A Nationwide Analysis of Cleft Palate Repair: Impact of Local Anesthesia on Operative Outcomes and Hospital Cost.

BACKGROUND: This study investigates the associations between local anesthesia practice and perioperative complication, length of stay, and hospital cost for palatoplasty in the United States. METHODS: Patients undergoing cleft palate repair between 2004 and 2015 were abstracted from the Pediatric Health Information System database. Perioperative complication, length of stay, and hospital cost were compared by local anesthesia status. Multiple logistic regressions controlled for patient demographics, comorbidities, and hospital characteristics. RESULTS: Of 17,888 patients from 49 institutions who met selection criteria, 8631 (48 percent), 4447 (25 percent), and 2149 (12 percent) received epinephrine-containing lidocaine, epinephrine-containing bupivacaine, and bupivacaine or ropivacaine alone, respectively. The use of epinephrine-containing bupivacaine or bupivacaine or ropivacaine alone was associated with decreased perioperative complication [adjusted OR, 0.75 (95 percent CI, 0.61 to 0.91) and 0.63 (95 percent CI, 0.47 to 0.83); p = 0.004 and p = 0.001, respectively]. Only bupivacaine- or ropivacaine-alone recipients experienced a significantly reduced risk of prolonged length of stay on adjusted analysis [adjusted OR, 0.71 (95 percent CI, 0.55 to 0.90); p = 0.005]. Risk of increased cost was reduced in users of any local anesthetic (p < 0.001 for all). CONCLUSIONS: Epinephrine-containing bupivacaine or bupivacaine or ropivacaine alone was associated with reduced perioperative complication following palatoplasty, while only the latter predicted a decreased postoperative length of stay. Uses of epinephrine-containing lidocaine, epinephrine-containing bupivacaine, and bupivacaine or ropivacaine alone were all associated with decreased hospital costs. Future prospective studies are warranted to further delineate the role of local anesthesia in palatal surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

National level data analysis of facial lacerations in Korea using the National Health Insurance Service (NHIS) database.

ABSTRACT: No national epidemiological investigations have been conducted recently regarding facial lacerations. The study was performed using the data of 3,634,229 people during the 5-year period from 2014 to 2018 archived by the National Health Information Database (NHID) of the Health Insurance Review and Assessment Service. Preschool and children under 10 years old accounted for about one-third of patients. Facial lacerations were concentrated in the "T-shaped" area, which comprised forehead, nose, lips, and the perioral area. The male to female ratio for all study subjects was 2.16:1. Age and gender are significantly related with each other (P < .001). Mean hospital stays decreased, and numbers of outpatient department visits per patient were highest for hospitals and lowest for health agencies. Over the study period, hospital costs per patient in tertiary and general hospitals increased gradually. Preschool and school-aged children are vulnerable to trauma. Male patients outnumbered female patients by a factor of more than 2. The "T-shaped'" area around forehead is vulnerable to injury. Total cost of medical care benefits per patient in tertiary hospitals was about 7 times on average than in health agencies. Regarding functional, behavioral, and aesthetic outcomes, more attention should be paid to epidemiologic data and hospital costs for facial lacerations.

ACERTO Project - 15 years changing perioperative care in Brazil.

The ACERTO project is a multimodal perioperative care protocol. Implemented in 2005, the project in the last 15 years has disseminated the idea of a modern perioperative care protocol, based on evidence and with interdisciplinary team work. Dozens of published studies, using the protocol, have shown benefits such as reduced hospital stay, postoperative complications and hospital costs. Disseminated in Brazil, the project is supported by the Brazilian College of Surgeons and the Brazilian Society of Parenteral and Enteral Nutrition, among others. This article compiles publications by the authors who belong to the CNPq research group "Acerto em Nutrição e Cirurgia", refers to the experience of other national authors in various surgical specialties, and finally outlines the evolution of the ACERTO project in the timeline.

