Harnessing the potential of data-driven strategies to optimise transfusion practice.

No one doubts the significant variation in the practice of transfusion medicine. Common examples are the variability in transfusion thresholds and the use of tranexamic acid for surgery with likely high blood loss despite evidence-based standards. There is a long history of applying different strategies to address this variation, including education, clinical guidelines, audit and feedback, but the effectiveness and cost-effectiveness of these initiatives remains unclear. Advances in computerised decision support systems and the application of novel electronic capabilities offer alternative approaches to improving transfusion practice. In England, the National Institute for Health and Care Research funded a Blood and Transplant Research Unit (BTRU) programme focussing on 'A data-enabled programme of research to improve transfusion practices'. The overarching aim of the BTRU is to accelerate the development of data-driven methods to optimise the use of blood and transfusion alternatives, and to integrate them within routine practice to improve patient outcomes. One particular area of focus is implementation science to address variation in practice.

Carrier-Envelope Phase-Dependent Strong-Field Excitation.

We present a joint experimental-theoretical study on the effect of the carrier-envelope phase (CEP) of a few-cycle pulse on the atomic excitation process. We focus on the excitation rates of argon at intensities in the transition between the multiphoton and tunneling regimes. Through numerical simulations, we show that the resulting bound-state population is highly sensitive to both the intensity and the CEP. The experimental data clearly agree with the theoretical prediction, and the results encourage the use of precisely tailored laser fields to coherently control the strong-field excitation process. We find a markedly different behavior for the CEP-dependent bound-state population at low and high intensities with a clear boundary, which we attribute to the transition from the multiphoton to the tunneling regime.

Burden of osteoarthritis in India and its states, 1990-2019: findings from the Global Burden of disease study 2019.

OBJECTIVE: To describe the burden of osteoarthritis (OA) in India from 1990 to 2019. DESIGN: Data from Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 were used. The burden of OA -knee OA, hip OA, hand OA, and other OA- was estimated for India and its states from 1990 to 2019 through a systematic analysis of prevalence, incidence, years lived with disability (YLD), and disability-adjusted life years (DALY) using methods reported in GBD 2019 study. RESULT: Around 23.46 million individuals in India had OA in 1990; this increased to 62.35 million in 2019. The age-standardised prevalence of OA increased from 4,895 (95% uncertainty interval (UI):4,420-5,447) in 1990-5313 (95%UI:4,799-5,898) in 2019, per 100,000 persons. Similarly, DALYs due to OA increased from 0.79 million (95%UI:0.40-1.55) to 2.12 million (95%UI:1.07-4.23); while age-standardised DALYs increased from 164 (95%UI:83-325) to 180 (95%UI:91-361) per 100,000 persons from 1990 to 2019. OA was the 20th most common cause of YLDs in India in 2019, accounting for 1.48% (95%UI:0.88-2.78) of all YLDs; increasing from 23rd most common cause in 1990 (1.25%(95%UI:0.74-2.34)). Knee OA was the most common form of OA, followed by hand OA. The prevalence, incidence, and DALYs for OA and knee OA were consistently higher in females than males. CONCLUSION: The burden and impact of OA in India are substantial and is increasing. Adopting suitable control and preventive community measures to reduce modifiable risk factors (obesity, injuries, occupational stress) are needed to reduce the current and future burden of OA in India.

Long-term cost-effectiveness of Dexcom G6 real-time continuous glucose monitoring system in people with type 1 diabetes in Australia.

