Quality of referrals for lower extremity ultrasonography and computed tomography pulmonary angiography and associations with positive findings of venous thromboembolism.

INTRODUCTION: The referral is the basis for radiologists' assessment of modality, protocol and urgency, and insufficient information may threaten patient safety. The aim of this study was to assess the completeness of referrals for lower extremity venous duplex ultrasonography (LEVDUS) and computed tomography pulmonary angiography (CTPA), and to investigate associations between the provided clinical information including risk factors, symptoms and lab results in the referrals and positive findings of deep vein thrombosis (DVT) and pulmonary embolism (PE), respectively. METHODS: Referrals for LEVDUS (801) and CTPA (800) performed from 2016 to 2019 were obtained. Three categories of clinical information from the referrals were recorded: symptoms, risk factors and laboratory results, as well as positive imaging findings of venous thromboembolism (VTE). Referral completeness was rated from zero to three according to how many categories of clinical information the referral provided. RESULTS: Information from all three clinical information categories was provided in 15% and 25% of referrals for LEVDUS and CTPA, respectively, while 2% and 10% of referrals did not contain any clinical information. Symptoms were provided most often (85% for LEVDUS and 94% for CTPA). Provided information about risk factors was significantly associated with positive findings for LEVDUS, (p = 0.02) and CTPA (p < 0.001). CONCLUSION: A great majority of referrals failed to provide one or more categories of clinical information. Risk factors were associated with a positive finding of VTE on LEVDUS and CTPA. IMPLICATIONS FOR PRACTICE: Improving clinical information in referrals may improve justification, patient safety and quality of radiology services.

Budget impact analysis of surgical treatment for obesity in Sweden.

BACKGROUND: The recent substantial increase in the number of obese surgeries performed in Sweden has raised concerns about the budget impact. OBJECTIVE: Our aim in this paper is to present an assessment of the budgetary impact of different policies for surgical intervention for obese and overweight subjects from a healthcare perspective in Sweden. METHODS: The model simulates the annual expected treatment costs of obesity related diseases and surgery in patients of different sex, age and Body Mass Index (BMI). Costs evaluated are costs of surgery plus the excess treatment costs that an obese patient has over and above the treatment costs of a normal-weight patient. The diagnoses that are included for costs assessment are diabetes and cardiovascular disease since these diagnoses are the principal diagnoses associated with obesity. Four different scenarios over the number of surgical operations performed each year are simulated and compared: (1) no surgical operation, (2) 3 000 surgical operations in persons with BMI > 40, (3) 4 000 (BMI > 40), and (4) 5 000 (expanded to BMI > 38). RESULTS: Comparing Scenario 2 with Scenario 1 results in a net budget impact of on average SEK 121 million per annum or SEK 40 000 per patient. This implies that 55 percent of the cost of surgery, set equal to SEK 90 000 for each patient, has been offset by a reduction in the excess treatment costs of obesity related diseases. Expanding annual surgery from 3000 to 4000 the cost-offset increased to 58%. By expanding annual surgery further from 4000 to 5000 and at the same time expanding the indication for surgery from BMI > 40 to BMI > 38, no cost-offset is obtained. CONCLUSION: A cost-minimization strategy for bariatric surgery in Sweden should not expand indication, but rather increase the number of surgeries within the currently accepted indication.

Cost effectiveness of Becaplermin in the treatment of diabetic foot ulcers in four European countries.

OBJECTIVE: The primary objective of this study was to estimate the cost effectiveness of treating diabetic foot ulcers with becaplermin (Regranex) plus good wound care (GWC) compared with GWC alone in a variety of European healthcare settings. A secondary objective was to analyse the effect of different treatment practices on the economics of caring for diabetic foot ulcers. DESIGN AND SETTING: Markov-based simulation study from the perspective of a national health system. METHODS: A 12-month Markov computer simulation model was used to assess the cost effectiveness in 4 European countries of treating diabetic foot ulcers with becaplermin plus GWC versus GWC alone. Transition probabilities were taken from a prospective study of 183 patients and becaplermin efficacy was based on 20-week healing rates in a recent meta-analysis of clinical trials involving 449 patients. Country-specific treatment cost data were collected in collaboration with local economic consultations and combined with the disease model to estimate the incremental cost per ulcer-free month gained. The model was then run using hypothetical low- and high-intensity resource usage profiles to investigate the economics of caring for diabetic foot ulcers. RESULTS: Over the course of 1 year, individuals who received becaplermin plus GWC were, on average, predicted to spend an additional 0.81 months (24% longer) free of ulcers and to experience a 9% lower risk of undergoing a lower extremity amputation than individuals who received GWC alone. Consequently, becaplermin plus GWC was estimated to be net cost saving in Sweden, Switzerland and the UK. In France, the addition of becaplermin was estimated to add $US19 (1999 values) for each additional ulcer-free month gained. There were substantial intercountry differences in treatment practices and the costs of treating diabetic foot ulcers. CONCLUSIONS: Becaplermin may be a cost-effective treatment for neuropathic diabetic foot ulcers in a wide range of European settings. In Sweden, Switzerland and the UK, becaplermin may even be cost saving. Substantial intercountry differences in resource patterns appear, at least partly, to be the logical outcome of differences in unit costs.

