Assessment of resource use and costs associated with parathyroidectomy for secondary hyperparathyroidism in end stage renal disease in the UK.

INTRODUCTION: Secondary hyperparathyroidism (SHPT) is a major complication of end stage renal disease (ESRD). For the National Health Service (NHS) to make appropriate choices between medical and surgical management, it needs to understand the cost implications of each. A recent pilot study suggested that the current NHS healthcare resource group tariff for parathyroidectomy (PTX) (£2071 and £1859 in patients with and without complications, respectively) is not representative of the true costs of surgery in patients with SHPT. OBJECTIVE: This study aims to provide an estimate of healthcare resources used to manage patients and estimate the cost of PTX in a UK tertiary care centre. METHODS: Resource use was identified by combining data from the Proton renal database and routine hospital data for adults undergoing PTX for SHPT at the University Hospital of Wales, Cardiff, from 2000-2008. Data were supplemented by a questionnaire, completed by clinicians in six centres across the UK. Costs were obtained from NHS reference costs, British National Formulary and published literature. Costs were applied for the pre-surgical, surgical, peri-surgical, and post-surgical periods so as to calculate the total cost associated with PTX. RESULTS: One hundred and twenty-four patients (mean age=51.0 years) were identified in the database and 79 from the questionnaires. The main costs identified in the database were the surgical stay (mean=£4066, SD=£,130), the first month post-discharge (£465, SD=£176), and 3 months prior to surgery (£399, SD=£188); the average total cost was £4932 (SD=£4129). From the questionnaires the total cost was £5459 (SD=£943). It is possible that the study was limited due to missing data within the database, as well as the possibility of recall bias associated with the clinicians completing the questionnaires. CONCLUSION: This analysis suggests that the costs associated with PTX in SHPT exceed the current NHS tariffs for PTX. The cost implications associated with PTX need to be considered in the context of clinical assessment and decision-making, but healthcare policy and planning may warrant review in the light of these results.

Role of insulin resistance indices in predicting new-onset diabetes after kidney transplantation.

New-onset diabetes mellitus (NODAT) is a serious complication following renal transplantation. In this cohort study, we studied 118 nondiabetic renal transplant recipients to examine whether indices of insulin resistance and secretion calculated before transplantation and at 3 months post-transplantation are associated with the development of NODAT within 1 year. We also analysed the long-term impact of early diagnosed NODAT. Insulin indices were calculated using homeostasis model assessment (HOMA) and McAuley's Index. NODAT was diagnosed using fasting plasma glucose. Median follow-up was 11 years. The cumulative incidence of NODAT at 1 year was 37%. By logistic regression, recipient age (per year) was the only significant pretransplant predictor of NODAT (OR 1.04, CI 1.009-1.072), while age (OR 1.04, CI 1.005-1.084) and impaired fasting glucose (OR 2.97, CI 1.009-8.733) were significant predictors at 3 months. Pretransplant and 3-month insulin resistance and secretion indices did not predict NODAT. All-cause mortality was significantly higher in recipients developing NODAT within 1 year compared with those remaining nondiabetic (44% vs. 22%, log-rank P = 0.008). By Cox's regression analysis, age (HR 1.075, CI 1.042-1.110), 1-year creatinine (HR 1.007, CI 1.004-1.010) and NODAT within 3 months (HR 2.4, CI 1.2-4.9) were independent predictors of death. In conclusion, NODAT developing early after renal transplantation was associated with poor long-term patient survival. Insulin indices calculated pretransplantation using HOMA and McAuley's Index did not predict NODAT.

Characterizing the relationship between health utility and renal function after kidney transplantation in UK and US: a cross-sectional study.

