to update this previous work and describe recent challenges in providing contraceptive care in independent abortion settings following the ACA, as well as the strategies used to address these challenges. METHODS: We conducted two focus groups and 19 semi-structured interviews with clinic administrators and directors at independent abortion clinics. RESULTS: Challenges to providing contraceptive care in independent abortion clinics included navigating new guidelines under the Affordable Care Act for establishing coverage agreements with health insurance plans and receiving timely and sufficient reimbursement for services provided. Study respondents described strategies related to adjusting clinic flow and protocols to address patient needs regarding receiving contraception during abortion care. CONCLUSION: Staff working in independent abortion clinics in the United States experience a tension between trying to provide holistic, patient-centered care - including contraceptive care - and navigating restrictive political and healthcare contexts for the delivery of abortion care.

The effect of pre- and post-operative physical activity on recovery after colorectal cancer surgery (PHYSSURG-C): study protocol for a randomised controlled trial.

BACKGROUND: Surgery for colorectal cancer is associated with a high risk of post-operative adverse events, re-operations and a prolonged post-operative recovery. Previously, the effect of prehabilitation (pre-operative physical activity) has been studied for different types of surgery, including colorectal surgery. However, the trials on colorectal surgery have been of limited methodological quality and size. The aim of this trial is to compare the effect of a combined pre- and post-operative intervention of moderate aerobic physical activity and inspiratory muscle training (IMT) with standard care on post-operative recovery after surgery for colorectal cancer. METHODS/DESIGN: We are conducting a randomised, controlled, parallel-group, open-label, multi-centre trial with physical recovery within 4 weeks after cancer surgery as the primary endpoint. Some 640 patients planned for surgery for colorectal cancer will be enrolled. The intervention consists of pre- and post-operative physical activity with increased daily aerobic activity of moderate intensity as well as IMT. In the control group, patients will be advised to continue their normal daily exercise routine. The primary outcome is patient-reported physical recovery 4 weeks post-operatively. Secondary outcomes are length of sick leave, complication rate and severity, length of hospital stay, re-admittances, re-operations, post-operative mental recovery, quality of life and mortality, as well as changes in insulin-like growth factor 1 and insulin-like growth factor-binding protein 3, perception of pain and a health economic analysis. DISCUSSION: An increase in moderate-intensity aerobic physical activity is a safe, cheap and feasible intervention that would be possible to implement in standard care for patients with colorectal cancer. If shown to be effective, this lifestyle intervention could be a clinical parallel to pre-operative smoke cessation that has already been implemented with good clinical results. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02299596 . Registered on 17 November 2014.

Impact of Neuromuscular Electrical Stimulation (NMES) on 90-Day Episode Costs and Post-Acute Care Utilization in Total Knee Replacement Patients with Disuse Atrophy.

INTRODUCTION: This study evaluated differences in: 1) total episode payments, 2) probability of hospital readmission, 3) probability of inpatient rehab facility (IRF) and utilization, and 4) probability of skilled nursing care facility (SNF) utilization in patients who had disuse atrophy and underwent a total knee arthroplasty (TKA) and either did, or did not, receive preoperative home-based neuromuscular electrical stimulation (NMES) therapy. MATERIALS AND METHODS: We used the Medicare limited dataset for a 5% sample of beneficiaries from 2014 and 2015 to construct episodes-of-care for TKA (DRG-470) patients with disuse atrophy who underwent a TKA during the 30 days prior to hospital admission and 90 days post-discharge. Patients were stratified into those who either did or did not receive pre- and postoperative NMES therapy. An ordinary least square (OLS) model was used to estimate the impact of NMES on total episode. Linear probability models were used to estimate the impact of NMES on SNF or IRF utilization and readmission. RESULTS: A $3,274 reduction in episode payments for patients who used preoperative NMES versus those who did not (p<0.001) was demonstrated. The probability of readmission was 12.7% lower for those who used preoperative NMES therapy versus those who did not (p=0.609). The probability of utilizing IRF and SNF was 56.7% (p=0.061) and 46.4% (p=<0.001) lower for those who used pre- and postoperative NMES versus those who did not, respectively. CONCLUSION: Significant reduction in total episode payments and SNF utilization for TKA patients with disuse atrophy who had NMES therapy was demonstrated.