INTRODUCTION: Real-time continuous glucose monitoring (rt-CGM) allows patients with diabetes to adjust insulin dosing, potentially improving glucose control. This study aimed to compare the long-term cost-effectiveness of the Dexcom G6 rt-CGM device versus self-monitoring of blood glucose (SMBG) and flash glucose monitoring (FGM) in Australia in people with type 1 diabetes (T1D). METHODS: Long-term costs and clinical outcomes were estimated using the CORE Diabetes Model. Clinical input data for the analysis of rt-CGM versus SMBG and FGM were sourced from the DIAMOND study and a network meta-analysis, respectively. Rt-CGM and FGM were associated with quality of life (QoL) benefits due to reduced fear of hypoglycaemia (FoH) and fingerstick testing. Analyses were performed over a lifetime time horizon from an Australian healthcare payer perspective, including direct costs from published data. Future costs and clinical outcomes were discounted at 5% per annum. RESULTS: Rt-CGM was associated with an increased quality-adjusted life expectancy of 1.199 quality-adjusted life years (QALYs), increased mean total lifetime costs of AUD 21,596 and an incremental cost-effectiveness ratio (ICER) of AUD 18,020 per QALY gained compared with SMBG. Compared with FGM, rt-CGM was associated with an increased quality-adjusted life expectancy of 0.569 QALYs, increased mean total lifetime costs of AUD 11,064 and an ICER of AUD 19,455 per QALY gained. Key drivers of outcomes included HbA1c benefits and QoL benefits associated with reduced FoH and fingerstick testing. CONCLUSIONS: Due to improved clinical outcomes and QoL gains rt-CGM is highly cost-effective compared with SMBG and FGM in people with T1D in Australia.

Development and validation of the risk engine for an Australian Health Economics Model of Osteoporosis.

The Australian Health Economics Model of Osteoporosis (AusHEMO) has shown good face, internal and cross validities, and can be used to assist healthcare decision-making in Australia. PURPOSE: This study aimed to document and validate the risk engine of the Australian Health Economics Model of Osteoporosis (AusHEMO). METHODS: AusHEMO is a state-transition microsimulation model. The fracture risks were simulated using fracture incidence rates from the Dubbo Osteoporosis Epidemiology Study. The AusHEMO was validated regarding its face, internal and cross validities. Goodness-of-fit analysis was conducted and Lin's coefficient of agreement and mean absolute difference with 95% limits of agreement were reported. RESULTS: The development of AusHEMO followed general and osteoporosis-specific health economics guidelines. AusHEMO showed good face validity regarding the model's structure, evidence, problem formulation and results. In addition, the model has been proven good internal and cross validities in goodness-of-fit test. Lin's coefficient was 0.99, 1 and 0.94 for validation against the fracture incidence rates, Australian life expectancies and residual lifetime fracture risks, respectively. CONCLUSIONS: In summary, the development of the risk engine of AusHEMO followed the best practice for osteoporosis disease modelling and the model has been shown to have good face, internal and cross validities. The AusHEMO can be confidently used to predict long-term fracture-related outcomes and health economic evaluations when costs data are included. Health policy-makers in Australia can use the AusHEMO to select which osteoporosis interventions such as medications and public health interventions represent good value for money.

trips4health: Protocol of a single-blinded randomised controlled trial incentivising adults to use public transport for physical activity gain.

BACKGROUND: Public transport (PT) users typically accumulate more physical activity (PA) than private motor vehicle users yet redressing physical inactivity through transport-related PA (TRPA) interventions has received limited attention. Further, incentive-based strategies can increase leisure-time PA but their impact on TRPA, is unclear. This study's objective is to determine the impact of an incentive-based strategy on TRPA in a regional Australian setting. METHODS: trips4health is a single-blinded randomised controlled trial with a four-month intervention phase and subsequent six-month maintenance phase. Participants will be randomised to: an incentives-based intervention (bus trip credit for reaching bus trip targets, weekly text messages to support greater bus use, written PA guidelines); or an active control (written PA guidelines only). Three hundred and fifty adults (≥18 years) from southern Tasmania will be recruited through convenience methods, provide informed consent and baseline information, then be randomised. The primary outcome is change in accelerometer measured average daily step count at baseline and four- and ten-months later. Secondary outcomes are changes in: measured and self-reported travel behaviour (e.g. PT use), PA, sedentary behaviour; self-reported and measured (blood pressure, waist circumference, height, weight) health; travel behaviour perspectives (e.g. enablers/barriers); quality of life; and transport-related costs. Linear mixed model regression will determine group differences. Participant and PT provider level process evaluations will be conducted and intervention costs to the provider determined. DISCUSSION: trips4health will determine the effectiveness of an incentive-based strategy to increase TRPA by targeting PT use. The findings will enable evidence-informed decisions about the worthwhileness of such strategies. TRIAL REGISTRATION: ACTRN12619001136190. UNIVERSAL TRIAL NUMBER: U1111-1233-8050.