Acerto Project - 15 years changing perioperative care in Brazil / Projeto Acerto - 15 anos modificando cuidados perioperatórios no Brasil

ABSTRACT The ACERTO project is a multimodal perioperative care protocol. Implemented in 2005, the project in the last 15 years has disseminated the idea of a modern perioperative care protocol, based on evidence and with interdisciplinary team work. Dozens of published studies, using the protocol, have shown benefits such as reduced hospital stay, postoperative complications and hospital costs. Disseminated in Brazil, the project is supported by the Brazilian College of Surgeons and the Brazilian Society of Parenteral and Enteral Nutrition, among others. This article compiles publications by the authors who belong to the CNPq research group "Acerto em Nutrição e Cirurgia", refers to the experience of other national authors in various surgical specialties, and finally outlines the evolution of the ACERTO project in the timeline.

RESUMO O projeto ACERTO é um protocolo multimodal de cuidados perioperatórios. Implementado em 2005, o projeto, nos últimos 15 anos, tem disseminado a ideia de moderno protocolo de cuidados perioperatórios baseados em evidência e com atuação interprofissional. Dezenas de estudos publicados com o uso do protocolo têm mostrado benefícios como redução do tempo de internação, complicações pós-operatórias e custos hospitalares. Disseminado pelo Brasil, o projeto tem apoio do Colégio Brasileiro de Cirurgiões e da Sociedade Brasileira de Nutrição Parenteral e Enteral, entre outros. Este artigo compila publicações dos autores que compõem o grupo de pesquisa do CNPq "Acerto em Nutrição e Cirurgia", cita a experiência de outros autores nacionais em diversas especialidades cirúrgica e finalmente, delineia a evolução do projeto ACERTO ao longo da linha do tempo.

DRG-Oriented Mathematical Calculation Model and Method of Integrated Medical Service Cost.

In the context of the new round of medical and health reform, in order to alleviate the problem of "difficult to see a doctor and expensive to see a doctor," the state focuses on reducing the cost of medical services, so it puts forward the calculation and method research of medical costs. The purpose of this study is to calculate and predict the cost of medical services in a DRG-oriented integrated environment. In this study, activity-based costing and weighted moving average methods are used. First, basic data of medical services are collected, then all medical activities are confirmed and all service costs are collected, then a cost database is established, and a calculation model of medical costs is designed. Finally, calculation suggestions and optimization methods are put forward by analyzing the calculated data. The experimental results show that the actual demand of drugs predicted by the general moving average method is relatively insufficient, with the maximum error of 41%, the minimum of 5%, and the average error of 19.8%; the maximum error of drug demand predicted by the weighted moving average method is 24%, the minimum is 2%, and the average is 15.4%. It can be concluded that the prediction effect of the weighted moving average method is better than that of the ordinary moving average method, which plays a good and effective role in the prediction of medical cost. The activity-based costing method is more detailed and organized for the cost calculation and classification of medical services. It provides a certain value for the effective management and control of medical service cost.

Evaluating the Cost-Effectiveness of the ABCDE Bundle: Impact of Bundle Adherence on Inpatient and 1-Year Mortality and Costs of Care.

OBJECTIVES: Growing evidence supports the Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility (ABCDE) bundle processes as improving a number of short- and long-term clinical outcomes for patients requiring ICU care. To assess the cost-effectiveness of this intervention, we determined the impact of ABCDE bundle adherence on inpatient and 1-year mortality, quality-adjusted life-years, length of stay, and costs of care. DESIGN: We conducted a 2-year, prospective, cost-effectiveness study in 12 adult ICUs in six hospitals belonging to a large, integrated healthcare delivery system. SETTING: Hospitals included a large, urban tertiary referral center and five community hospitals. ICUs included medical/surgical, trauma, neurologic, and cardiac care units. PATIENTS: The study included 2,953 patients, 18 years old or older, with an ICU stay greater than 24 hours, who were on a ventilator for more than 24 hours and less than 14 days. INTERVENTION: ABCDE bundle. MEASUREMENTS AND MAIN RESULTS: We used propensity score-adjusted regression models to determine the impact of high bundle adherence on inpatient mortality, discharge status, length of stay, and costs. A Markov model was used to estimate the potential effect of improved bundle adherence on healthcare costs and quality-adjusted life-years in the year following ICU admission. We found that patients with high ABCDE bundle adherence (≥ 60%) had significantly decreased odds of inpatient mortality (odds ratio 0.28) and significantly higher costs ($3,920) of inpatient care. The incremental cost-effectiveness ratio of high bundle adherence was $15,077 (95% CI, $13,675-$16,479) per life saved and $1,057 per life-year saved. High bundle adherence was associated with a 0.12 increase in quality-adjusted life-years, a $4,949 increase in 1-year care costs, and an incremental cost-effectiveness ratio of $42,120 per quality-adjusted life-year. CONCLUSIONS: The ABCDE bundle appears to be a cost-effective means to reduce in-hospital and 1-year mortality for patients with an ICU stay.