Medical and Economic Advantages of Postoperative Blood Salvage in Total Knee Replacement.

BACKGROUND: Total knee replacement surgery causes large blood loss leading to worsening of the patient's physical capacity, difficulties in rehabilitation and necessity of transfusions. The re-infusion of drainage fluid has been described as an alternative way to improve hematological parameters. The aim of the study was to determine the effectiveness of re-transfusion with regard to the allogeneic transfusion rate, duration of treatment and costs. MATERIAL AND METHODS: We performed a prospective randomized study of 101 patients, divided into an RTF group for re-transfusion from the drain and a DRN group for standard drainage. We could not re-transfuse drainage blood in 6 cases. 38 patients (RTF2) received their blood back and the remaining 63 patients (DRN2) did not. Depending on blood loss, laboratory tests and general condition, decisions were made to proceed with allogeneic transfusions. RESULTS: In spite of the re-transfusion, 39.4% of the patients in RTF2 required an additional transfusion, compared to 53.9% of the patients in DRN2 (p=0.15). Mean deterioration in hematological parameters was 72.9% of baseline in RTF2 and 75.0% in DRN2 (p=0.45), mean treatment time was 10.3 days for RTF2 and 11.1 for DRN2 (p=0,24) and mean cost was PLN 5426.5 in RTF versus PLN 5587.21 in DRN (p=0.76). CONCLUSION: The effect of re-transfusion on reducing allogeneic blood usage is not significant, does not alter patients' general condition and lab test results and does not eliminate the need for transfusion or influence the duration of hospital stay and the costs.

Influence of early goal-directed therapy using arterial waveform analysis on major complications after high-risk abdominal surgery: study protocol for a multicenter randomized controlled superiority trial.

BACKGROUND: Early goal-directed therapy refers to the use of predefined hemodynamic goals to optimize tissue oxygen delivery in critically ill patients. Its application in high-risk abdominal surgery is, however, hindered by safety concerns and practical limitations of perioperative hemodynamic monitoring. Arterial waveform analysis provides an easy, minimally invasive alternative to conventional monitoring techniques, and could be valuable in early goal-directed strategies. We therefore investigate the effects of early goal-directed therapy using arterial waveform analysis on complications, quality of life and healthcare costs after high-risk abdominal surgery. METHODS/DESIGN: In this multicenter, randomized, controlled superiority trial, 542 patients scheduled for elective, high-risk abdominal surgery will be included. Patients are allocated to standard care (control group) or early goal-directed therapy (intervention group) using a randomization procedure stratified by center and type of surgery. In the control group, standard perioperative hemodynamic monitoring is applied. In the intervention group, early goal-directed therapy is added to standard care, based on continuous monitoring of cardiac output with arterial waveform analysis. A treatment algorithm is used as guidance for fluid and inotropic therapy to maintain cardiac output above a preset, age-dependent target value. The primary outcome measure is a combined endpoint of major complications in the first 30 days after the operation, including mortality. Secondary endpoints are length of stay in the hospital, length of stay in the intensive care or post-anesthesia care unit, the number of minor complications, quality of life, cost-effectiveness and one-year mortality and morbidity. DISCUSSION: Before the start of the study, hemodynamic optimization by early goal-directed therapy with arterial waveform analysis had only been investigated in small, single-center studies, including minor complications as primary endpoint. Moreover, these studies did not include quality of life, healthcare costs, and long-term outcome in their analysis. As a result, the definitive role of arterial waveform analysis in the perioperative hemodynamic assessment and care for high-risk surgical patients is unknown, which gave rise to the present trial. Patient inclusion started in May 2012 and is expected to end in 2016. TRIAL REGISTRATION: This trial was registered in the Dutch Trial Register (registration number NTR3380) on 3 April 2012.

Patient blood management in elective total hip- and knee-replacement surgery (Part 1): a randomized controlled trial on erythropoietin and blood salvage as transfusion alternatives using a restrictive transfusion policy in erythropoietin-eligible patients.

