RESUMEN
BACKGROUND: The ideal approach for treating anterior cruciate ligament (ACL) injury is still disputed. This study aimed to determine the more cost-effective strategy by comparing early ACL reconstruction (ACLR) surgery to conservative treatment (rehabilitation with optional delayed reconstruction) for ACL injury in a lower/middle-income country (LMIC), Indonesia. METHODS: A decision tree model was constructed for cost-utility analysis of early ACLR versus conservative treatment. The transition probabilities between states were obtained from the literature review. Utilities were measured by the EQ-5D-3 L from a prospective cohort study in a local hospital. The costs were obtained from a previous study that elaborated on the burden and cost of ACLR in Indonesia. Effectiveness was expressed in quality-adjusted life years gained (QALYs). Principal outcome measure was the incremental cost-effectiveness ratios (ICER). Willingness-to-pay was set at US$12,876 - three times the Indonesian GDP per capita in 2021 - the currently accepted standard in Indonesia as suggested by the World Health Organization Choosing Interventions that are Cost-Effective criterion (WHO-CHOICE). RESULTS: The early ACLR group showed an incremental gain of 0.05 QALYs over the conservative treatment group, with a higher overall cost to society of US$976. The ICER of ACLR surgery was US$19,524 per QALY, above the WTP threshold of US$12,876. The ICER was sensitive to cost of conservative treatment, cost of ACLR, and rate of cross-over to delayed ACLR numbers in the conservative treatment group. Using the WTP threshold of US$12,876, the probability of conservative treatment being preferred over early ACLR was 64%. CONCLUSIONS: Based on the current model, early ACLR surgery does not seem more cost-effective compared to conservative treatment for ACL injury patients in Indonesia. Because the result was sensitive to the rate of cross-over probabilities from the conservative treatment alone to delayed ACLR, a future study with a long-term perspective is needed to further elucidate its impact.
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Lesiones del Ligamento Cruzado Anterior , Reconstrucción del Ligamento Cruzado Anterior , Tratamiento Conservador , Análisis Costo-Beneficio , Árboles de Decisión , Años de Vida Ajustados por Calidad de Vida , Humanos , Indonesia , Tratamiento Conservador/economía , Lesiones del Ligamento Cruzado Anterior/cirugía , Lesiones del Ligamento Cruzado Anterior/terapia , Reconstrucción del Ligamento Cruzado Anterior/economía , Países en Desarrollo , Masculino , Femenino , Estudios Prospectivos , AdultoRESUMEN
OBJECTIVE: To determine the lifetime cost of 3 treatments for canine hip osteoarthritis: (1) conservative management, (2) femoral head and neck excision (FHNE), or (3) total hip replacement. We hypothesized that FHNE would be the least expensive treatment at all ages. SAMPLE: Cost estimates from 11 private and academic referral centers from 8 randomly chosen cities across the US. METHODS: Costs of surgeries were collected from practices in 8 US cities. The literature was used to determine expected postoperative costs. For conservative management, costs of pain medications and diet were obtained by use of online pharmacies. A 4.5% inflation adjustment was used for costs in subsequent years. RESULTS: For a dog aged 1 to 7 years, FHNE had the lowest lifetime cost. Total hip replacement had the second lowest cost until age 4, after which conservative management was lower. For dogs > 8 years, conservative management was the most cost-effective. CLINICAL RELEVANCE: For dogs presenting with clinical signs at or under 1 year of age, the perceived benefits of total hip replacement may not be financially prohibitive if lifetime cost of care is considered. Femoral head and neck excision was also less expensive than long-term conservative management. This can help veterinarians inform owners on costs of treatments over the lifetime of their pet. This type of analysis is limited to financial costs alone and does not account for differences in outcomes, as these are not well established. It should be expanded in the future as better data on outcomes and impacts of care become available.
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Enfermedades de los Perros , Osteoartritis de la Cadera , Perros , Animales , Enfermedades de los Perros/economía , Enfermedades de los Perros/cirugía , Enfermedades de los Perros/terapia , Osteoartritis de la Cadera/veterinaria , Osteoartritis de la Cadera/economía , Osteoartritis de la Cadera/cirugía , Osteoartritis de la Cadera/terapia , Tratamiento Conservador/veterinaria , Tratamiento Conservador/economía , Artroplastia de Reemplazo de Cadera/veterinaria , Artroplastia de Reemplazo de Cadera/economía , Estados UnidosRESUMEN
INTRODUCTION: Nonoperative management (NOM) of uncomplicated appendicitis (UA) has been increasingly utilized in recent years. The aim of this study was to describe nationwide trends of sociodemographic characteristics, outcomes, and costs of patients undergoing medical versus surgical management for UA. METHODS: The 2018-2019 National (Nationwide) Inpatient Sample was queried for adults (age ≥18 y) with UA; diagnosis, as well as laparoscopic and open appendectomy, were defined by the International Classification of Diseases, 10th Revision, Clinical Modification codes. We examined several characteristics, including cost of care and length of hospital stay. RESULTS: Among the 167,125 patients with UA, 137,644 (82.4%) underwent operative management and 29,481 (17.6%) underwent NOM. In bivariate analysis, we found that patients who had NOM were older (53 versus 43 y, P < 0.001) and more likely to have Medicare (33.6% versus 16.1%, P < 0.001), with higher prevalence of comorbidities such as diabetes (7.8% versus 5.5%, P < 0.001). The majority of NOM patients were treated at urban teaching hospitals (74.5% versus 66.3%, P < 0.001). They had longer LOS's (5.4 versus 2.3 d, P < 0.001) with higher inpatient costs ($15,584 versus $11,559, P < 0.001) than those who had an appendectomy. Through logistic regression we found that older patients had up to 4.03-times greater odds of undergoing NOM (95% CI: 3.22-5.05, P < 0.001). CONCLUSIONS: NOM of UA is more commonly utilized in patients with comorbidities, older age, and those treated in teaching hospitals. This may, however, come at the price of longer length of stay and higher costs. Further guidelines need to be developed to clearly delineate which patients could benefit from NOM.