The cost-effectiveness of treating diabetic lower extremity ulcers with becaplermin (Regranex): a core model with an application using Swedish cost data.

OBJECTIVES: The objective of this study was to develop a model capable of assessing the cost-effectiveness in Sweden of treating diabetic neuropathic lower extremity ulcers with becaplermin gel (Regranex) plus good wound care (GWC) relative to treating them with GWC alone. METHODS: A Markov simulation model was developed that includes six health states: Uninfected Ulcer, Infected Ulcer, Gangrene, Healed Ulcer, Healed Ulcer-History of Amputation, and Deceased. To predict clinical outcomes, information was taken from a specially designed prospective 9-month follow-up study of 183 neuropathic patients in the US treated with GWC. Cost of treatment data were taken primarily from a study of a cohort of 314 patients in Sweden. The efficacy of becaplermin was assumed equal to that achieved in a pooled analysis of four randomized clinical trials. A model application provides expected clinical outcomes for a cohort of patients. Annual treatment costs per patient were estimated using treatment practice and unit prices from Sweden. RESULTS: Due to a higher rate of healing and a shorter average healing time, treatment with becaplermin gel was predicted to increase the average number of months spent in the healed state over the first year following development of an ulcer by 24% relative to GWC alone. In addition, the corresponding number of amputations was 9% lower for the becaplermin-treated cohort. The average expected cost of $12,078 US for an individual treated with GWC alone declines to $11,708 US for one treated with becaplermin, in spite of $1262 becaplermin costs. Expenses related to topical treatment and inpatient care account for 83% of the resources conserved. CONCLUSIONS: Our results suggest that in Sweden treatment with becaplermin in conjunction with GWC consumes fewer resources and generates better outcomes than treatment with GWC alone for diabetic neuropathic ulcers. In light of the high and increasing incidence of such ulcers, the potential savings in costs and suffering may be important. Results are difficult to extrapolate internationally because they are strongly related to country-specific treatment practices and price levels.

Cost of long-term complications of deep venous thrombosis of the lower extremities: an analysis of a defined patient population in Sweden.

BACKGROUND: Little information is available on the epidemiology and economic effect of long-term complications developing after deep venous thrombosis. OBJECTIVE: To determine the extent of, timing of, and treatment costs associated with long-term complications developing after deep venous thrombosis of the lower extremities. DESIGN: 15-year retrospective cohort study. SETTING: County hospital in Sweden. PATIENTS: 257 patients with deep venous thrombosis and 241 age- and sex-matched controls without deep venous thrombosis. MEASUREMENTS: Data on use of health care resources and costs of inpatient and outpatient care, pharmaceutical agents, and treatment of complications. RESULTS: After 15 years of follow-up, 35% of the patients with thrombosis and 57% of the controls were alive. Two hundred forty-two complications were reported among the patients with thrombosis, and 25 similar events were reported among the controls. The average expected present value of the health care cost of treating complications of thrombosis was estimated to be about $4659 in the patients with thrombosis and $375 in the controls. In controls, primary deep venous thrombosis cost about $6000; thus, the additional long-term health care cost of post-thrombotic complications is about 75% of the cost of primary deep venous thrombosis. CONCLUSIONS: The economic effect of post-thrombotic complications is considerable. The use of measures to prevent thromboembolism and its long-term complications are justified on both clinical and economic grounds.

The economic cost of a streptococcal tonsillitis episode.

