Cost minimization analysis of the treatment of distal radial fractures in the elderly.

AIMS: The aim of this study was to test the null hypothesis that there is no difference, from the payer perspective, in the cost of treatment of a distal radial fracture in an elderly patient, aged > 65 years, between open reduction and internal fixation (ORIF) and closed reduction (CR). MATERIALS AND METHODS: Data relating to the treatment of these injuries in the elderly between January 2007 and December 2015 were extracted using the Humana and Medicare Advantage Databases. The primary outcome of interest was the cost associated with treatment. Secondary analysis included the cost of common complications. Statistical analysis was performed using a non-parametric t-test and chi-squared test. RESULTS: Our search yielded 8924 patients treated with ORIF and 5629 patients treated with CR. The mean cost of an uncomplicated ORIF was more than a CR ($7749 versus $2161). The mean additional cost of a complication in the ORIF group was greater than in the CR group ($1853 versus $1362). CONCLUSION: These findings show that there are greater payer fees associated with ORIF than CR in patients aged > 65 years with a distal radial fracture. CR may be a higher-value intervention in these patients. Cite this article: Bone Joint J 2018;100-B:205-11.

The critical care costs of the influenza A/H1N1 2009 pandemic in Australia and New Zealand.

The aim of this study was to determine the critical care and associated hospital costs for 2009 influenza A/H1N1 patients admitted to intensive care units (ICU) in Australia and New Zealand during the southern hemisphere winter All 762 patients admitted to ICUs in Australian and New Zealand between 1 June and 31 August 2009 with confirmed 2009 H1N1 influenza A were included. Costs were assigned based on ICU and hospital length-of-stay, using data from a single Australian ICU which estimated the daily cost of an ICU bed, along with published costs for a ward bed. Additional costs were assigned for allied health, overheads and extracorporeal membrane oxygenation services. The median (interquartile range) ICU and total hospital costs per patient were AU$35,942 ($10,269 to $82,152) and AU$51,294 ($22,849 to $110,340) respectively, while the mean (standard deviation) ICU and total hospital costs per patient were AU$63,298 ($78,722) and AU$85,395 ($147,457), respectively. A multivariate analysis found death was significantly associated with a reduction in the log of total costs, while the use of mechanical ventilation and ICU admission with viral pneumonitis/acute respiratory distress syndrome or secondary bacterial pneumonia were significantly associated with an increase in the log of total costs. The cost of 2009 H1N1 patients in ICU was significantly higher than the previously published costs for an average ICU admission, and the total cost of treating 2009 H1N1 patients in ICU admitted during winter 2009 was more than $65,000,000.

Effects of intermittent hydrostatic pressure and BMP-2 on osteoarthritic human chondrocyte metabolism in vitro.

PURPOSE: This study examined effects of intermittent hydrostatic pressure (IHP) and a chondrogenic growth factor, bone morphogenetic protein-2 (BMP-2), on anabolic, catabolic, and other metabolic markers in human osteoarthritic (OA) chondrocytes in vitro. METHODS: Articular chondrocytes, isolated from femoral OA cartilage and maintained in high-density monolayer culture, were examined for effects of BMP-2 and IHP on gene expression of matrix-associated proteins (aggrecan, type II collagen, and SOX9) and catabolic matrix metalloproteinases (MMP-2 and MMP-3) and culture medium levels of the metabolic markers MMP-2, nitric oxide (NO), and glycosaminoglycan (GAG). The results were analyzed using a mixed linear regression model to investigate the effects of load and growth factor concentration. RESULTS: IHP and BMP-2 modulated OA chondrocyte metabolism in accordance with growth factor concentration independently, without evidence of synergism or antagonism. Each type of stimulus acted independently on anabolic matrix gene expression. Type II collagen and SOX9 gene expression were stimulated by both IHP and BMP-2 whereas aggrecan was increased only by BMP-2. IHP exhibited a trend to decrease MMP-2 gene expression as a catabolic marker whereas BMP-2 did not. NO production was increased by addition of BMP-2 and IHP exhibited a trend for increased levels. GAG production was increased by BMP-2. CONCLUSIONS: This study confirmed the hypothesis that human OA chondrocytes respond to a specific type of mechanical load, IHP, through enhanced articular cartilage macromolecule gene expression and that IHP, in combination with a chondrogenic growth factor BMP-2, additively enhanced matrix gene expression without interactive effects.

Incidence of critical events in professional practice: a statewide survey of psychotherapy providers.