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Apendicectomía , Apendicitis , Tiempo de Internación , Humanos , Apendicitis/cirugía , Apendicitis/economía , Apendicitis/terapia , Apendicitis/epidemiología , Adulto , Masculino , Femenino , Persona de Mediana Edad , Apendicectomía/economía , Apendicectomía/estadística & datos numéricos , Estados Unidos/epidemiología , Tiempo de Internación/estadística & datos numéricos , Tiempo de Internación/economía , Anciano , Adulto Joven , Adolescente , Laparoscopía/economía , Laparoscopía/estadística & datos numéricos , Estudios Retrospectivos , Tratamiento Conservador/economía , Tratamiento Conservador/estadística & datos numéricos , Costos de Hospital/estadística & datos numéricosRESUMEN
Objetivo Conocer el coste económico a largo plazo asociado al tratamiento de la incontinencia fecal grave mediante SNS frente al tratamiento conservador sintomático y la colostomía definitiva. Métodos Estudio descriptivo pormenorizado de los costes del proceso asistencial (intervenciones, consultas, dispositivos, pruebas complementarias, hospitalización, etc.) de 3 alternativas de tratamiento de la incontinencia fecal empleando herramientas de gestión y contabilidad analítica del propio Servicio de Salud con base en datos de actividad clínica. Se estimó, en cada caso, la frecuencia de uso de recursos sanitarios o la cantidad de productos dispensados en farmacias (medicación, pañales, material de ostomía, etc.). Se incluyeron costes derivados de situaciones adversas. Se incluyeron pacientes con incontinencia fecal grave, definida por una puntación superior a 9 en la escala de severidad de Wexner, en los que han fracasado los tratamientos de primera línea. Se emplearon datos de una cohorte consecutiva de 93 pacientes a los que se realizó una SNS entre los años 2002 y 2016; de pacientes intervenidos de colostomía definitiva (n=2); hernia paraestomal (n=3) y estenosis de colostomía (n=1). Resultados El coste medio acumulado en 10 años por paciente en cada alternativa fue: 10.972,9 para el tratamiento sintomático (62% pañales); 17.351,57 para la SNS (95,83% intervenciones; 81,6% dispositivos), y 25.858,54 para la colostomía definitiva (70,4% material de ostomía) Conclusiones El manejo de la incontinencia fecal grave implica un gran impacto en términos económicos. La colostomía es la alternativa que más costes directos genera, seguida de la SNS y el tratamiento sintomático (AU)
Introduction Find out the long-term economic cost associated with the treatment of severe fecal incontinence by SNS versus symptomatic conservative treatment and definitive colostomy. Methods Detailed descriptive study of the costs of the healthcare process (interventions, consultations, devices, complementary tests, hospitalization, etc.) of 3 treatment alternatives for fecal incontinence using analytical accounting tools of the Health Service based on clinical activity data. The frequency of use of health resources or the quantity of products dispensed in pharmacies (medication, diapers, ostomy material, etc.) was estimated in each case. Costs derived from adverse situations were included. Patients with severe fecal incontinence, defined by a score greater than 9 on the Wexner severity scale, in whom first-line treatments had failed, were included. Data from a consecutive cohort of 93 patients who underwent an SNS between 2002 and 2016 were used; patients who underwent definitive colostomy (n=2); parastomal hernia (n=3), and colostomy stenosis (n=1). Results The mean cumulative cost in 10 years per patient in each alternative was: 10,972.9 symptomatic treatment (62% diapers); 17,351.57 SNS (95.83% interventions; 81.6% devices); 25,858.54 definitive colostomy (70.4% ostomy material and accessories). Conclusions Management of severe fecal incontinence implies a great burden in economic terms. The colostomy is the alternative that generates the most direct cost, followed by SNS and symptomatic treatment (AU)
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Humanos , Incontinencia Fecal/economía , Incontinencia Fecal/terapia , Tratamiento Conservador/economía , Colostomía/economía , Costos de la Atención en Salud , Índice de Severidad de la Enfermedad , Análisis de Impacto Presupuestario de Avances TerapéuticosAsunto(s)
Artroplastia de Reemplazo de Rodilla/economía , Artroplastia de Reemplazo de Rodilla/métodos , Tratamiento Conservador/economía , Política de Salud , Osteoartritis de la Rodilla/economía , Osteoartritis de la Rodilla/terapia , Adulto , COVID-19/epidemiología , Humanos , Prótesis de la Rodilla , Manejo del Dolor , Pandemias , Complicaciones Posoperatorias/prevención & control , Diseño de Prótesis , SARS-CoV-2RESUMEN
BACKGROUND: The costs and health effects associated with lower extremity complications in diabetes mellitus are an increasing burden to society. In selected patients, lower extremity nerve decompression is able to reduce symptoms of neuropathy and the concomitant risks of diabetic foot ulcers and amputations. To estimate the health and economic effects of this type of surgery, the cost-effectiveness of this intervention compared to current nonsurgical care was studied. METHODS: To estimate the incremental cost-effectiveness of lower extremity nerve decompression over a 10-year period, a Markov model was developed to simulate the onset and progression of diabetic foot disease in patients with diabetes and neuropathy who underwent lower extremity nerve decompression surgery, compared to a group undergoing current nonsurgical care. Mean survival time, health-related quality of life, presence or risk of lower extremity complications, and in-hospital costs were the outcome measures assessed. Data from the Rotterdam Diabetic Foot Study were used as current care, complemented with information from international studies on the epidemiology of diabetic foot disease, resource use, and costs, to feed the model. RESULTS: Lower extremity nerve decompression surgery resulted in improved life expectancy (88,369.5 life-years versus 86,513.6 life-years), gain of quality-adjusted life-years (67,652.5 versus 64,082.3), and reduced incidence of foot complications compared to current care (490 versus 1087). The incremental cost-effectiveness analysis was -59,279.6 per quality-adjusted life-year gained, which is below the Dutch critical threshold of less than 80,000 per quality-adjusted life-year. CONCLUSIONS: Decompression surgery of lower extremity nerves improves survival, reduces diabetic foot complications, and is cost saving and cost-effective compared with current care, suggesting considerable socioeconomic benefit for society.