Efficacy Oral Glutamine to Prevent Oral Mucositis and Reduce Hospital Costs During Chemotherapy in Children with Acute Lymphoblastic Leukemia.

OBJECTIVE: To investigate the use of glutamine administered orally during Methotrexate chemotherapy to prevent oral mucositis and reduce hospital costs in children with acute lymphoblastic leukemia (ALL). METHODS: Twenty-four children received oral glutamine (400 mg/kg body weight per day) and twenty four received placebo on days of chemotherapy administration and for at least 14 additional days. Oral mucositis  was graded daily at each day of treatment till completion of therapy. The study groups were compared for the oral mucositis development using the WHO scale. RESULTS: Oral mucositis occurred in 4.2 % of the glutamine group and 62.5% in the placebo group. The use of glutamine was directly associated with prevention of oral mucositis than placebo (OR 0,026; 95% CI: 0,003-0,228). The duration of length hospital stay was lower in the glutamine group than in the placebo group ((8 vs 12 days); p = 0,005). Hospital cost per day for glutamine group was 40 USD per day while placebo group was 48 USD per day. CONCLUSIONS: There was significant difference in the prevention of oral mucositis by oral glutamine vs placebo. The hospital cost for glutamine supplementation was lower than control group.

Cannabis Use in Hospitalized Patients with Chronic Pain.

INTRODUCTION: To date, no study has reported the prevalence of cannabis use in chronic pain patients. The aim of this study is to investigate the trends in cannabis use among chronic pain in-patients from 2011 to 2015 in the USA. METHODS: Patients were identified from the National Inpatient Sample (NIS) database using the International Classification of Diseases, Ninth and Tenth Revision, diagnosis codes for chronic pain and cannabis use. Annual estimates and trends were determined for cannabis use, patient characteristics, cannabis use among subgroups of chronic pain conditions, cost, length of stay, and associated discharge diagnosis. RESULTS: Between 2011 to 2015, a total of 247,949 chronic pain patients were cannabis users, increasing from 33,189 to 72,115 (P < 0.001). There were upward trends of cannabis use in females (38.7-40.7%; P = 0.03), Medicare insured patients (32.7-40.4%; P < 0.01), patients with lowest annual household income (36.1-40.9%; P = 0.02), patients aged 45-64 years (45.9-49.2%; P < 0.001), and patients with tobacco use disorder (63.8-72.4%; P < 0.0001). Concurrently, cannabis use decreased among patients with opioid use disorder (23.8-19.9%; P < 0.001). Cannabis use increased from 2011 to 2015 in patients with chronic regional pain syndrome, trauma, spondylosis, and failed back surgery syndrome. Adjusted total hospitalization cost increased from $31,271 ($1333) in 2011 to $38,684 ($946) in 2015 (P < 0.001). CONCLUSIONS: Cannabis use increased substantially from 2011 to 2015, while the rates of cannabis use in opioid users down-trended simultaneously. Disparities in cannabis use among subgroups should be explored further.

Can vertically integrated health systems provide greater value: The case of hospitals under the comprehensive care for joint replacement model?