The goal was to tabulate the incidences of clients' suicide, attack by a client, and sexual contact with clients in an Alaskan sample of masters and doctoral-level psychotherapy providers (excluding psychiatrists) and to assess which, if any, demographic or professional characteristics were associated with each critical event. Results from 151 respondents (response rate 43.5%) indicated that 42.7% of providers had experienced at least one client's suicide, 28% had been physically attacked by a client, 4% reported having had sexual contact with a then current client, and 6% reported sexual contact with a former client. Areas for research are outlined, specifically the importance of using methods other than surveys and exploring variables other than standard demographic data.

Psychometric properties of the Life Regard Index-Revised: a validation study of a measure of personal meaning.

A validation study of the English version of the 28-item Life Regard Index-Revised was undertaken with a sample of 91 participants from the general population. All previous studies of the Index have examined the Dutch version. The test-retest reliabilities at 8 wk. for the total Index (r =.87), Framework (r =.82), and Fulfillment (r =.81) subscales were very high. Cronbach alphas were .92, .83, and .87, respectively. A significant restriction of range was observed at the high-meaning end of the scale. Factor analysis only weakly supported the theorized two-factor structure. A very high disattenuated correlation between the Framework and Fulfillment subscales was observed (r=.94). The Index appeared to have adequate evidence supporting its concurrent and discriminant validity when compared with measures of hopelessness, spiritual well-being, and other measures of personal meaning. A significant positive association was found between the index and the Marlowe-Crowne Social Desirability Scale (r=.38). The Index was also significantly associated with sex (women scoring higher) and marital status (divorced people scoring lower). Revisions of the English version may address the restriction of range problem by employing a 5-point rating scale, instead of the current 3-point scale, or by adding more discriminating items. Further factor-analytic studies with larger samples are needed before conclusions can be drawn regarding this scale's factor structure.

Spiritually and religiously oriented health interventions.

Controlled intervention studies offer considerable promise to better understand relationships and possible mechanisms between spiritual and religious factors and health. Studies examining spiritually augmented cognitive-behavioral therapies, forgiveness interventions, different meditation approaches, 12-step fellowships, and prayer have provided some evidence, albeit modest, of efficacy in improving health under specific conditions. Researchers need to describe spiritual and religious factors more clearly and precisely, as well as demonstrate that such factors independently influence treatment efficacy. Inclusion of potential moderating and mediating variables (e.g. extent of religious commitment, intrinsic religiousness, specific religious coping strategy) in intervention designs could help explain relationships and outcomes. Using a variety of research designs (e.g. randomized clinical trials, single-subject experimental designs) and assessment methods (e.g. daily self-monitoring, ambulatory physiological measures, in-depth structured interviews) would avoid current limitations of short-term studies using only questionnaires.

Menstrually related symptom changes in women with schizophrenia.

In this study, affective, somatic, behavioral and psychotic symptom ratings were collected daily in an attempt to evaluate the level and significance of menstrual cycle changes in a cohort of women with a DSM-III-R diagnosis of schizophrenia. Thirty-nine hospitalized women were examined longitudinally on the Brief Psychiatric Rating Scale and the retrospective and prospective versions of the Premenstrual Assessment Form. Results indicated that similar to normal and depressed women, the symptoms that were most exacerbated were affective and somatic in nature, rather than psychotic symptoms that are characteristic of schizophrenic symptomatology. In addition, the presence and exacerbation of the symptoms were not specific to the premenstrual phase. Some symptoms were reported menstrually and postmenstrually. Overall the findings did not confirm exacerbation of symptoms that are specific to schizophrenia. Rather, menstrually related changes seem to be a discrete phenomenon with its own symptom profile which may be superimposed on psychiatric disorders, both those with and without a predominant affective component. However, it should be noted that all subjects were on psychotropic medication that could have obscured fluctuations of psychotic symptoms. Further investigation and clearer guidelines are necessary for determining the ovulatory cycle and endocrine factors in this population before any conclusions can be made.

The methodology of cost-effectiveness analysis: avoiding common pitfalls.

Clinicians need to be familiar with the core methodology of cost-effectiveness economic analysis, as this information will increasingly be used in clinical decision-making. Just as in clinical trials, there are rules to be followed, and many pitfalls for the novice.

Indomethacin attenuation of radiation-induced hyperthermia does not modify radiation-induced motor hypoactivity.

Exposure of rats to 5-10 Gy of ionizing radiation produces hyperthermia and reduces motor activity. Previous studies suggested that radiation-induced hyperthermia results from a relatively direct action on the brain and is mediated by prostaglandins. To test the hypothesis that hypoactivity may be, in part, a thermoregulatory response to this elevation in body temperature, adult male rats were given indomethacin (0.0, 0.5, 1.0, and 3.0 mg/kg, intraperitoneally), a blocker of prostaglandin synthesis, and were either irradiated (LINAC 18.6 MeV (nominal) high-energy electrons, 10 Gy at 10 Gy/min, 2.8 microseconds pulses at 2 Hz) or sham-irradiated. The locomotor activity of all rats was then measured for 30 min in a photocell monitor for distance traveled and number of vertical movements. Rectal temperatures of irradiated rats administered vehicle only were elevated by 0.9 +/- 0.2 degree C at the beginning and the end of the activity session. Although indomethacin, at the two higher doses tested, attenuated the hyperthermia in irradiated rats by 52-75%, it did not attenuate radiation-induced reductions in motor activity. These results indicate that motor hypoactivity after exposure to 10 Gy of high-energy electrons is not due to elevated body temperature or to the increased synthesis of prostaglandins.