Peri-operative administration of tranexamic acid in lower limb arthroplasty: a multicentre, prospective cohort study.

In the UK, tranexamic acid is recommended for all surgical procedures where expected blood loss exceeds 500 ml. However, the optimal dose, route and timing of administration are not known. This study aimed to evaluate current practice of peri-operative tranexamic acid administration. Patients undergoing primary total hip arthroplasty, total knee arthroplasty or unicompartmental knee arthroplasty during a 2-week period were eligible for inclusion in this prospective study. The primary outcome was the proportion of patients receiving tranexamic acid in the peri-operative period. Secondary outcomes included: dose, route and timing of tranexamic acid administration; prevalence of pre- and postoperative anaemia; estimated blood loss; and red blood cell transfusion rates. In total, we recruited 1701 patients from 56 NHS hospitals. Out of these, 1523 (89.5%) patients received tranexamic acid and of those, 1052 (69.1%) received a single dose of 1000 mg intravenously either pre- or intra-operatively. Out of the 1701 patients, 571 (33.6%) and 1386 (81.5%) patients were anaemic (haemoglobin < 130 g.l-1 ) in the pre- and postoperative period, respectively. Mean (SD) estimated blood loss for all included patients was 792 (453) ml and 54 patients (3.1%) received a red blood cell transfusion postoperatively. The transfusion rate for patients with pre-operative anaemia was 6.5%, compared with 1.5% in patients without anaemia. Current standard of care in the UK is to administer 1000 mg of tranexamic intravenously either pre- or intra-operatively. Approximately one-third of patients present for surgery with anaemia, although the overall red blood cell transfusion rate is low. These data provide useful comparators when assessing the efficacy of tranexamic acid and other patient blood management interventions in future studies.

The role of intra-operative cell salvage in patient blood management for revision hip arthroplasty: a prospective cohort study.

Cell salvage is an important component of blood management in patients undergoing revision hip arthroplasty surgery. However concerns regarding efficacy and patient selection remain. The aims of this study were to describe intra-operative blood loss, cell salvage re-infusion volumes and red blood cell transfusion rates for revision hip procedures and to identify factors associated with the ability to salvage sufficient blood intra-operatively to permit processing and re-infusion. Data were collected from a prospective cohort of 664 consecutive patients undergoing revision hip surgery at a single tertiary centre from 31 March 2015 to 1 April 2018. Indications for revision surgery were aseptic (n = 393 (59%)) fracture (n = 160 (24%)) and infection (n = 111 (17%)). Salvaged blood was processed and re-infused when blood loss exceeded 500 ml. Mean (SD) intra-operative blood loss was 1038 (778) ml across all procedures. Salvaged blood was re-infused in 505 of 664 (76%) patients. Mean (SD) re-infusion volume was 253 (169) ml. In total, 246 of 664 (37%) patients received an allogeneic red blood cell transfusion within 72 h of surgery. Patients undergoing femoral component revision only (OR (95%CI) 0.41 (0.23-0.73)) or acetabular component revision only (0.53 (0.32-0.87)) were less likely to generate sufficient blood salvage volume for re-infusion compared with revision of both components. Compared with aseptic indications, patients undergoing revision surgery for infection (1.87 (1.04-3.36)) or fracture (4.43 (2.30-8.55)) were more likely to generate sufficient blood salvage volume for re-infusion. Our data suggest that cell salvage is efficacious in this population. Cases where the indication is infection or fracture and where both femoral and acetabular components are to be revised should be prioritised.

Strategies to minimize intraoperative blood loss during major surgery.