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Tratamiento Conservador/economía , Análisis Costo-Beneficio , Descompresión Quirúrgica/economía , Neuropatías Diabéticas/cirugía , Amputación Quirúrgica/economía , Amputación Quirúrgica/estadística & datos numéricos , Tratamiento Conservador/estadística & datos numéricos , Descompresión Quirúrgica/estadística & datos numéricos , Pie Diabético/economía , Pie Diabético/epidemiología , Pie Diabético/prevención & control , Neuropatías Diabéticas/economía , Costos de la Atención en Salud/estadística & datos numéricos , Humanos , Extremidad Inferior/inervación , Extremidad Inferior/cirugía , Cadenas de Markov , Persona de Mediana Edad , Modelos Económicos , Países Bajos/epidemiología , Calidad de Vida , Años de Vida Ajustados por Calidad de Vida , Resultado del TratamientoRESUMEN
ABSTRACT: Previous studies on hospital specialization in spinal joint disease have been limited to patients requiring surgical treatment. The lack of similar research on the nonsurgical spinal joint disease in specialized hospitals provides limited information to hospital executives.To analyze the relationship between hospital specialization and health outcomes (length of stay and medical expenses) with a focus on nonsurgical spinal joint diseases.The data of 56,516 patients, which were obtained from the 2018 National Inpatient Sample, provided by the Health Insurance Review and Assessment Service, were utilized. The study focused on inpatients with nonsurgical spinal joint disease and used a generalized linear mixed model with specialization status as the independent variable. Hospital specialization was measured using the Inner Herfindahl-Hirschman Index (IHI). The IHI (value ≤1) was calculated as the proportion of hospital discharges accounted for by each service category out of the hospital's total discharges. Patient and hospital characteristics were the control variables, and the mean length of hospital stay and medical expenses were the dependent variables.The majority of the patients with the nonsurgical spinal joint disease were female. More than half of all patients were middle-aged (40-64âyears old). The majority did not undergo surgery and had mild disease, with Charlson Comorbidity Index score ≤1. The mean inpatient expense was 1265.22 USD per patient, and the mean length of stay was 9.2âdays. The specialization status of a hospital had a negative correlation with the length of stay, as well as with medical expenses. An increase in specialization status, that is, IHI, was associated with a decrease in medical expenses and the length of stay, after adjusting for patient and hospital characteristics.Hospital specialization had a positive effect on hospital efficiency. The results of this study could inform decision-making by hospital executives and specialty hospital-related medical policymakers.
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Tratamiento Conservador , Hospitales Especializados , Artropatías , Enfermedades de la Columna Vertebral , Tratamiento Conservador/economía , Tratamiento Conservador/métodos , Eficiencia Organizacional/normas , Femenino , Costos de Hospital , Hospitales Especializados/clasificación , Hospitales Especializados/estadística & datos numéricos , Humanos , Artropatías/economía , Artropatías/epidemiología , Artropatías/terapia , Tiempo de Internación/economía , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Evaluación de Necesidades , Alta del Paciente/estadística & datos numéricos , República de Corea/epidemiología , Índice de Severidad de la Enfermedad , Enfermedades de la Columna Vertebral/economía , Enfermedades de la Columna Vertebral/epidemiología , Enfermedades de la Columna Vertebral/terapiaRESUMEN
ABSTRACT: To investigate the effect of cervical cerclage or conservative treatment on maternal and neonatal outcomes in singleton gestations with a sonographic short cervix, and further compare the relative treatment value.A retrospective study was conducted among women with singleton gestations who had a short cervical length (<25âmm) determined by ultrasound during the period of 14 to 24 weeks' gestation in our institution. We collected clinical data and grouped the patients according to a previous spontaneous preterm birth (PTB) at <34âweeks of gestation or second trimester loss (STL) and sub-grouped according to treatment option, further comparing the maternal and neonatal outcomes between different groups.In the PTB or STL history cohort, the cerclage group had a later gestational age at delivery (35.3â±â3.9âweeks vs 31.6â±â6.7âweeks) and a lower rate of perinatal deaths (2% vs 29.3%) compared with the conservative treatment group. In the non-PTB-STL history cohort, the maternal and neonatal outcomes were not significantly different between the cerclage group and conservative treatment group. More importantly, for patients with a sonographic short cervix who received cervical cerclage, there was no significant difference in the maternal and neonatal outcomes between the non-PTB-STL group and PTB or STL group.For singleton pregnant with a history of spontaneous PTB or STL and a short cervical length (<25âmm), cervical cerclage can significantly improve maternal and neonatal outcomes; however, conservative treatment (less invasive and expensive than cervical cerclage) was more suitable for those pregnant women without a previous PTB and STL history.