Home care for venous leg ulcers.

More than a quarter of the adult population in the United States is afflicted with lower extremity venous insufficiency, and 1 in 100 have had, or now have, stasis ulcers. Most of these patients will be treated on an outpatient basis, with many of them requiring home health care. The cost to treat venous ulcers alone has been estimated at $750 million to $1 billion a year. Understanding the pathogenesis and treatment of the problem is imperative as home health care nurses move into an era of cost containment and demographic shift toward an increasingly larger elderly population.

Cost effectiveness of day stay versus inpatient radiofrequency (RF) ablation for the treatment of supraventricular tachyarrhythmias.

BACKGROUND: It is well established that radiofrequency (RF) ablation is the most cost effective treatment strategy for patients with supraventricular tachycardia. Previous cost estimates assumed at least an overnight stay following RF ablation. Day stay RF ablation however appears to be a safe alternative. AIMS: The aim of this study was to compare day stay and inpatient catheter ablation in terms of cost, efficacy and safety. METHODS: This was a retrospective cost effectiveness analysis. The study population consisted of 25 consecutive patients who underwent day stay RF ablation and 25 consecutive patients who underwent inpatient RF ablation (historical controls). Economic analysis was based upon a detailed clinical costing. RESULTS: The mean overall cost per patient of inpatient RF ablation in 1994 Australian dollar values is $2354 (SD, $642) compared with $1876 (SD, $595) for day stay RF ablation (p < 0.01). Day stay RF ablation is a cost effective alternative to inpatient RF ablation.

Possible involvement of prostaglandins in increases in rat plasma adrenocorticotropic hormone and corticosterone levels induced by radiation and interleukin-1 alpha alone or combined.

Exposing rats to 1-10 Gy of ionizing radiation increased plasma adrenocorticotropic hormone (ACTH) and corticosterone (CORT) levels. In both irradiated and nonirradiated rats, recombinant human interleukin-1 alpha (rhIL-1 alpha; 1 hr before radiation/sham exposure) enhanced plasma ACTH and CORT levels. Indomethacin, a cyclooxygenase inhibitor, attenuated plasma ACTH and CORT levels induced by radiation. Indomethacin also attenuated ACTH and CORT levels induced by radiation and interleukin-1 alpha alone or combined. These results suggest that prostaglandins are involved in the increase in plasma ACTH and CORT levels induced by radiation and rhIL-1 alpha alone or combined.

Hospital inpatient costs resulting from road crashes in Western Australia.

The purpose of this study was to estimate the inpatient costs of road crashes in Western Australia, and to investigate factors relating to casualties and their injuries that affect the hospital costs resulting from road crashes. All road crash casualties who were injured severely enough to be hospitalised in Western Australia in 1988 were included. A casemix classification system was used to classify patients into diagnostic related groups. Hospital costs were assigned to individual patients on the basis of their diagnostic related group and length of hospital stay. The annual cost of hospital treatment for road crash casualties was estimated as $13.9 million, and 33 per cent of this was incurred by those with lower extremity injuries and 27 per cent by those with head injuries. Hospital costs per casualty ranged from an average of $1388 for those sustaining minor (Abbreviated Injury Scale severity score of 1 or 2) spinal injuries to $16,580 and $33,424, respectively, for those sustaining severe (Abbreviated Injury Scale severity score of 4 or 5) head and spinal injuries. A multivariate analysis of variance revealed the following factors as having a significant independent effect on the hospital inpatient costs of road crash casualties: type of hospital (teaching or nonteaching), body region of injury, injury severity level and road user group. There were also significant interaction effects between different factors. Since hospital inpatient costs vary considerably across factors, using average cost data in the specific economic evaluation of road safety interventions for groups of road users is inappropriate.

Behavioral endpoints for radiation injury.

The relative behavioral effectiveness of heavy particles was evaluated. Using the taste aversion paradigm in rats, the behavioral toxicity of most types of radiation (including 20Ne and 40Ar) was similar to that of 60Co photons. Only 56Fe and 93Nb particles and fission neutrons were significantly more effective. Using emesis in ferrets as the behavioral endpoint, 56Fe particles and neutrons were again the most effective; however, 60Co photons were significantly more effective than 18 MeV electrons. These results suggest that LET does not completely predict behavioral effectiveness. Additionally, exposing rats to 10 cGy of 56Fe particles attenuated amphetamine-induced taste aversion learning. This behavior is one of a broad class of behaviors which depends on the integrity of the dopaminergic system and suggests the possibility of alterations in these behaviors following exposure to heavy particles in a space radiation environment.