OBJECTIVE: We aim to assess whether system providers perform better than nonsystem providers under an alternative payment model that incentivizes high-quality, cost-efficient care. We posit that the payment environment and the incentives it provides can affect the relative performance of vertically integrated health systems. To examine this potential influence, we compare system and nonsystem hospitals participating in Medicare's Comprehensive Care for Joint Replacement (CJR) model. DATA SOURCES: We used hospital cost and quality data from the Centers for Medicare & Medicaid Services linked to data from the Agency for Healthcare Research and Quality's Compendium of US Health Systems and hospital characteristics from secondary sources. The data include 706 hospitals in 67 metropolitan areas. STUDY DESIGN: We estimated regressions that compared system and nonsystem hospitals' 2017 cost and quality performance providing lower joint replacements among hospitals required to participate in CJR. PRINCIPAL FINDINGS: Among CJR hospitals, system hospitals that provided comprehensive services in their local market had 5.8 percent ($1612) lower episode costs (P = .01) than nonsystem hospitals. System hospitals that did not provide such services had 3.5 percent ($967) lower episode costs (P = .14). Quality differences between system hospitals and nonsystem hospitals were mostly small and statistically insignificant. CONCLUSIONS: When operating under alternative payment model incentives, vertical integration may enable hospitals to lower costs with similar quality scores.

Targeting malnutrition: Nutrition programs yield cost savings for hospitalized patients.

BACKGROUND & AIMS: Between 30 and 50% of Colombian patients are malnourished or at-risk of malnutrition on hospital admission. Malnutrition is associated with poor outcomes and increased costs. We used cost modeling to estimate savings that could be derived from implementation of a nutrition therapy program for patients at malnutrition risk. METHODS: The budget impact analysis was performed using previously-published outcomes data. Outcomes included length of stay, 30-day readmissions, and infectious/non-infectious complications. We developed a Markov model that compared patients who were assigned to receive early nutrition therapy (started within 24-48 h of hospital admission) with those assigned to receive standard nutrition therapy (not started early). Our model used a 60-day time-horizon and estimated event probabilities based on published data. RESULTS: Average total costs over 60 days were $3770 US dollars for patients with delayed nutrition therapy vs $2419 for patients with early nutrition therapy-a savings of $1351 (35.8% decrease) per nutrition-treated patient. Cost differences between the groups were: $2703 vs $1600 for hospital-associated costs; $883 vs $665 for readmissions; and $176 vs $94 for complications. Taken broadly, the potential costs savings from a nutrition care program for an estimated 638,318 hospitalized Colombian patients at malnutrition risk is $862.6 million per year. CONCLUSIONS: Our budget impact analysis demonstrated the potential for hospital-based nutrition care programs to improve health outcomes and reduce healthcare costs for hospitalized patients in Colombia. These findings provide a rationale for implementing comprehensive nutrition care in Colombian hospitals.

Characterizing the Financial Value of In-Home Palliative Care for Patients, Payers, and Hospitals.

BACKGROUND: The holistic and multidisciplinary approach of in-home palliative care (IHPC) is known to offer high-quality and cost-effective care for patients at the end of life. However, the financial benefits of upstream IHPC programs to hospitals, patients, and payers have not been fully characterized for patients with comorbid chronic conditions. AIM: To characterize the financial benefits that upstream IHPC offers to patients with multiple chronic conditions. METHODS: A structured retrospective patient record review was conducted on the number of emergency department (ED) visits, number of inpatient hospitalizations, hospital length of stay (LOS), and payments made to the hospital for all patients (N = 71) enrolled in an IHPC program between January 1, 2016, and June 30, 2016. Discharge history from each patient's medical record was also assessed. Comparisons were drawn between patients' LOS on IHPC and an equivalent time period prior to enrollment in IHPC. RESULTS: After patients enrolled in IHPC, average ED and inpatient utilization declined significantly by 41% (P = .01) and 71% (P < .001), respectively. The payers for health-care services realized a significant decline of US$2,201 (P < .001) in hospital payments per patient per month. Inpatient LOS was also significantly lower than expected once patients enrolled in the program (P = .01). CONCLUSIONS: As the need for chronic disease management continues to grow, managers of health systems, managed care organizations, and home health agencies should be cognizant of the financial value that IHPC has to offer.

Effect of the Melhor em Casa program on hospital costs.