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Aborto Espontáneo/epidemiología , Cerclaje Cervical/estadística & datos numéricos , Cuello del Útero/anomalías , Tratamiento Conservador/estadística & datos numéricos , Nacimiento Prematuro/epidemiología , Aborto Espontáneo/etiología , Aborto Espontáneo/prevención & control , Adulto , Puntaje de Apgar , Peso al Nacer , Cerclaje Cervical/economía , Cuello del Útero/diagnóstico por imagen , Cuello del Útero/cirugía , Tratamiento Conservador/economía , Femenino , Edad Gestacional , Humanos , Recien Nacido Extremadamente Prematuro , Recién Nacido , Recién Nacido de muy Bajo Peso , Muerte Perinatal/prevención & control , Embarazo , Resultado del Embarazo , Nacimiento Prematuro/etiología , Nacimiento Prematuro/prevención & control , Estudios Retrospectivos , Resultado del Tratamiento , UltrasonografíaRESUMEN
We describe a case of a middle-aged woman who presented with progressive jaundice and was suspected to have rebound choledocholithiasis, which was initially managed with balloon extraction through endoscopic retrograde cholangiopancreatography at her first presentation. Healthcare in Pakistan, like many other developing countries, is divided into public and private sectors. The public sector is not always completely free of cost. Patients seeking specialised care in the public sector may find lengthy waiting times for an urgent procedure due to a struggling system and a lack of specialists and technical expertise. Families of many patients find themselves facing 'catastrophic healthcare expenditure', an economic global health quandary much ignored.
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Colangiopancreatografia Retrógrada Endoscópica/economía , Coledocolitiasis/terapia , Tratamiento Conservador/economía , Accesibilidad a los Servicios de Salud/economía , Ictericia Obstructiva/terapia , Coledocolitiasis/complicaciones , Coledocolitiasis/diagnóstico , Coledocolitiasis/economía , Conducto Colédoco/diagnóstico por imagen , Conducto Colédoco/cirugía , Tratamiento Conservador/métodos , Países en Desarrollo/economía , Progresión de la Enfermedad , Femenino , Fuerza Laboral en Salud/economía , Hospitales Privados/economía , Hospitales Públicos/economía , Humanos , Ictericia Obstructiva/economía , Ictericia Obstructiva/etiología , Persona de Mediana Edad , Pakistán , Cuidados Paliativos , Índice de Severidad de la Enfermedad , Tiempo de Tratamiento/economía , UltrasonografíaRESUMEN
STUDY DESIGN: Survey study. OBJECTIVE: Assess practices and opinions of spine specialists from Europe and North America on orthosis use in adult patients with acute thoracolumbar (TL) fractures. Evaluate cost of the devices. SUMMARY OF BACKGROUND DATA: Although orthosis are traditionally used in conservative treatment of TL fractures, recent systematic reviews showed no benefit in patient's outcomes. METHODS: A search for contact authors with publications on spine fractures from all European and North American countries was performed. An online questionnaire was sent on demographic data, practice setting, mean number of fractures treated, use of orthosis upon choice for conservative treatment, and average orthosis cost. Data was analyzed based in world regions, economic rank of the country, and health expenditure. RESULTS: We received 130 answers, from 28 European and five North American countries. Most responders had more than 9 years of practice and worked at a public hospital. 6.2% did not prescribe a brace in any patient with acute TL fractures conservatively treated and 11.5% brace all patients. In a scale from 1 to 5, 21 considered that there is no/low benefit (1) and 14 that bracing is essential (5), with a mean of 3.18. Europeans use orthosis less commonly than North Americans (Pâ<â0.05). Orthosis mean cost was $611.4â±â716.0, significantly higher in North America compared with Europe and in high income, when compared with upper middle income countries (both Pâ<â0.05). Although hospital costs were not evaluated, orthosis is costlier when it involves admission of the patient (Pâ<â0.05). An increase in orthosis cost associated with higher gross domestic product (GDP) per capita and higher health expenditure was found. CONCLUSION: More than 90% of spine specialists still use orthosis in conservative treatment of adult patients with acute TL fractures. Orthosis cost vary significantly between continents, and it is influenced by the country's economy.Level of Evidence: 4.