BACKGROUND: Chronic allograft nephropathy (CAN) occurs in a large share of transplant recipients and it is the leading cause of graft loss despite the introduction of new and effective immunosuppressants. The reduction in renal function secondary to immunologic and non-immunologic CAN leads to several complications, including anemia and calcium-phosphorus metabolism imbalance and may be associated to worsening Health-Related Quality of Life. We sought to evaluate the relationship between kidney function and Euro-Qol 5 Dimension Index (EQ-5Dindex) scores after kidney transplantation and evaluate whether cross-cultural differences exist between UK and US. METHODS: This study is a secondary analysis of existing data gathered from two cross-sectional studies. We enrolled 233 and 209 subjects aged 18-74 years who received a kidney transplant in US and UK respectively. For the present analysis we excluded recipients with multiple or multi-organ transplantation, creatinine kinase ≥200 U/L, acute renal failure, and without creatinine assessments in 3 months pre-enrollment leaving 281 subjects overall. The questionnaires were administered independently in the two centers. Both packets included the EQ-5Dindex and socio-demographic items. We augmented the analytical dataset with information abstracted from clinical charts and administrative records including selected comorbidities and biochemistry test results. We used ordinary least squares and quantile regression adjusted for socio-demographic and clinical characteristics to assess the association between EQ-5Dindex and severity of chronic kidney disease (CKD). RESULTS: CKD severity was negatively associated with EQ-5Dindex in both samples (UK: ρ= -0.20, p=0.02; US: ρ= -0.21, p=0.02). The mean adjusted disutility associated to CKD stage 5 compared to CKD stage 1-2 was Δ= -0.38 in the UK sample, Δ= -0.11 in the US sample and Δ= -0.22 in the whole sample. The adjusted median disutility associated to CKD stage 5 compared to CKD stage 1-2 for the whole sample was 0.18 (p<0.01, quantile regression). Center effect was not statistically significant. CONCLUSIONS: Impaired renal function is associated with reduced health-related quality of life independent of possible confounders, center-effect and analytic framework.

How efficient can an emergency unit be? A perfect world model.

Various approaches have been used to identify possible routes for improvement of patient flow within an emergency unit (EU). One such approach is to use simulation to create a 'real world' model of an EU and carry out various tests to gauge ways of improvement. This paper proposes a novel approach in which simulation is used to create a 'perfect world model'. The EU at a major UK hospital is modelled not as it is, but as it could be. The 'efficiency gap' between the 'perfect world' and the 'real world' demonstrates how operational research can be used effectively to identify the location of bottlenecks in the current 'whole hospital' patient pathway and can be used in the planning and managing of hospital resources to ensure the most effective use of those resources.

The burden of new-onset diabetes mellitus after transplantation.

The clinical impact of new-onset diabetes mellitus (NODM) is frequently underestimated by clinicians. NODM occurs in approximately 15-20% of renal transplant patients and 15% of liver transplant recipients. Diabetes after transplantation is a leading risk factor for cardiovascular events, with a higher prognostic value than in the non-transplant population. NODM also appears to have a negative influence on graft function, and graft survival rates after renal transplantation are significantly lower in patients who develop diabetes than in controls. Patient mortality following renal transplantation is generally found to be higher in patients with NODM, due to increased cardiovascular and peripheral vascular disease, accelerated graft deterioration and diabetes-related complications, notably infection. A renal registry analysis has reported an increase of 87% in risk of death following onset of NODM. There is also limited evidence that NODM is associated with increased risk of death in liver transplant patients. The relative incidence and severity of diabetic complications in transplant recipients have not been assessed rigorously in a clinical trial but registry data indicate that 20% of renal transplant patients with NODM experience at least one clinically significant diabetic complication within three years. Financially, the additional healthcare costs incurred over the first two years following onset of NODM amount to 21,500 dollars. Routine pre-transplant assessment of diabetic risk, with requisite modification of lifestyle, glycaemic monitoring and immunosuppressive regimens, and coupled with standardized, aggressive hypoglycaemic management as necessary, offers an important opportunity to alleviate the burden of NODM for transplant patients.