BACKGROUND: Patient blood management combines the use of several transfusion alternatives. Integrated use of erythropoietin, cell saver, and/or postoperative drain reinfusion devices on allogeneic erythrocyte use was evaluated using a restrictive transfusion threshold. METHODS: In a factorial design, adult elective hip- and knee-surgery patients with hemoglobin levels 10 to 13 g/dl (n = 683) were randomized for erythropoietin or not, and subsequently for autologous reinfusion by cell saver or postoperative drain reinfusion devices or for no blood salvage device. Primary outcomes were mean allogeneic intra- and postoperative erythrocyte use and proportion of transfused patients (transfusion rate). Secondary outcome was cost-effectiveness. RESULTS: With erythropoietin (n = 339), mean erythrocyte use was 0.50 units (U)/patient and transfusion rate 16% while without (n = 344), these were 0.71 U/patient and 26%, respectively. Consequently, erythropoietin resulted in a nonsignificant 29% mean erythrocyte reduction (ratio, 0.71; 95% CI, 0.42 to 1.13) and 50% reduction of transfused patients (odds ratio, 0.5; 95% CI, 0.35 to 0.75). Erythropoietin increased costs by €785 per patient (95% CI, 262 to 1,309), that is, €7,300 per avoided transfusion (95% CI, 1,900 to 24,000). With autologous reinfusion, mean erythrocyte use was 0.65 U/patient and transfusion rate was 19% with erythropoietin (n = 214) and 0.76 U/patient and 29% without (n = 206). Compared with controls, autologous blood reinfusion did not result in erythrocyte reduction and increased costs by €537 per patient (95% CI, 45 to 1,030). CONCLUSIONS: In hip- and knee-replacement patients (hemoglobin level, 10 to 13 g/dl), even with a restrictive transfusion trigger, erythropoietin significantly avoids transfusion, however, at unacceptably high costs. Autologous blood salvage devices were not effective.

Patient blood management in elective total hip- and knee-replacement surgery (part 2): a randomized controlled trial on blood salvage as transfusion alternative using a restrictive transfusion policy in patients with a preoperative hemoglobin above 13 g/dl.

BACKGROUND: Patient blood management is introduced as a new concept that involves the combined use of transfusion alternatives. In elective adult total hip- or knee-replacement surgery patients, the authors conducted a large randomized study on the integrated use of erythropoietin, cell saver, and/or postoperative drain reinfusion devices (DRAIN) to evaluate allogeneic erythrocyte use, while applying a restrictive transfusion threshold. Patients with a preoperative hemoglobin level greater than 13 g/dl were ineligible for erythropoietin and evaluated for the effect of autologous blood reinfusion. METHODS: Patients were randomized between autologous reinfusion by cell saver or DRAIN or no blood salvage device. Primary outcomes were mean intra- and postoperative erythrocyte use and proportion of transfused patients (transfusion rate). Secondary outcome was cost-effectiveness. RESULTS: In 1,759 evaluated total hip- and knee-replacement surgery patients, the mean erythrocyte use was 0.19 (SD, 0.9) erythrocyte units/patient in the autologous group (n = 1,061) and 0.22 (0.9) erythrocyte units/patient in the control group (n = 698) (P = 0.64). The transfusion rate was 7.7% in the autologous group compared with 8.3% in the control group (P = 0.19). No difference in erythrocyte use was found between cell saver and DRAIN groups. Costs were increased by €298 per patient (95% CI, 76 to 520). CONCLUSION: In patients with preoperative hemoglobin levels greater than 13 g/dl, autologous intra- and postoperative blood salvage devices were not effective as transfusion alternatives: use of these devices did not reduce erythrocyte use and increased costs.

Safety, efficacy, and cost savings of single parathyroid hormone measurement for risk stratification after total thyroidectomy.