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Tratamiento Conservador/economía , Vértebras Lumbares/lesiones , Aparatos Ortopédicos/economía , Fracturas de la Columna Vertebral/economía , Cirujanos/economía , Vértebras Torácicas/lesiones , Adulto , Tirantes , Tratamiento Conservador/tendencias , Europa (Continente)/epidemiología , Testimonio de Experto/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , América del Norte/epidemiología , Aparatos Ortopédicos/tendencias , Fracturas de la Columna Vertebral/epidemiología , Fracturas de la Columna Vertebral/terapia , Cirujanos/tendencias , Encuestas y CuestionariosRESUMEN
STUDY DESIGN: Retrospective cohort. OBJECTIVE: To determine surgery-free survival of patients receiving conservative management of lumbar disc herniation (LDH) in the military healthcare system (MHS) and risk factors for surgical intervention. SUMMARY OF BACKGROUND DATA: Radiculopathy from LDH is a major cause of morbidity and cost. METHODS: The Military Data Repository was queried for all patients diagnosed with LDH from FY2011-2018; the earliest such diagnosis in a military treatment facility (MTF) was kept for each patient as the initial diagnosis. Follow-up time to surgical intervention was defined as the time from diagnosis to first encounter for lumbar microdiscectomy or lumbar decompression in either a MTF or in the civilian sector. The Military Data Repository was also queried for history of tobacco use at any time during MHS care, age at the time of diagnosis, sex, MHS beneficiary category, and diagnosing facility characteristics. Multivariable Cox proportional hazards models were used to evaluate the associations of patient and diagnosing facility characteristics with time to surgical intervention. RESULTS: A total of 84,985 MHS beneficiaries including 62,771 active duty service members were diagnosed with LDH in a MTF during the 8-year study period. A total of 10,532 (12.4%) MHS beneficiaries, including 7650 (10.9%) active duty, failed conservative management onto surgical intervention with lumbar microdiscectomy or lumbar decompression. Median follow-up time of the cohort was 5.2 (interquartile range 2.6, 7.5) years. Among all healthcare beneficiaries, several patient-level (younger age, male sex, and history of tobacco use) and facility-level characteristics (hospital vs. clinic and surgical care vs. primary care clinic) were independently associated with higher risk of surgical intervention. CONCLUSION: LDH compromises military readiness and negatively impacts healthcare costs. MHS beneficiaries with LDH have a good prognosis with approximately 88% of patients successfully completing conservative management. However, strategies to improve outcomes of conservative management in LDH should address risks associated with both patient and facility characteristics.Level of Evidence: 4.
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Tratamiento Conservador/tendencias , Discectomía/tendencias , Degeneración del Disco Intervertebral/cirugía , Desplazamiento del Disco Intervertebral/cirugía , Vértebras Lumbares/cirugía , Servicios de Salud Militares/tendencias , Adulto , Factores de Edad , Estudios de Cohortes , Tratamiento Conservador/economía , Análisis Costo-Beneficio/tendencias , Progresión de la Enfermedad , Discectomía/economía , Femenino , Estudios de Seguimiento , Humanos , Degeneración del Disco Intervertebral/economía , Degeneración del Disco Intervertebral/epidemiología , Desplazamiento del Disco Intervertebral/economía , Desplazamiento del Disco Intervertebral/epidemiología , Masculino , Persona de Mediana Edad , Servicios de Salud Militares/economía , Estudios Retrospectivos , Fumar/economía , Fumar/epidemiologíaRESUMEN
There is a paucity of data characterizing regional variations in the utilization and costs of conservative management in patients suffering from cervical stenosis prior to anterior cervical discectomy and fusion (ACDF) surgery. An understating of these regional trends becomes critical as outcomes-based reimbursement strategies become standard. The objective of this investigation was to evaluate for regional differences in the utilization and overall costs of maximal non-operative therapy (MNT) prior to ACDF surgery. Medical records from patients with symptomatic cervical stenosis undergoing a ≤3-level index ACDF procedure between 2007 and 2016 were accessed from a large insurance database. Geographic regions (Midwest, Northeast, South, and West) reflected U.S. Census Bureau definitions. MNT utilization within 2-years prior to ACDF surgery was analyzed. An index ACDF surgery was performed in 15,825 patients. Patient regional breakdown was as follows: South (67.6% of patients), Midwest (21.8% of patients), West (8.9% of patients), Northeast (1.6% of patients). Regional variations were identified in the number of patients utilizing NSAIDs (p < 0.001), opioids (p < 0.001), muscle relaxants (p < 0.001), cervical epidural steroid injections (p = 0.001), physical therapy/occupational therapy treatments (p < 0.001), and chiropractor visits (p < 0.001). The West (64.5%) and South (63.5%) had the greatest proportion of patients utilizing narcotics. When normalized by the number of opioid using-patients however, the Northeast (691.4 pills/patient) and South (674.4 pills/patient) billed for the most opioid pills. The total direct cost associated with all MNT prior to index ACDF was $17,255,828. The Midwest ($1,277.72 per patient) and South ($1,047.86 per patient) had the greatest average dollars billed.
