In-Hospital Mortality in a 4-Year Cohort Study of 3,093,254 Operations in Seniors.

BACKGROUND: Surgery-related mortality depends on a number of factors including the type of surgical procedure, quality of healthcare, co-morbidities, and age of patient. The objective of the study was to assess the in-hospital mortality in the elderly undergoing surgical treatment. METHODS: This was a national data-based retrospective cohort study. Data were extracted from the National Health Fund, a public organization financing medical procedures in Poland. Adult citizens who underwent 9,344,384 surgical interventions (including 3,093,254 cases in seniors who were above 65 years old) between 2009 and 2012 were included in this study. Overall, surgery type-dependent, age-stratified in-hospital mortality related to surgery was assessed. RESULTS: Overall in-hospital surgery-related mortality rate in seniors was stable (approximately 2 % annually, P for trend = 0.104). It doubled with each successive decade of life (1.2, 2.3, 5.6, and 13 % in 65-74, 75-84, 85-94 and ≥ 95 years old groups, respectively, in 2012). In ≥ 75-year-old mortality exceeded 10 % only after neurological surgeries, in ≥ 85-year-old after neurological, vascular, gastrointestinal, and endocrinological surgeries, and in ≥ 95-year-old also after heart and circulation, bones and muscles, liver, pancreas, and spleen operations. However, even in the oldest individuals it was low after genitourinary, female genital tract, head and neck, and eye surgeries. CONCLUSIONS: The overall rate of in-hospital mortality after surgery, although increasing with age, is rather low up to the ninth decade of life. Whereas some surgeries pose a significant risk, others may be relatively safe even in the oldest subjects.

Relative effectiveness assessment of pharmaceuticals: similarities and differences in 29 jurisdictions.

OBJECTIVE: Assessment of the effectiveness compared with alternative treatment(s) plays an important role in many jurisdictions in determining the reimbursement status of pharmaceuticals. This type of assessment is often referred to as a relative effectiveness assessment (REA) and is carried out by many jurisdictions. Increased sharing of information across jurisdictions may save costs and reduce duplication. The objective of this study was to explore the main similarities and differences in the major methodological aspects of REA in multiple jurisdictions. METHODS: Data were gathered with a standardized data extraction form by searching publicly available information and by eliciting information from representatives at relevant organizations. RESULTS: Of the initially included 35 jurisdictions, data were gathered for 29 jurisdictions. There seem to be substantial similarities on the choice of the comparator, the role of indirect comparisons, and preferred end points in REAs (except for the use of health state utilities). Jurisdictions, however, differ in whether effectiveness (usual circumstances of health care practice) is estimated in case no (comparative) effectiveness data are available and how this is done. CONCLUSION: Some important methodological aspects for REA are approached in a similar way in many jurisdictions, indicating that collaboration on assessments may be feasible. Enhanced collaboration in the development of methods and best practices for REA between jurisdictions will be a necessary first step. Important topics for developing best practice are indirect comparisons and how to handle the gap between efficacy and effectiveness data in case good quality comparative effectiveness data are not yet available at the time of reimbursement decisions.

Risk sharing arrangements for pharmaceuticals: potential considerations and recommendations for European payers.

BACKGROUND: There has been an increase in 'risk sharing' schemes for pharmaceuticals between healthcare institutions and pharmaceutical companies in Europe in recent years as an additional approach to provide continued comprehensive and equitable healthcare. There is though confusion surrounding the terminology as well as concerns with existing schemes. METHODS: A literature review was undertaken to identify existing schemes supplemented with additional internal documents or web-based references known to the authors. This was combined with the extensive knowledge of health authority personnel from 14 different countries and locations involved with these schemes. RESULTS AND DISCUSSION: A large number of 'risk sharing' schemes with pharmaceuticals are in existence incorporating both financial-based models and performance-based/outcomes-based models. In view of this, a new logical definition is proposed. This is "risk sharing' schemes should be considered as agreements concluded by payers and pharmaceutical companies to diminish the impact on payers' budgets for new and existing schemes brought about by uncertainty and/or the need to work within finite budgets". There are a number of concerns with existing schemes. These include potentially high administration costs, lack of transparency, conflicts of interest, and whether health authorities will end up funding an appreciable proportion of a new drug's development costs. In addition, there is a paucity of published evaluations of existing schemes with pharmaceuticals. CONCLUSION: We believe there are only a limited number of situations where 'risk sharing' schemes should be considered as well as factors that should be considered by payers in advance of implementation. This includes their objective, appropriateness, the availability of competent staff to fully evaluate proposed schemes as well as access to IT support. This also includes whether systematic evaluations have been built into proposed schemes.

Readmissions and repeat procedures after catheter ablation for atrial fibrillation.

BACKGROUND: The aim of this study was to assess the frequency of all-cause rehospitalization and due to atrial fibrillation/flutter (AF/AFl), repeat ablation of AF/AFl, mortality within 30 days and 1-year follow-up in patients after AF/AFl ablation procedure. METHODS: Using data from the National Health Fund we identified a database comprising 2,022 patients who underwent AF/AFl ablation between January, 2012 and December, 2012 in Poland. The primary endpoint was readmission to hospital with discharge diagnosis AF/AFl. The secondary endpoints included: repeat AF/AFl ablation, cardiovascular hospitalization, all-cause hospitalization, all-cause mortality assessed in 30-day and 1-year time frame. RESULTS: The mean age was 58.6 ± 10.9 years (66.8% male). The mean time of the index ablation hospitalization was 3.8 ± 2.6 days. After discharge, 123 (6.1%) and 540 (26.7%) patients were hospitalized because of AF/AFl within 30 days and 1 year, respectively. During 1-year follow-up, 192 (9.5%) patients underwent subsequent AF/AFl ablations. The patients that underwent the second ablation were younger (56.6 ± 11.0 vs. 59.1 ± 10.8; p = 0.019) and the time of the index hospitalization was shorter (3.75 ± 2.16 vs. 4.45 ± 3.26; p = 0.03). Within 30 days 194 (9.6%) patients were hospitalized and 747 (36.9%) in 1-year follow-up. All-cause mortality was 0.1% and 1.4% in 30-day and 1-year follow-up, respectively. In a 1-year follow-up patients hospitalized from AF/AFl recurrence were more frequently hospitalized due to cardiovascular diseases other than AF/AFl (9.6% vs. 6.7%; p = 0.026), especially due to hypertension (2.9% vs. 0.7%; p < 0.001). CONCLUSIONS: Over 1 out of 4 patients who underwent AF/AFl ablation were hospitalized due to arrhythmia recurrence in 1 year.