OBJECTIVE: To verify if the Melhor em Casa program can actually reduce hospitalization costs. METHODS: We use as an empirical strategy a Regression Discontinuity Design, which reduces endogeneity problems of our model. We also performed tests of heterogeneous responses and robustness. Data on the dependent variable, namely hospitalization costs, were collected in the Department of Informatics of the Unified Health System (DATASUS), using the microdata set from the Hospital Admissions System of the Unified Health System (SUS) from 2010 to 2013, totaling 3,609,384 observations. The covariates or control variables used were age and costs with patients in the intensive care unit, also from DATASUS. RESULTS: The results point out that the Melhor em Casa program effectively reduced hospitalization costs by approximately 4.7% in 2011, 5.8% in 2012 and 10.2% in 2013. CONCLUSIONS: Based on the analyses, we observed that maintaining the program can effectively improve the management of public resources, since it reduced the hospitalization costs in the three years studied. The program reduced hospitalization costs of risk groups and also in situations that usually increase hospital costs such as lack of equipment and elective hospitalizations. Thus, it can be affirmed that the program can reduce hospitalization costs, especially in risk and more vulnerable groups, showing efficiency as a public policy.

Intussusception Protocol Implementation: Single-Site Outcomes With Clinician and Family Satisfaction.

BACKGROUND: The objective of this study was to evaluate clinical outcomes, costs, and clinician and parent satisfaction after implementation of a protocol to discharge patients from the emergency department (ED) after successful reduction of uncomplicated ileocolic intussusception. MATERIALS AND METHODS: In March 2017, an intussusception management protocol was implemented for children presenting with ultrasound findings of ileocolic intussusception. Those meeting inclusion criteria were observed after successful radiological reduction in the ED and discharged after 6 h with resolution of symptoms. Retrospective chart review was completed for cases before and after protocol implementation for clinical outcomes and costs. Clinicians and parents were surveyed to assess overall satisfaction. RESULTS: Charts were reviewed before (42 encounters, 37 patients) and after (30 encounters, 23 patients) protocol implementation. After implementation, admission rates decreased from 95% (40/42) to 23% (7/30; P < 0.001) and antibiotic use was eliminated (91% to 0%, P < 0.001). There was no difference in recurrence rates (17% versus 23%, P = 0.44). Median total length of stay decreased from 18.87 to 9.52 h (P < 0.001), whereas median ED length of stay increased from 4.37 to 9.87 h (P < 0.001). In addition, there was an overall hospital cost saving of over $2000 ($9595 ± 3424 to $7465 ± 3723; P = 0.009) per encounter. Clinicians and parents were overall satisfied with the protocol and parents showed no changes in patient satisfaction with protocol implementation. CONCLUSIONS: An intussusception protocol can facilitate early discharge from the ED and improve patient care without increased risk of recurrence. Additional benefits include decreased hospital- and patient-related costs, elimination of antibiotic use, and parent as well as clinician satisfaction.

Value-Based Care Has Not Resulted in Biased Patient Selection: Analysis of a Single Center's Experience in the Care for Joint Replacement Bundle.

BACKGROUND: Bundled reimbursement models for total knee arthroplasty (TKA) by the Center for Medicare and Medicaid Services have resulted in an effort to decrease the cost of care. However, these models may incentivize bias in patient selection to avoid excess cost of care. We sought to determine the impact of the Comprehensive Care for Joint Replacement (CJR) model at a single center. METHODS: This is a retrospective review of primary TKA patients from July 2015 to December 2017. Patients were stratified by whether or not their surgery was performed before or after implementation of the CJR bundle. Patient demographic data including age, sex, and body mass index were collected in addition to Elixhauser comorbidities and American Society of Anesthesiologists score. In-hospital outcomes were then examined including surgery duration, length of stay, discharge disposition, and direct cost of care. RESULTS: A total of 1248 TKA patients (546 Medicare and 702 commercial insurance) were evaluated, with 27.0% undergoing surgery before the start of the bundle. Compared to patients following implementation of the bundle, there was no significant difference in age, gender, or body mass index. However, pre-CJR Medicare patients were more likely to have fewer Elixhauser comorbidities (P < .001), prolonged length of stay (P < .001), and greater discharges to inpatient facilities (P = .019). There was no significant difference in direct hospital costs or operative service time comparing pre-bundle and post-bundle patients. CONCLUSION: Implementation of the bundled reimbursement model did not result in biased patient selection at our institution; importantly, it also did not result in decreased hospital costs despite apparent improvement in value-based outcome metrics. This should be taken into consideration as future adaptations to reimbursement are made by the Center for Medicare and Medicaid Services.