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Vértebras Cervicales , Tratamiento Conservador/economía , Tratamiento Conservador/estadística & datos numéricos , Enfermedades de la Columna Vertebral/epidemiología , Enfermedades de la Columna Vertebral/terapia , Adulto , Vértebras Cervicales/cirugía , Tratamiento Conservador/métodos , Constricción Patológica/terapia , Discectomía/economía , Discectomía/métodos , Discectomía/estadística & datos numéricos , Femenino , Humanos , Persona de Mediana Edad , Estudios Retrospectivos , Fusión Vertebral/economía , Fusión Vertebral/métodos , Fusión Vertebral/estadística & datos numéricos , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
A paucity of evidence exists regarding the optimal composition of conservative therapies to best treat patients diagnosed with cervical stenosis prior to consideration of surgery. The purpose of this study was to compare the nonoperative therapy utilization strategies in cervical stenosis patients successfully managed with conservative treatments versus those that failed medical management and opted for an anterior cervical discectomy and fusion (ACDF) surgery. Medical records from adult patients with a diagnosis of cervical stenosis from 2007 to 2017 were collected retrospectively from a large insurance database. Patients were divided into two cohorts: patients treated successfully with nonoperative therapies and patients that failed conservative management and opted for ACDF surgery. Nonoperative therapies utilized by the two cohorts were collected over a 2-year surveillance window. A total of 90,037 adult patients with cervical stenosis comprised the base population. There were 83,384 patients (92.6%) successfully treated with nonoperative therapies alone, while 6,653 patients (7.4%) ultimately failed conservative management and received an ACDF. Failure rates of non-operative therapies were higher in smokers (11.2%), patients receiving cervical epidural steroid injections (11.2%), and male patients (8.1%). A greater percentage of patients who failed conservative management utilized opioid medications (p < 0.001), muscle relaxants (p < 0.001), and CESIs (p < 0.001). The costs of treating patients that failed conservative management was double the amount of the successfully treated group (failed cohort: $1,215.73 per patient; successful cohort: $659.58 per patient). A logistic regression analysis demonstrated that male patients, smokers, opioid utilization, and obesity were independent predictors of conservative treatment failure.
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Tratamiento Conservador/métodos , Estenosis Espinal/terapia , Resultado del Tratamiento , Adulto , Anciano , Anciano de 80 o más Años , Vértebras Cervicales/cirugía , Tratamiento Conservador/economía , Costos y Análisis de Costo , Bases de Datos Factuales , Discectomía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Fusión Vertebral , Estenosis Espinal/economía , Adulto JovenRESUMEN
BACKGROUND: Patients diagnosed with osteoarthritis (OA) and presenting with symptoms are seeking conservative treatment options to reduce pain, improve function, and avoid surgery. Sustained acoustic medicine (SAM), a multi-hour treatment has demonstrated improved clinical outcomes for patients with knee OA. The purpose of this analysis was to compare the costs and effectiveness of multi-hour SAM treatment versus the standard of care (SOC) over a 6-month timeframe for OA symptom management. METHODS: A decision tree analysis was used to compare the costs and effectiveness of SAM treatment versus SOC in patients with OA. Probabilities of success for OA treatment and effectiveness were derived from the literature using systematic reviews and meta-analyses. Costs were derived from Medicare payment rates and manufacturer prices. Functional effectiveness was measured as the effect size of a therapy and treatment pathways compared to a SOC treatment pathway. A sensitivity analysis was performed to determine which cost variables had the greatest effect on deciding which option was the least costly. An incremental cost-effectiveness plot comparing SAM treatment vs. SOC was also generated using 1000 iterations of the model. Lastly, the incremental cost-effectiveness ratio (ICER) was calculated as the (cost of SAM minus cost of SOC) divided by (functional effectiveness of SAM minus functional effectiveness of SOC). RESULTS: Base case demonstrated that over 6 months, the cost and functional effectiveness of SAM was $8641 and 0.52 versus SOC at: $6281 and 0.39, respectively. Sensitivity analysis demonstrated that in order for SAM to be the less expensive option, the cost per 15-min session of PT would need to be greater than $88, or SAM would need to be priced at less than or equal to $2276. Incremental cost-effectiveness demonstrated that most of the time (84%) SAM treatment resulted in improved functional effectiveness but at a higher cost than SOC. CONCLUSION: In patients with osteoarthritis, SAM treatment demonstrated improved pain and functional gains compared to SOC but at an increased cost. Based on the SAM treatment ICER score being ≤ $50,000, it appears that SAM is a cost-effective treatment for knee OA.
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Artralgia/terapia , Tratamiento Conservador/economía , Tratamiento Conservador/métodos , Análisis Costo-Beneficio/economía , Costos de la Atención en Salud , Osteoartritis de la Rodilla/terapia , Modalidades de Fisioterapia , Terapia por Ultrasonido/economía , Terapia por Ultrasonido/métodos , Artralgia/etiología , Femenino , Humanos , Masculino , Osteoartritis de la Rodilla/complicaciones , Modalidades de Fisioterapia/economía , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Appendicitis has traditionally been treated surgically. Recently, nonoperative management is emerging as a viable alternative to the traditional operative approach. This raises the question of what are the unintended consequences of nonoperative management of appendicitis with respect to cost and patient burden. METHODS: National Readmissions Database was queried between 2010 and 2014. Patients who were admitted with acute appendicitis between January and June of each year were identified. Patients who underwent appendectomy were compared with those treated nonoperatively. Six-month all-cause readmission rates and aggregate costs between index hospitalization and readmissions were calculated. RESULTS: We identified 438,995 adult admissions for acute appendicitis. Most cases were managed with appendectomy (93.2%). There was a significant increase in the rate of nonoperative management, from 3.6% in 2010 to 6.8% in 2014 (P value for trend <0.01). Discharges receiving nonoperative management tended to be older and have more comorbidities. There was a 59% decreased adjusted odds of readmission within 6 mo among patients receiving appendectomy in comparison to those managed nonoperatively. Despite this, in multivariable linear regression, there was an adjusted $2900 cost increase associated with surgical management (P < 0.01). CONCLUSIONS: This study shows that nonoperative management is increasing. Patients treated nonoperatively may have an increased risk of readmission within 6 mo but incur a decreased average adjusted total cost. Given this, it is important that surgeons critically assess patients who are being considered for nonoperative management of appendicitis.