The management of hypocalcemia (HC) after total thyroidectomy (TTx) is a challenge as TTx is transitioned into a same-day surgery. Measurement of parathyroid hormone (PTH) level after TTx may allow for prediction of postoperative HC and lead to shorter hospital stays. A prospective database was queried between January 2010 and June 2012 with 95 patients who had undergone TTx identified. Patient demographics; preoperative diagnosis; laboratory values and cost; complications; intravenous calcium supplementation; and length of stay (LOS) were analyzed. A PTH-based algorithm was retrospectively applied and theoretical cost savings were analyzed in terms of laboratory cost, LOS, and total cost. Ninety-five patients underwent TTx: 37 patients (38.9%) had cancer, whereas 27 (28.4%) had Graves' disease and the remaining 31 (32.6%) had a benign multinodular goiter. Postoperative PTH was recorded in 72 patients (74.4%); 46 (63.8%) had PTH greater than 10 pg/mL and 26 (36.9%) had PTH less than 10 pg/mL. Transient HC occurred in 10 patients (38.4%) with PTH less than 10 pg/mL (relative risk, 17.69; P = 0.0001). Patients with PTH less than 10 pg/mL incurred a 14.9 per cent higher hospital cost compared with those with PTH greater than 10 pg/mL. With retrospective implementation of the algorithm, there is a potential 46.4 per cent cost savings for the PTH less than 10 pg/mL group, 67.3 per cent savings for the PTH greater than 10 pg/mL group, and 46.7 per cent savings when taken altogether. Algorithmic risk stratification based on postoperative PTH less than 10 pg/mL serves as both a sensitive (100%) and specific (76.7%) predictor of postoperative HC. Such risk stratification may allow for same-day discharge in a number of patients, and even in patients requiring an overnight stay, result in cost savings as a result of a reduction in laboratory expenditures.

Cost-effectiveness of nutritional intervention in elderly subjects after hip fracture. A randomized controlled trial.

UNLABELLED: Hip fracture patients can benefit from nutritional supplementation during their recovery. Up to now, cost-effectiveness evaluation of nutritional intervention in these patients has not been performed. Costs of nutritional intervention are relatively low as compared with medical costs. Cost-effectiveness evaluation shows that nutritional intervention is likely to be cost-effective. INTRODUCTION: Previous research on the effect of nutritional intervention on clinical outcome in hip fracture patients yielded contradictory results. Cost-effectiveness of nutritional intervention in these patients remains unknown. The aim of this study was to evaluate cost-effectiveness of nutritional intervention in elderly subjects after hip fracture from a societal perspective. METHODS: Open-label, multi-centre randomized controlled trial investigating cost-effectiveness of intensive nutritional intervention comprising regular dietetic counseling and oral nutritional supplementation for 3 months postoperatively. Patients allocated to the control group received care as usual. Costs, weight and quality of life were measured at baseline and at 3 and 6 months postoperatively. Incremental cost-effectiveness ratios (ICERs) were calculated for weight at 3 months and quality adjusted life years (QALYs) at 6 months postoperatively. RESULTS: Of 152 patients enrolled, 73 were randomized to the intervention group and 79 to the control group. Mean costs of the nutritional intervention was 613 Euro. Total costs and subcategories of costs were not significantly different between both groups. Based on bootstrapping of ICERs, the nutritional intervention was likely to be cost-effective for weight as outcome over the 3-month intervention period, regardless of nutritional status at baseline. With QALYs as outcome, the probability for the nutritional intervention being cost-effective was relatively low, except in subjects aged below 75 years. CONCLUSION: Intensive nutritional intervention in elderly hip fracture patients is likely to be cost-effective for weight but not for QALYs. Future cost-effectiveness studies should incorporate outcome measures appropriate for elderly patients, such as functional limitations and other relevant outcome parameters for elderly.

Return on investment for essential obstetric care training in Ghana: do trained public sector midwives deliver postabortion care?