BACKGROUND: Reducing operative blood loss improves patient outcomes and reduces healthcare costs. The aim of this article was to review current surgical, anaesthetic and haemostatic intraoperative blood conservation strategies. METHODS: This narrative review was based on a literature search of relevant databases up to 31 July 2019 for publications relevant to reducing blood loss in the surgical patient. RESULTS: Interventions can begin early in the preoperative phase through identification of patients at high risk of bleeding. Directly acting anticoagulants can be stopped 48 h before most surgery in the presence of normal renal function. Aspirin can be continued for most procedures. Intraoperative cell salvage is recommended when anticipated blood loss is greater than 500 ml and this can be continued after surgery in certain situations. Tranexamic acid is safe, cheap and effective, and routine administration is recommended when anticipated blood loss is high. However, the optimal dose, timing and route of administration remain unclear. The use of topical agents, tourniquet and drains remains at the discretion of the surgeon. Anaesthetic techniques include correct patient positioning, avoidance of hypothermia and regional anaesthesia. Permissive hypotension may be beneficial in selected patients. Promising haemostatic strategies include use of pharmacological agents such as desmopressin, prothrombin complex concentrate and fibrinogen concentrate, and use of viscoelastic haemostatic assays. CONCLUSION: Reducing perioperative blood loss requires a multimodal and multidisciplinary approach. Although high-quality evidence exists in certain areas, the overall evidence base for reducing intraoperative blood loss remains limited.

ANTECEDENTES: La reducción de la pérdida hemática operatoria mejora los resultados y reduce los costes sanitarios. El objetivo de este artículo es revisar las estrategias actuales intraoperatorias quirúrgicas, anestésicas y hemostáticas de ahorro de sangre. MÉTODOS: Revisión descriptiva basada en publicaciones destacadas que analizaban la forma de reducir la pérdida de sangre en el paciente quirúrgico, seleccionadas a partir de una búsqueda bibliográfica en bases de datos relevantes hasta el 31 de julio de 2019. RESULTADOS: Las intervenciones se pueden iniciar precozmente en el período preoperatorio a través de la identificación de pacientes con elevado riesgo de hemorragia. Se pueden suspender los anticoagulantes de acción directa 48 horas antes de la mayoría de las operaciones quirúrgicas si la función renal es normal. Se puede continuar la administración de aspirina en la mayoría de las intervenciones. En el período intraoperatorio, se recomienda el uso de rescate celular cuando la pérdida de sangre prevista es superior a 500 ml y este método se puede continuar después de la operación en determinadas situaciones. La administración de ácido tranexámico es segura, barata y eficaz y se recomienda de forma rutinaria cuando la pérdida hemática prevista es alta. Sin embargo, la dosis óptima, el momento y la vía de administración no están bien establecidos. El uso de agentes tópicos, torniquetes y drenajes queda a discreción del cirujano. Las técnicas anestésicas incluyen la correcta posición del paciente, así como evitar la hipotermia y la anestesia regional. La hipotensión controlada puede ser beneficiosa en casos seleccionados. Las estrategias hemostáticas innovadoras incluyen agentes farmacológicos como la desmopresina, los concentrados del complejo de protrombina y concentrados de fibrinógeno, y el uso de hemostáticos viscoelásticos, pero se requiere disponer de evidencia sobre su beneficio. CONCLUSIÓN: La reducción de la pérdida hemática perioperatoria requiere un enfoque multimodal y multidisciplinario. Aunque existe evidencia de alta calidad en ciertas áreas, la evidencia general para reducir la pérdida hemática intraoperatoria sigue siendo limitada.

Primary stability of a short bone-conserving femoral stem: a two-year randomized controlled trial using radiostereometric analysis.

Aims: The aim of this study was to determine the stability of a new short femoral stem compared with a conventional femoral stem in patients undergoing cementless total hip arthroplasty (THA), in a prospective randomized controlled trial using radiostereometric analysis (RSA). Patients and Methods: A total of 53 patients were randomized to receive cementless THA with either a short femoral stem (MiniHip, 26 patients, mean age: 52 years, nine male) or a conventional length femoral stem (MetaFix, 23 patients, mean age: 53 years, 11 male). All patients received the same cementless acetabular component. Two-year follow-up was available on 38 patients. Stability was assessed through migration and dynamically inducible micromotion. Radiographs for RSA were taken postoperatively and at three, six, 12, 18, and 24 months. Results: At two years, there was significantly less subsidence (inferior migration) of the short femoral stem (head, 0.26 mm, 95% confidence interval (CI) 0.08 to 0.43, sd 0.38; tip, 0.11 mm, 95% CI -0.08 to 0.31, sd 0.42) compared with the conventional stem (head, 0.62 mm, 95% CI 0.34 to 0.90, sd 0.56, p = 0.02; tip, 0.43 mm, 95% CI 0.21 to 0.65, sd 0.44, p = 0.03). There was no significant difference in dynamically inducible micromotion, rate of complications or functional outcome. Conclusion: This study demonstrates that the short femoral stem has a stable and predictable migration. However, longer-term survival analysis still needs to be determined. Cite this article: Bone Joint J 2018;100-B:1148-56.