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Apendicitis/terapia , Tratamiento Conservador/estadística & datos numéricos , Readmisión del Paciente/estadística & datos numéricos , Adolescente , Adulto , Anciano , Apendicectomía/economía , Apendicitis/economía , Apendicitis/mortalidad , Tratamiento Conservador/economía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Estados Unidos/epidemiología , Adulto JovenRESUMEN
STUDY DESIGN: Longitudinal comparative cohort. OBJECTIVE: The purpose of this study is to report on the cost-effectiveness of surgical versus non-surgical treatment for Adult Symptomatic Lumbar Scoliosis (ASLS) using the as-treated data and provide a comparison to previously reported intent-to-treat (ITT) analysis. Adult spinal deformity is a relatively prevalent condition for which surgical treatment has become increasingly common but concerns surrounding complications, revision rates and cost-effectiveness remain unresolved. Of these issues, cost-effectiveness is perhaps the most difficult to quantify as the requisite data is difficult to obtain. The purpose of this study is to report on the cost-effectiveness of surgical versus non-surgical treatment for ASLS using the as-treated data and provide a comparison to previously reported ITT analysis. METHODS: Patients with at least 5-year follow-up data within the same treatment arm were included. Data collected every 3 months included use of nonoperative modalities, medications and employment status. Costs for surgeries and non-operative modalities were determined using Medicare Allowable rates. Medication costs were determined using the RedBook and indirect costs were calculated based on the reported employment status and income. Quality-Adjusted Life Years (QALY) was determined using the SF-6D. RESULTS: Of 226 patients, 195 patients (73 Non-op, 122 Op) met inclusion criteria. At 5 years, 29 (24%) patients in the Op group had a revision surgery of whom two had two revisions and one had three revisions. The cumulative cost for the Op group was $111,451 with a cumulative QALY gain of 2.3. The cumulative cost for the Non-Op group was $29,124 with a cumulative QALY gain of 0.4. This results in an ICER of $44,033 in favor of Op treatment. CONCLUSION: This as-treated cost-effectiveness analysis demonstrates that surgical treatment for adult lumbar scoliosis becomes favorable at year-three, 1 year earlier than suggested by a previous intent-to-treat analysis. LEVEL OF EVIDENCE: II.
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Tratamiento Conservador/economía , Análisis Costo-Beneficio/métodos , Vértebras Lumbares/cirugía , Escoliosis/economía , Escoliosis/cirugía , Fusión Vertebral/economía , Adulto , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Escoliosis/terapia , Fusión Vertebral/métodos , Factores de TiempoRESUMEN
BACKGROUND: Nonoperative management (NOM) of uncomplicated appendicitis has gained recognition as an alternative to surgery. In the largest published randomized trial (Appendicitis Acuta), patients received a 3-d hospital stay for intravenous antibiotics; however, cost implications for health care systems remain unknown. We hypothesized short stay protocols would be cost saving compared with a long stay protocol. MATERIALS AND METHODS: We constructed a Markov model comparing the cost of three protocols for NOM of acute uncomplicated appendicitis: (1) long stay (3-d hospitalization), (2) short stay (1-d hospitalization), and (3) emergency department (ED) discharge. The long stay protocol was modeled on data from the APPAC trial. Model variables were abstracted from national database and literature review. One-way and two-way sensitivity analyses were performed to determine the impact of uncertainty on the model. RESULTS: The long stay treatment protocol had a total 5-y projected cost of $10,735 per patient. The short stay treatment protocol costs $8026 per patient, and the ED discharge protocol costs $6,825, which was $2709 and $3910 less than the long stay protocol, respectively. One-way sensitivity analysis demonstrated that the relative risk of treatment failure with the short stay protocol needed to exceed 6.3 (absolute risk increase of 31%) and with the ED discharge protocol needed to exceed 8.75 (absolute risk increase of 45%) in order for the long stay protocol to become cost saving. CONCLUSIONS: Short duration hospitalization protocols to treat appendicitis nonoperatively with antibiotics are cost saving under almost all model scenarios. Future consideration of patient preferences and health-related quality of life will need to be made to determine if short stay treatment protocols are cost-effective.