INTRODUCTION: In Ghana, the provision of postabortion care (PAC) by trained midwives is critical to the efficient and cost-effective reduction of unsafe abortion morbidity and mortality. METHODS: We performed a secondary analysis of provider data from a representative sample of Ghanaian health facilities in order to consider the determinants of PAC provision among both physicians and midwives. RESULTS: In the previous 5 years, more than 58% of providers had participated in at least one type of essential obstetric training. Overall, 28% of clinicians were offering PAC services (80% of physicians as compared to 20% of midwives). Bivariately, the provision of PAC services was associated with in-service training. After adjusting for select provider and facility characteristics, PAC/MVA training, working in a facility with the National Reproductive Health Standards and Policy available, and not working in a publicly run facility were associated with midwives offering PAC services. DISCUSSION: Although the provision of PAC by midwives is an efficient and cost-effective strategy for reducing maternal morbidity and mortality, clinical training of midwives leads to a lower yield of PAC providers when compared to physicians. Policy and practice should continue to support PAC expansion by trained midwives in the public sector and by understanding the barriers to provision of services by midwives working in public facilities.

Costs and quality of life for prehabilitation and early rehabilitation after surgery of the lumbar spine.

UNLABELLED: During the recent years improved operation techniques and administrative procedures have been developed for early rehabilitation. At the same time preoperative lifestyle intervention (prehabilitation) has revealed a large potential for additional risk reduction. The aim was to assess the quality of life and to estimate the cost-effectiveness of standard care versus an integrated programme including prehabilitation and early rehabilitation. METHODS: The analyses were based on the results from 60 patients undergoing lumbar fusion for degenerative lumbar disease; 28 patients were randomised to the integrated programme and 32 to the standard care programme. Data on cost and health related quality of life was collected preoperatively, during hospitalisation and postoperatively. The cost was estimated from multiplication of the resource consumption and price per unit. RESULTS: Overall there was no difference in health related quality of life scores. The patients from the integrated programme obtained their postoperative milestones sooner, returned to work and soaked less primary care after discharge. The integrated programme was 1,625 euros (direct costs 494 euros + indirect costs 1,131 euros) less costly per patient compared to the standard care programme. CONCLUSION: The integrated programme of prehabilitation and early rehabilitation in spine surgery is more cost-effective compared to standard care programme alone.

Efficacy and economics of postoperative blood salvage in patients undergoing elective total hip replacement.

INTRODUCTION: Patients undergoing total hip replacement (THR) regularly receive allogenic blood transfusions. The infusion of allogenic blood exposes the recipient to significant risks including the transmission of infection, anaphylactic and haemolytic reactions. The purpose of this study was to determine the effect of introducing a system to retransfuse salvaged drainage blood in patients undergoing primary THR. PATIENTS AND METHODS: We reviewed records of 109 consecutive patients who underwent THR following the introduction of the ABTrans autologous retransfusion system at our institution in January 2000. For comparison, we reviewed the medical records of 109 patients who underwent the same procedure immediately before the introduction of the retransfusion system. RESULTS: Overall, 9% of patients treated with blood salvage and 30% treated without blood salvage required allogenic blood transfusions. Patients treated with the salvage system had significantly smaller haemoglobin drops in the peri-operative period (difference 0.56 g/dl; P = 0.001). The overall cost of using the retransfusion system was similar to that of routine vacuum drainage when the savings of reduced allogenic blood transfusion were taken into account. CONCLUSIONS: The retransfusion of postoperative drainage blood is a simple, effective and safe way of providing autologous blood for patients undergoing primary THR.

"ProvenCareSM": a provider-driven pay-for-performance program for acute episodic cardiac surgical care.