OBJECTIVE: To estimate the cost of a streptococcal tonsillitis episode from the data of a questionnaire. SETTING: Five primary health centres in the west of Sweden. PARTICIPANTS: 101 consecutive patients treated for streptococcal tonsillitis. MAIN OUTCOME MEASURE: The cost estimation included costs for physician visit and drug, travel costs to and from the primary health centre, cost of lost production resulting from the patient's or the guardian's absence from work for physician visit or sick-leave, and cost of telephone consultation with a physician or nurse. RESULTS: The period of illness was on average seven days, time to recovery after treatment five days, and the mean period of sick-leave 2.5 days. The total cost of a tonsillitis episode was about SEK 3,300 (385 USD). Of this sum, the cost for the antibiotic accounted for only 3% and loss of production for 75%. CONCLUSION: Differences in the cost of drugs only have a minor influence on the total cost, while factors causing loss of production, such as efficacy and side effects of the drug, have a greater influence. Economic evaluation of pharmaceuticals will be more relevant in the future, and in the search for the most effective treatment, cost effective studies will be integrated with clinical trials.

Improved medium for the transportation of gonococcal specimens.

A modification of Stuart medium, denominated SIFF transport medium, was compared with Stuart (Ringertz's modification), Amies and SBL transport media for its ability to preserve viability of gonococci during transport. The SIFF medium was superior both when using laboratory strains of Neisseria gonorrhoeae and when using clinical specimens. The new transport medium distinguishes itself mainly by an increased osmotic pressure and by its starch content.

Frequency of simultaneous carriage of Neisseria gonorrhoeae and Neisseria meningitidis.

Gonococci were found by culture in 112 of 442 patients suspected of having gonorrhoea. Meningococci were cultured from the pharynx more than twice as often in patients harbouring gonococci (26%) than in patients from whom gonococci could not be cultured (11%). These results could indicate an individual susceptibility to Neisseria organisms or they could be caused by a difference in the behaviour of patients with and without gonorrhoea, the conduct of the former making them not only more likely to be infected with Neisseria gonorrhoeae but possibly more exposed to Neisseria meningitidis as well.

Isolation of Neisseria meningitidis in urogenital/rectal infections.

In 9 cases (6 men, 3 women) during 1975 we have isolated N. meningitidis from routine samples from urogenital/rectal locations to be examined for gonococci by culture. One of the men harboured meningococci in the rectum, the other 5 in the urethra. Two of the women had meningococci in the cervix and one in the urethra. Of the meningococci isolated, one belonged to serogroup A, 6 to group B and 2 to group C. Six of the patients, 4 men and 2 women, who attended the Department of Venereal Diseases, are described in greater detail. Of these, only one had symptoms. The meningococci disappeared spontaneously in 5 cases, whilst a man with unsymptomatic infection still harboured meningococci in the rectum after one month. Two of the 4 men were homosexual.

Isolation of a penicillinase producing strain of Neisseria gonorrhoeae.

A gram-negative diplococcus with the qualifications of a gonococcus was isolated from the urethra of a male infected with gonorrhoea in the Far East. The strain proved to be resistant to penicillin G and ampicillin as judged by the paper disc sensitivity test. The resistance was found to be caused by a powerful production of penicillinase which not only acted on penicillin G and ampicillin, but also on methicillin and partly on cephalosporin (cephalotin) by the test employed.

Lincomycin in selective medium for the isolation of Neisseria gonorrhoeae.

For the isolation of gonococci, the selective culture medium containing colistin, vancomycin, nystatin and trimethoprim which is usually employed has been changed by substituting lincomycin for vancomycin. The best result was obtained if a concentration of 1/2 mug lincomycin/ml medium was used. This is a concentration of lincomycin considerably lower than that which by other investigators is considered most suitable for the purpose. However, the culture medium used by the latter did not contain trimethoprim. The use of 1/2 mug lincomycin/ml instead of vancomycin 3 mug/ml in the medium caused a slightly more pronounced growth of unwanted organisms. In spite of this, the results obtained by the medium containing lincomycin showed that the number of samples positive for gonococci was 7 per cent higher, and that the number of patients with gonococcal infections to be discovered was 4 per cent higher than the numbers obtained by the medium containing vancomycin. The results were considered highly favourable and, accordingly, by now our laboratory uses 1/2 mug lincomycin/ml medium in the routine isolation of gonococci.