The support needs of patients waiting for publicly funded bariatric surgery - implications for health service planners.

The objective of this study was to investigate the experience of waiting for publicly funded bariatric surgery in an Australian tertiary healthcare setting. Focus groups and individual interviews involving people waiting for or who had undergone publicly funded bariatric surgery were audio-recorded, transcribed and analysed thematically. A total of 11 women and 6 men engaged in one of six focus groups in 2014, and an additional 10 women and 9 men were interviewed in 2015. Mean age was 53 years (range 23-66); mean waiting time was 6 years (range 0-12), and mean time since surgery was 4 years (range 0-11). Waiting was commonly reported as emotionally challenging (e.g. frustrating, depressing, stressful) and often associated with weight gain (despite weight-loss attempts) and deteriorating physical health (e.g. development of new or worsening obesity-related comorbidity or decline in mobility) or psychological health (e.g. development of or worsening depression). Peer support, health and mental health counselling, integrated care and better communication about waitlist position and management (e.g. patient prioritization) were identified support needs. Even if wait times cannot be reduced, better peer and health professional supports, together with better communication from health departments, may improve the experience or outcomes of waiting and confer quality-of-life gains irrespective of weight loss.

Past and projected temporal trends in arthroscopic hip surgery in England between 2002 and 2013.

INTRODUCTION: Hip arthroscopy is increasingly adopted for the treatment of intra-articular and extra-articular pathologies. Studies from USA demonstrate a 365% increase in the number of procedures performed between 2004 and 2009 and 250% increase between 2007 and 2011. There is limited evidence of long-term efficacy for this procedure and hip arthroscopy is not universally funded across England. The aim of this study is to describe temporal trends in the adoption of hip arthroscopy in England between 2002 and 2013 and to forecast trends for the next 10 years. METHODS: A search of the Hospital Episodes Database was performed for all codes describing arthroscopic hip procedures with patient age, sex and area of residence. RESULTS: 11 329 hip arthroscopies were performed in National Health Service hospitals in England between 2002 and 2013. The number of hip arthroscopies performed increased by 727% (p<0.0001) during this period and is forecast to increase by 1388% in 2023. Females represent 60% of all patients undergoing hip arthroscopy (p<0.001). Median age category is 40-44 for females and 35-39 for males and average age decreased during the study period (p<0.0001). There is significant regional variation in procedure incidence. In the final year of this study the highest incidence was in the Southwest (8.63/100 000 population) and lowest in East Midlands (1.29/100 000 population). CONCLUSIONS: The increase in number of hip arthroscopies performed in England reflects trends in USA and continued increases are forecast. Evidence from robust clinical trials is required to justify the increasing number of procedures performed and regional variation suggests potential inequality in the provision of this intervention.

The interaction of excited atoms and few-cycle laser pulses.

This work describes the first observations of the ionisation of neon in a metastable atomic state utilising a strong-field, few-cycle light pulse. We compare the observations to theoretical predictions based on the Ammosov-Delone-Krainov (ADK) theory and a solution to the time-dependent Schrödinger equation (TDSE). The TDSE provides better agreement with the experimental data than the ADK theory. We optically pump the target atomic species and measure the ionisation rate as the a function of different steady-state populations in the fine structure of the target state which shows significant ionisation rate dependence on populations of spin-polarised states. The physical mechanism for this effect is unknown.

Diverse approaches to the health economic evaluation of bariatric surgery: a comprehensive systematic review.