Impact of Co-Morbidities on the Cost of Care in Primary Elective Joint Arthroplasty.

BACKGROUND: The Comprehensive Care for Joint Replacement model is the newest iteration of the bundled payment methodology introduced by the Centers for Medicare and Medicaid Services. Comprehensive Care for Joint Replacement model, while incentivizing providers to deliver care at a lower cost, does not incorporate any patient-level risk stratification. Our study evaluated the impact of specific medical co-morbidities on the cost of care in total joint arthroplasty (TJA) patients. METHODS: A retrospective study was conducted on 1258 Medicare patients who underwent primary elective TJA between January 2015 and July 2016 at a single institution. There were 488 males, 552 hips, and the mean age was 71 years. Cost data were obtained from the Centers for Medicare and Medicaid Services. Co-morbidity information was obtained from a manual review of patient records. Fourteen co-morbidities were included in our final multiple linear regression models. RESULTS: The regression models significantly predicted cost variation (P < .001). For index hospital costs, a history of cardiac arrhythmias (P < .001), valvular heart disease (P = .014), and anemia (P = .020) significantly increased costs. For post-acute care costs, a history of neurological conditions like Parkinson's disease or seizures (P < .001), malignancy (P = .001), hypertension (P = .012), depression (P = .014), and hypothyroidism (P = .044) were associated with increases in cost. Similarly, for total episode cost, a history of neurological conditions (P < .001), hypertension (P = .012), malignancy (P = .023), and diabetes (P = .029) were predictors for increased costs. CONCLUSION: The cost of care in primary elective TJA increases with greater patient co-morbidity. Our data provide insight into the relative impact of specific medical conditions on cost of care and may be used in risk stratification in future reimbursement methodologies.

Phototherapy for Neonatal Unconjugated Hyperbilirubinemia: Examining Outcomes by Level of Care.

OBJECTIVES: Newborns hospitalized with unconjugated hyperbilirubinemia without critical comorbidities may receive intensive phototherapy (IP) in non-ICU levels of care, such as a mother-newborn unit, or ICU levels of care. Our aim was to compare outcomes between each level. METHODS: Using hospital discharge data from 2005 to 2011 in New York's State Inpatient Database, we performed multivariate analyses to compare outcomes that included total cost of hospitalization, length of stay, 30-day readmission rate after IP, and the number of cases of death, exchange transfusion, and γ globulin infusion. We included term newborns treated with IP in their first 30 days of life and without diagnosis codes for other critical illnesses. Explanatory variables included level of care, sex, race, insurance type, presence or absence of hemolysis, hospital, volume of IP performed at each hospital, and year of hospitalization. RESULTS: Ninety-nine percent of IP was delivered in non-ICU levels of care. Incidence of major complications was rare (≤0.1%). After adjusting for confounders, ICU level of care was not associated with difference in length of stay (relative risk: 1.2; 95% confidence interval [CI]: 0.91 to 1.15) or 30-day readmission rate (odds ratio: 0.74; 95% CI: 0.50 to 1.09) but was associated with 1.51 (95% CI: 1.47 to 1.56) times higher costs. CONCLUSIONS: For otherwise healthy term newborns with jaundice requiring IP, most received treatment in a non-ICU level of care, and those in intensive care had no difference in outcomes but incurred higher costs. IP guideline authors may want to be more prescriptive about IP level of care to improve value.

Minimally Invasive Treatment for Benign Prostatic Hyperplasia: Economic Evaluation from a Standardized Hospital Case Costing System.