OBJECTIVE: To test whether an integrated delivery system could successfully implement an evidence-based pay-for-performance program for coronary artery bypass graft (CABG) surgery. METHODS: The program consisted of 3 components: (1) establishing implementable best practices; (2) developing risk-based pricing; (3) establishing a mechanism for patient engagement. Surgeons reviewed all class I and IIa "2004 American Heart Association/American College of Cardiology Guidelines for CABG Surgery" and translated them into 40 verifiable behaviors. These were imbedded within a new ProvenCareSM program and "hardwired" within the electronic health record system, including order sets, templates, and "time outs". Concurrently preoperative, inpatient, and postoperative care within 90 days was packaged into a fixed price. A Patient Compact was developed to highlight the importance of patient activation. All elective CABG patients treated between February 2, 2006 and February 2, 2007 were included (ProvenCareSM Group) and compared with 137 patients treated in 2005 (Conventional Care Group). RESULTS: Initially, only 59% of patients received all 40 best practice components. At 3 months, program compliance reached 100%, but fell transiently to 86% over the next 3 months. Reliability subsequently increased to 100% and was sustained for the remainder of the study period. The overall trend in reliability was significant at P=0.001. Thirty-day clinical outcomes showed improved trends () but only the likelihood of discharge to home reached statistical significance. Length of stay decreased by 16% and mean hospital charges fell 5.2%.(Table is included in full-text article.) CONCLUSION: A provider-driven pay-for-performance process for CABG, enabled by an electronic health record system, can reliably deliver evidence-based care, fundamentally alter reimbursement incentives, and may ultimately improve outcomes and reduce resource use.

Cost-effectiveness analysis of local, regional and general anaesthesia for inguinal hernia repair using data from a randomized clinical trial.

BACKGROUND: Inguinal hernia repair is a common operation in general surgery and can be performed under local, regional or general anaesthesia. This multicentre randomized trial was undertaken to compare the costs of the three anaesthetic methods in general surgical practice. METHODS: Between January 1999 and December 2001, 616 patients at ten hospitals who underwent primary inguinal hernia repair were randomized to local, regional or general anaesthesia. The primary endpoints were direct costs. Secondary endpoints were indirect costs and recurrence rates. RESULTS: Total intraoperative, as well as total early postoperative, data showed local anaesthesia to have significant cost advantages over regional and general anaesthesia (P < 0.001). The advantage was also significant for total hospital and total healthcare costs (P < 0.001), whereas there was no significant difference between regional and general anaesthesia. CONCLUSION: The use of local anaesthesia for inguinal hernia repair was significantly less expensive than regional or general anaesthesia.

Changing blood transfusion practice in elective joint arthroplasty: a nursing initiative.

The use of re-infusion drains on 99 consecutive patients undergoing total knee arthroplasty surgery at a large hospital was analysed. As a control group the records of 99 patients treated without re-infusion were analysed retrospectively. The primary aim was to ascertain the cost effectiveness of the drains. Secondary aims were to assess safety of the drains, whether or not they reduced the need for allogeneic blood transfusion and whether they decreased the length of stay in hospital. The direct cost of consumables increased for the evaluation period. There was a smaller proportion of allogeneic blood transfusion (27% vs 38%) and a smaller mean number of units transfused (0.92 vs 0.54) in the re-infusion group compared to the control group. Patients benefited directly in that the mean length of stay was also significantly shorter in the re-infusion group. We anticipate more direct cost saving with experience and best practice and conclude that the use of re-infusion drains is a cost effective blood saving method in total knee joint arthroplasty.

[Comparison of cost-effectiveness in knee arthroscopy performed under local, general intravenous and spinal anesthesia]. / Porównanie kosztów wykonania artroskopii stawu kolanowego w znieczuleniu miejscowym, przewodowym (podpajeczynówkowym) i ogólnym dozylnym.

The study was performed to compare cost-effectiveness between local, regional (epidural) and general i.v. anesthesia in outpatient knee arthroscopy. The 520 outpatient diagnostic arthroscopy were performed in witch 443 underwent operative part. The cost of ambulatory surgery unit was 900 PLN/hour, postanesthesia care unit and care unit 315 PLN/hour each. The cost of local anesthesia 39 PLN, regional one 44 PLN and general one 58 PLN. The total cost of arthroscopy performed in local anesthesia, general and regional ones were respectively 1264, 1296 and 1567 PLN. Local anesthesia in 520 arthroscopies produces savings of 16667 and 157877 PLN comparing to general anesthesia and regional one. The biggest part of the costs in all types of anesthesia was ambulatory surgery unit cost and postanesthesia care unit cost which appears only in epidural anesthesia.

An economic justification for autologous blood re-infusion in primary total knee replacement surgery.