BACKGROUND: Health economic evaluations inform healthcare resource allocation decisions for treatment options for obesity including bariatric/metabolic surgery. As an important advance on existing systematic reviews, we aimed to capture, summarize and synthesize a diverse range of economic evaluations on bariatric surgery. METHODS: Studies were identified by electronic screening of all major biomedical/economic databases. Studies included if they reported any quantified health economic cost and/or consequence with a measure of effect for any type of bariatric surgery from 1995 to September 2015. Study screening, data extraction and synthesis followed international guidelines for systematic reviews. RESULTS: Six thousand one hundred eighty-seven studies were initially identified. After two levels of screening, 77 studies representing 17 countries (56% USA) were included. Despite study heterogeneity, common themes emerged, and important gaps were identified. Most studies adopted the healthcare system/third-party payer perspective; reported costs were generally healthcare resource use (inpatient/shorter-term outpatient). Out-of-pocket costs to individuals, family members (travel time, caregiving) and indirect costs due to lost productivity were largely ignored. Costs due to reoperations/complications were not included in one-third of studies. Body-contouring surgery included in only 14%. One study evaluated long-term waitlisted patients. Surgery was cost-effective/cost-saving for severely obese with type 2 diabetes mellitus. Study quality was inconsistent. DISCUSSION: There is a need for studies that assume a broader societal perspective (including out-of-pocket costs, costs to family and productivity losses) and longer-term costs (capture reoperations/complications, waiting, body contouring), and consequences (health-related quality-of-life). Full economic evaluation underpinned by reporting standards should inform prioritization of patients (e.g. type 2 diabetes mellitus with body mass index 30 to 34.9 kg/m(2) or long-term waitlisted) for surgery. © 2016 World Obesity.

Surrogate markers of long-term outcome in primary total hip arthroplasty: A systematic review.

OBJECTIVES: High failure rates of metal-on-metal hip arthroplasty implants have highlighted the need for more careful introduction and monitoring of new implants and for the evaluation of the safety of medical devices. The National Joint Registry and other regulatory services are unable to detect failing implants at an early enough stage. We aimed to identify validated surrogate markers of long-term outcome in patients undergoing primary total hip arthroplasty (THA). METHODS: We conducted a systematic review of studies evaluating surrogate markers for predicting long-term outcome in primary THA. Long-term outcome was defined as revision rate of an implant at ten years according to National Institute of Health and Care Excellence guidelines. We conducted a search of Medline and Embase (OVID) databases. Separate search strategies were devised for the Cochrane database and Google Scholar. Each search was performed to include articles from the date of their inception to June 8, 2015. RESULTS: Our search strategy identified 1082 studies of which 115 studies were included for full article review. Following review, 17 articles were found that investigated surrogate markers of long-term outcome. These included one systematic review, one randomised control trial (RCT), one case control study and 13 case series. Validated surrogate markers included Radiostereometric Analysis (RSA) and Einzel-Bild-Röntgen-Analyse (EBRA), each measuring implant migration and wear. We identified five RSA studies (one systematic review and four case series) and four EBRA studies (one RCT and three case series). Patient Reported Outcome Measures (PROMs) at six months have been investigated but have not been validated against long-term outcomes. CONCLUSIONS: This systematic review identified two validated surrogate markers of long-term primary THA outcome: RSA and EBRA, each measuring implant migration and wear. We recommend the consideration of RSA in the pre-market testing of new implants. EBRA can be used to investigate acetabular wear but not femoral migration. Further studies are needed to validate the use of PROMs for post-market surveillance.Cite this article: T. T. Malak, J. A. J. Broomfield, A. J. R. Palmer, S. Hopewell, A. Carr, C. Brown, D. Prieto-Alhambra, S. Glyn-Jones. Surrogate markers of long-term outcome in primary total hip arthroplasty: A systematic review. Bone Joint Res 2016;5:206-214. DOI: 10.1302/2046-3758.56.2000568.

A review of current surgical practice in the operative treatment of proximal humeral fractures: Does the PROFHER trial demonstrate a need for change?