Exposure to heavy charged particles affects thermoregulation in rats.

Rats exposed to 0.1-5 Gy of heavy particles (56Fe, 40Ar, 20Ne or 4He) showed dose-dependent changes in body temperature. Lower doses of all particles produced hyperthermia, and higher doses of 20Ne and 56Fe produced hypothermia. Of the four HZE particles, 56Fe particles were the most potent and 4He particles were the least potent in producing changes in thermoregulation. The 20Ne and 40Ar particles produced an intermediate level of change in body temperature. Significantly greater hyperthermia was produced by exposure to 1 Gy of 20Ne, 40Ar and 56Fe particles than by exposure to 1 Gy of 60Co gamma rays. Pretreating rats with the cyclo-oxygenase inhibitor indomethacin attenuated the hyperthermia produced by exposure to 1 Gy of 56Fe particles, indicating that prostaglandins mediate 56Fe-particle-induced hyperthermia. The hypothermia produced by exposure to 5 Gy of 56Fe particles is mediated by histamine and can be attenuated by treatment with the antihistamines mepyramine and cimetidine.

The cost-effectiveness of treatment of supraventricular arrhythmias related to an accessory atrioventricular pathway: comparison of catheter ablation, surgical division and medical treatment.

BACKGROUND: Treatment alternatives for patients with incapacitating supraventricular arrhythmias related to an accessory atrioventricular pathway include transcatheter radiofrequency (RF) ablation, surgical division and long-term antiarrhythmic therapy (medical). AIM: The aim of this study was to compare in terms of cost and efficacy, transcatheter, surgical and medical treatment of patients with incapacitating supraventricular arrhythmias resulting from an accessory pathway. METHODS: The study population consisted of 52 patients who underwent transcatheter RF ablation (20 consecutive patients), surgical treatment (20) and medical treatment (12). Two types of economic analysis were used. In all groups, a resource based costing method was used and in the medical and surgical treatment groups, a diagnostic related group (DRG) based costing method was used. RESULTS: Eighteen out of 20 (90%) patients who underwent catheter ablation remained asymptomatic during 8.4 +/- 1.6 months of follow-up. All surgically treated patients remained asymptomatic during 54 +/- 15 months of follow-up. Only one of the 12 patients in the medical treatment group remained completely free of symptoms during the mean 58 +/- 23 month follow-up period. The mean cost (1992 Australian dollars) per patient, calculated on the basis of actual resources used (with a DRG based costing given in brackets), was $2746 +/- $800 for catheter ablation, $12141 +/- $4465 ($12880 +/- $3998) for surgical treatment and $1713 +/- $748 ($1967 +/- $33) for medical treatment. The total cost of management over 20 years is estimated to be: $2911 for catheter ablation, $17467 for surgery and $4959 for medical treatment. CONCLUSIONS: In the long term transcatheter RF ablation is the most cost-effective treatment strategy for patients with incapacitating supraventricular arrhythmias related to an accessory pathway.

Deficits in the sensitivity of striatal muscarinic receptors induced by 56Fe heavy-particle irradiation: further "age-radiation" parallels.

We had previously shown that there was a loss of sensitivity of muscarinic receptors (mAChR) to stimulation by cholinergic agonists (as assessed by examining oxotremorine enhancement of K(+)-evoked release of dopamine from neostriatal slices) in animals that had been exposed to energetic particles (56Fe, 600 MeV/n), an important component of cosmic rays. This loss of mAChR sensitivity was postulated to be the result of radiation-induced alterations in phosphoinositide-mediated signal transduction. The present experiments were undertaken as a first step toward determining the locus of these radiation-induced deficits in signal transduction by examining K+ enhancement of release of dopamine in 56Fe-exposed animals (0, 0.1, and 1.0 Gy) with agents [A23187, a potent Ca2+ ionophore, or 1,4,5-inositol trisphosphate (IP3)] that "bypass" the mAChR-G protein interface and by comparing the response to oxotremorine-enhanced K(+)-evoked release of dopamine. Results showed that although oxotremorine-enhanced K(+)-evoked release of dopamine was reduced significantly in the radiation groups, no radiation effects were seen when A23187 or IP3 was used to enhance K(+)-evoked release of dopamine. Since similar findings have been observed in aging, the results are discussed in terms of the parallels between aging and radiation effects in signal transduction that might exist in the neostriatum.