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Antibacterianos/administración & dosificación , Apendicitis/tratamiento farmacológico , Apendicitis/terapia , Tratamiento Conservador/economía , Ahorro de Costo/estadística & datos numéricos , Administración Intravenosa , Simulación por Computador , Tratamiento Conservador/métodos , Tratamiento Conservador/estadística & datos numéricos , Análisis Costo-Beneficio , Humanos , Tiempo de Internación/economía , Tiempo de Internación/estadística & datos numéricos , Modelos Económicos , Calidad de Vida , Factores de TiempoRESUMEN
PURPOSE: To determine consensus among Asia-Pacific surgeons regarding nonoperative management for adolescent idiopathic scoliosis (AIS). METHODS: An online REDCap questionnaire was circulated to surgeons in the Asia-Pacific region during the period of July 2019 to September 2019 to inquire about various components of nonoperative treatment for AIS. Aspects under study included access to screening, when MRIs were obtained, quality-of-life assessments used, role of scoliosis-specific exercises, bracing criteria, type of brace used, maturity parameters used, brace wear regimen, follow-up criteria, and how braces were weaned. Comparisons were made between middle-high income and low-income countries, and experience with nonoperative treatment. RESULTS: A total of 103 responses were collected. About half (52.4%) of the responders had scoliosis screening programs and were particularly situated in middle-high income countries. Up to 34% obtained MRIs for all cases, while most would obtain MRIs for neurological problems. The brace criteria were highly variable and was usually based on menarche status (74.7%), age (59%), and Risser staging (92.8%). Up to 52.4% of surgeons elected to brace patients with large curves before offering surgery. Only 28% of responders utilized CAD-CAM techniques for brace fabrication and most (76.8%) still utilized negative molds. There were no standardized criteria for brace weaning. CONCLUSION: There are highly variable practices related to nonoperative treatment for AIS and may be related to availability of resources in certain countries. Relative consensus was achieved for when MRI should be obtained and an acceptable brace compliance should be more than 16 hours a day.
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Tirantes , Procedimientos Ortopédicos , Escoliosis/terapia , Adolescente , Asia/epidemiología , Tirantes/economía , Tirantes/estadística & datos numéricos , Niño , Consenso , Tratamiento Conservador/economía , Tratamiento Conservador/estadística & datos numéricos , Progresión de la Enfermedad , Femenino , Grupos Focales , Encuestas de Atención de la Salud/estadística & datos numéricos , Humanos , Internet , Imagen por Resonancia Magnética/economía , Imagen por Resonancia Magnética/estadística & datos numéricos , Masculino , Oceanía/epidemiología , Procedimientos Ortopédicos/economía , Procedimientos Ortopédicos/estadística & datos numéricos , Calidad de Vida , Escoliosis/diagnóstico , Escoliosis/economía , Escoliosis/epidemiología , Factores Socioeconómicos , Resultado del TratamientoRESUMEN
Patients with lumbar intervertebral disc herniation classically trial a brief course of conservative management prior to microdiscectomy surgery. Gender differences have previously been identified in the selection and symptomatic response to commonly-utilized nonoperative treatments. However, whether gender differences exist in the degree and cost of nonoperative therapy in this cohort remains unknown. Therefore, the purpose of this study was to assess for gender differences in the utilization and costs of nonoperative therapy in patients diagnosed with symptomatic lumbar intervertebral disc herniation 3-months prior to undergoing microdiscectomy. Medical records from adult patients diagnosed with a lumbar intervertebral disc herniation undergoing index microdiscectomy procedures from 2007 to 2017 were collected retrospectively from a large insurance database. The utilization of nonoperative therapy within 3-months after initial lumbar herniation diagnosis was determined. A total of 13,106 patients (55.4% Males) underwent index microdiscectomy. Male patients were more likely to fail conservative management and opt for surgery (Males: 2.9% vs. Females: 1.8%, p < 0.0001). A greater percentage of female patients utilized muscle relaxants (p = 0.0049), lumbar epidural steroid injections (p = 0.0007), and emergency department services (p = 0.001). The total direct cost of conservative treatment prior to microdiscectomy was $13,205,924, with males accountable for $7,457,023 (56.5%). When normalized by number of patients utilizing the respective therapy, males used fewer units of NSAIDs (males: 84.2 pills/patient; females: 97.3 pills/patient) and muscle relaxants (males: 77.5 pills/patient; females: 89.0 pills/patient). These results suggest that gender differences exist in the utilization of nonoperative therapies for the management of a lumbar intervertebral herniated disc prior to microdiscectomy surgery.
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Tratamiento Conservador , Discectomía , Desplazamiento del Disco Intervertebral/terapia , Factores Sexuales , Adulto , Estudios de Cohortes , Tratamiento Conservador/economía , Tratamiento Conservador/métodos , Tratamiento Conservador/estadística & datos numéricos , Costos y Análisis de Costo , Discectomía/economía , Discectomía/métodos , Discectomía/estadística & datos numéricos , Femenino , Humanos , Vértebras Lumbares/cirugía , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
PURPOSE OF REVIEW: Complications of otitis media are a cause of significant morbidity and mortality, compounded in resource-constrained settings in which human and physical resources to manage disease are suboptimal. Here, we examine the current best evidence to devise a protocol for management, in particular exploring the opportunity for conservative or nonspecialist management. RECENT FINDINGS: Reviews of the literature suggest that intratemporal and extracranial infections can be managed with antibiotics in the first instance, with aspiration or incision and drainage of abscess. Failure to respond necessitates mastoidectomy, which need not be extensive, and can be performed with hammer and gouge. Suspected or possible intracranial extension requires referral for computed tomography (CT) imaging. Intracranial infection can in some instances be managed with antibiotics, but large or persistent intracranial abscess, or the presence of cholesteatoma requires management in a centre for specialist surgery. SUMMARY: Many complications of otitis media could be managed by nonspecialists in appropriately equipped local or regional health facilities, and supported by appropriate training. However, regional centres with CT imaging and specialist surgery are required for assessment and treatment of cases that are suspected of having complex or advanced disease, or that fail to respond to initial treatment. Those involved in planning healthcare provision should look to develop infrastructure to support such management.