PURPOSE: Minimally invasive alternatives to transurethral resection of the prostate (TURP) such as prostate arterial embolization (PAE) and photoselective vaporization of the prostate (PVP) are being explored as adjuncts in the care of patients with benign prostatic hyperplasia. However, there are conflicting reports of the costs of these procedures. The purpose of this study was to compare the direct and indirect hospital costs of TURP, PAE and PVP. MATERIALS AND METHODS: A chart review was performed in patients who underwent TURP, PVP and PAE from April 2015 to March 2017. All hospital costs were collected in accordance with the Ontario Case Costing Initiative, a standardized medical case costing system. Costs were characterized as direct or indirect and fixed or variable. Probabilistic sensitivity analysis was conducted to study cost uncertainty. RESULTS: During the study period, a total of 209 men underwent TURP, 28 PVP and 21 PAE. Mean age (years) was as follows: TURP 71.43; PVP 73.66; PAE 70.77 (p = 0.366). Mean length of stay (days) was as follows: TURP 1.63; PVP 1.55; PAE 1 (p = 0.076). Total costs of the PAE group ($3829, SD $1582) were less than both PVP ($5719, SD $1515) and TURP groups ($5034, SD $1997, p < 0.001). There was no significant difference in direct costs between the groups. Monte Carlo simulation demonstrated that PAE was the least costly alternative majority of the time. CONCLUSIONS: The total hospital costs of PAE at our institution are significantly lower than those of PVP and TURP.

Economic and epidemiological impact of dengue illness over 16 years from a public health system perspective in Brazil to inform future health policies including the adoption of a dengue vaccine.

INTRODUCTION: Dengue is a serious global health problem endemic in Brazil. Consequently, our aim was to measure the costs and disease burden of symptomatic dengue infections in Brazil from the perspective of the Brazilian Public Health System (SUS) between 2000 and 2015, using Brazilian public health system databases. Specific age group incidence estimates were used to calculate the disability-adjusted life years (DALYs) to gain a better understanding of the disease burden. Areas covered: SUS spent almost USD159 million and USD10 million to treat dengue and severe dengue, respectively, between 2000 and 2015. This is principally hospitalization costs, with the majority of patients self-treated at home with minor symptoms. The average notification rate for dengue was 273 per 100,000 inhabitants and three per 100,000 for severe dengue, with annual DALYs estimates ranging between 72.35 and 6,824.45 during the 16 years. Expert commentary: The epidemiological and morbidity burden associated with dengue is substantial in Brazil, with costs affected by the fact that most patients self-treat at home with these costs not included in SUS. The Brazilian government urgently needs to proactively evaluate the real costs and clinical benefits of any potential dengue vaccination program by the National Immunization Program to guide future decision-making.

Adultos con influenza, evolución clínica, costos y grupos relacionados por el diagnóstico, resultados de 4 años. Clínica Dávila. Santiago de Chile / Adults patients with influenza, clinical evolution, cost and diagnosis related groups, four years results. Clinica Dávila, Santiago, Chile

Resumen Introducción: En 2009 la Influenza A H1N1pdm09 provocó en Chile 12.258 casos y 155 muertes. Objetivo: Analizar en adultos egresados de Clínica Dávila con influenza, en 2009, 2010, 2012 y 2014, soporte ventilatorio, costo de hospitalización, Grupos Relacionados por el Diagnóstico (GRD) y letalidad. Material y Método: Estudio descriptivo retrospectivo usando la ficha médica electrónica. Resultados: Egresaron 115.673 adultos, 338 (0,29%) con diagnóstico de Influenza, edad 56,5 ± 22 años, 59% mujeres, letalidad 4%. Hubo 3 grupos, Grupo 1: sin ningún soporte ventilatorio, 295 pacientes, edad 63 ± 20, estadía 6,6 ± 6,9 días, costo promedio de hospitalización $2.885.261, mediana peso GRD 0,41 (p25 = 0,38 y p75 = 0,62), letalidad 1,01% (3 pacientes). Grupo 2: Ventilación mecánica no invasiva (VMNI), 23 casos, edad 77,1 ± 13, letalidad 22% (5 casos), estadía 16,8 ± 12,4, costo $9.245.242, GRD 0,79 (p25 = 0,62 y p75=1,03). Grupo 3: Intubación y ventilación mecánica invasiva (VMI), 20 pacientes, edad 56,4 ± 15, estadía 36,9 ± 41,4, costo $38.681.099, GRD 5,86 (p25 = 5,82 y p75 = 5,86) y letalidad 30% (6 pacientes). Los GRD grupo VMI versus grupo VMNI y ningún soporte fueron diferentes (p < 0,0001 y p < 0,0001 respectivamente). La letalidad por influenza el 2014 fue de 8,5%, mientras que en los años 2012, 2010 y 2009 fue 1,5%, 3% y 2,5% respectivamente. La mediana de edad el año 2009 fue 37,5 años, menor que la de los otros años (p < 0,0001). Conclusiones: En 2009 los pacientes fueron más jóvenes, la necesidad de soporte ventilatorio provocó un peso GRD, estadía, costo y letalidad mayores que aquellos que no lo requirieron.