INTRODUCTION: To justify economically the use of autologous blood re-infusion after total knee replacement surgery compared with vacuum drains. To determine if the patients using autologous re-infusion units have a reduced allogenic blood transfusion requirement and hospital stay. PATIENTS AND METHODS: Prospectively, 50 patients undergoing primary unilateral total knee replacements with autologous re-infusion units were studied. They were matched for age, sex, type of prosthesis and the month in which surgery took place to a second group undergoing the same surgery with vacuum drains. The results for the second group were obtained retrospectively from the notes. The outcome measures were the need for allogenic blood transfusion and length of postoperative hospital stay. RESULTS: The use of re-infusion units reduced the need for postoperative allogenic blood transfusion from 28% to 4% in total knee replacement surgery. The cost of using re-infusion units was the same as vacuum drains. Overall, the autologous re-infusion patients were discharged 2 days earlier (99% confidence interval). CONCLUSIONS: Re-infusion units are no more expensive than vacuum drains. In addition, autologous blood has many clinical benefits compared to allogenic blood. Re-infusion may shorten the hospital stay for patients undergoing total knee replacement surgery.

Randomized clinical trial of the effects of preoperative and postoperative oral nutritional supplements on clinical course and cost of care.

BACKGROUND: Postoperative oral nutritional supplementation has been shown to be of clinical benefit. This study examined the clinical effects and cost of administration of oral supplements both before and after surgery. METHODS: This was a randomized clinical trial conducted in three centres. Patients undergoing lower gastrointestinal tract surgery were randomized to one of four groups: group CC received no nutritional supplements, group SS took supplements both before and after surgery, group CS received postoperative supplements only, and group SC were given supplements only before surgery. Preoperative supplements were given from the time it was decided to operate to 1 day before surgery. Postoperative supplements were started when the patient was able to take free fluids and continued for 4 weeks after discharge from hospital. Data collected included weight change, complications, length of stay, nutritional intake, anthropometrics, quality of life and detailed costings covering all aspects of care. RESULTS: Some 179 patients were randomized, of whom 27 were withdrawn and 152 analysed (CC 44, SS 32, CS 35, SC 41). Dietary intake was similar in all four groups throughout the study. Mean energy intake from preoperative supplements was 536 and 542 kcal/day in the SS and SC groups respectively; that 2 weeks after discharge from hospital was 274 and 361 kcal/day in the SS and CS groups respectively. There was significantly less postoperative weight loss in the SS group than in the CC and CS groups (P < 0.050), and significantly fewer minor complications in the SS and CS groups than the CC group (P < 0.050). There were no differences in the rate of major complications, anthropometrics and quality of life. Mean overall costs were greatest in the CC group, although differences between groups were not significant. CONCLUSION: Perioperative oral nutritional supplementation started before hospital admission for lower gastrointestinal tract surgery significantly diminished the degree of weight loss and incidence of minor complications, and was cost-effective.

Costs of thalamic deep brain stimulation for movement disorders in patients with multiple sclerosis.

Several studies have shown that thalamic deep brain stimulation (DBS) reduces tremor and improves hand performance in patients with multiple sclerosis (MS). The purpose of this paper is to describe the cost implications of DBS in MS patients and to highlight postoperative medical requirements that can be associated with this therapy. In a prospective study of thalamic DBS in MS patients the mean equipment costs were pounds 4769 (median pounds 7010, Medtronic, 1998 prices); mean neurosurgical inpatient costs per operated patient (n = 15) were pounds 4848 (range pounds 1982-8920, median pounds 5110); and mean in-patient postoperative rehabilitation cost pounds 4602 (range pounds 0-32,225, median pounds 1783). In addition there were transport and follow up costs. Mean neurosurgical inpatient stay following stereotactic DBS implantation was 15 days (median 12 days); and mean inpatient, postoperative rehabilitation stay 54 days (median 25 days). Although there were significant improvements in hand function and tremor reduction at 12 months postoperation, the level of patient performance in activities of daily living, their perception of their handicap and ipse facto the amount of home support required were unchanged from preoperative levels. This study has highlighted significant unforeseen medical requirements and costs that can occur in MS patients who have thalamic DBS surgery.