Introduction: In 2009 Influenza A H1N1pdm09 caused in Chile 12,258 cases and 155 deaths. Objective: To analyze ventilatory support, cost of hospitalization, Diagnosis Related Groups (DRG) and lethality in adults patients with influenza discharged from our institution, during 2009, 2010, 2012 and 2014. Patients and Method: Retrospective descriptive study using electronic medical records. Results: 115,673 adults were discharged, 338 (0.29%) with diagnosis of Influenza, age 56.5 ± 22 yr.o., 59% women, lethality 4%. There were 3 groups, Group 1: without any ventilatory support, 295 patients, age 63 ± 20, stay 6.6 ± 6.9 days, average cost of hospitalization 2,885,261 clp, medium weight DRG 0.41 (p25 = 0.38) andp75 = 0.62), lethality 1.01% (3 patients). Group 2: Non-invasive mechanical ventilation (NIMV), 23 cases, age 77.1 ± 13, lethality 22% (5 cases), stay 16.8 ± 12.4, cost 9,245,242 clp, DRG 0.79 (p25 = 0.62 and p75 = 1.03). Group 3: Intubation and invasive mechanical ventilation (IMV), 20 patients, age 56.4 ± 15, stay 36.9 ± 41.4, cost 38.681.099 clp, DRG 5.86 (p25 = 5.82 and p75 = 5,86) and lethality 30% (6 patients). The DRG group VMI versus group VMNI and no support were different (p < 0.0001 and p < 0.0001 respectively). The lethality for influenza in 2014 was 8.5%, while in 2012, 2010 and 2009 it was 1.5%, 3% and 2.5% respectively. The median age in 2009 was 37.5 yr.o significantly minor, than the other years (p < 0.0001). Conclusions: In 2009 the patients were younger, the need for ventilatory support led to a higher DRG weight, stay, cost and lethality than those who did not require it.

Major influence of postoperative complications on costs of cytoreductive surgery and HIPEC in patients with colorectal peritoneal metastases.

Complications after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) result in impaired short- and long-term outcomes. However, financial consequences of complications after CRS and HIPEC in a European health care setting are unknown. This study aims to assess the consequences of complications on hospital costs after CRS and HIPEC.In this prospective observational cohort study, patients with colorectal peritoneal metastases treated with CRS and HIPEC were included. Financial information was collected according to the Dutch manual for costs analyses. Costs were compared between patients without complications (NC), minor complications (MC), or severe complications (SC), according to the Clavien-Dindo classification.One hundred and sixty-one patients were included, of whom 42% experienced NC, 27% MC and 31% SC. Mean hospital costs were &OV0556;9.406 ±â€Š2.235 in NC patients, &OV0556;12.471 ±â€Š3.893 in MC patients, and &OV0556;29.409 ±â€Š22.340 in SC patients. The 31% of patients with severe complications accounted for 56% of all hospital costs. Hospital admission costs in SC patients were 320% higher compared to NC patients. Costs of complications were estimated to be 43% of all admission costs.Severe postoperative complications have major influence on costs after CRS and HIPEC and result in a threefold increase of hospital costs in affected patients. This finding stresses the need for adequate risk assessment of developing severe complications after CRS and HIPEC.