OBJECTIVES: The PROximal Fracture of the Humerus: Evaluation by Randomisation (PROFHER) trial has recently demonstrated that surgery is non-superior to non-operative treatment in the management of displaced proximal humeral fractures. The objective of this study was to assess current surgical practice in the context of the PROFHER trial in terms of patient demographics, injury characteristics and the nature of the surgical treatment. METHODS: A total of ten consecutive patients undergoing surgery for the treatment of a proximal humeral fracture from each of 11 United Kingdom hospitals were retrospectively identified over a 15 month period between January 2014 and March 2015. Data gathered for the 110 patients included patient demographics, injury characteristics, mode of surgical fixation, the grade of operating surgeon and the cost of the surgical implants. RESULTS: A majority of the patients were female (66%, 73 of 110). The mean patient age was 62 years (range 18 to 89). A majority of patients met the inclusion criteria for the PROFHER trial (75%, 83 of 110). Plate fixation was the most common mode of surgery (68%, 75 patients), followed by intramedullary fixation (12%, 13 patients), reverse shoulder arthroplasty (10%, 11 patients) and hemiarthroplasty (7%, eight patients). The consultant was either the primary operating surgeon or supervising the operating surgeon in a large majority of cases (91%, 100 patients). Implant costs for plate fixation were significantly less than both hemiarthroplasty (p < 0.05) and reverse shoulder arthroplasty (p < 0.0001). Implant costs for intramedullary fixation were significantly less than plate fixation (p < 0.01), hemiarthroplasty (p < 0.0001) and reverse shoulder arthroplasty (p < 0.0001). CONCLUSIONS: Our study has shown that the majority of a representative sample of patients currently undergoing surgical treatment for a proximal humeral fracture in these United Kingdom centres met the inclusion criteria for the PROFHER trial and that a proportion of these patients may, therefore, have been effectively managed non-operatively.Cite this article: Mr B. J. F. Dean. A review of current surgical practice in the operative treatment of proximal humeral fractures: Does the PROFHER trial demonstrate a need for change? Bone Joint Res 2016;5:178-184. DOI: 10.1302/2046-3758.55.2000596.

Screening for osteoporosis in Chinese post-menopausal women: a health economic modelling study.

UNLABELLED: Screening and appropriate treatment for osteoporosis has been proven to be cost-effective in many populations; however, it is not clear in the Chinese population. Simulations using a validated health economics model suggest that screening for osteoporosis in Chinese women is cost-effective and may even be cost-saving in Chinese post-menopausal women. INTRODUCTION: This study aimed at determining the cost-effectiveness of osteoporosis screening strategies in post-menopausal Chinese women. METHODS: A validated state-transition microsimulation model with a lifetime horizon was used to evaluate the cost-effectiveness of different screening strategies with treatment of alendronate compared with current osteoporosis management in China. Osteoporosis screening strategies assessed were (1) universal screening with dual-energy X-ray absorptiometry (DXA) alone; (2) Osteoporosis Self-Assessment Tool for Asians (OSTA) + DXA; and (3) quantitative ultrasound (QUS) + DXA with rescreening at 2, 5 or 10-year intervals for patients screened negative by DXA. The study was performed from the Chinese healthcare payer's perspective. All model inputs were retrieved from publically available literature. Uncertainties were addressed by one-way and probabilistic sensitivity analysis. RESULTS: Screening strategies all improved clinical outcomes at increased costs, and each were cost-effective compared with no screening in women aged 55 years given the Chinese willingness-to-pay threshold of USD 20,000 per quality-adjusted life year (QALY) gained. Pre-screening with QUS and subsequent DXA screening if the QUS T-score ≤ -0.5 with a 2-year rescreening interval was the most cost-effective strategy with the highest probability of being cost-effective across all non-dominated strategies. Screening strategies were cost-saving if screenings were initiated from age 65 years. One-way sensitivity analyses indicated that the results were robust. CONCLUSIONS: Pre-screening with QUS with subsequent DXA screening if the QUS T-score ≤ -0.5 with a 2-year rescreening interval in the Chinese women starting at age 55 is the most cost-effective. In addition, screening and treatment strategies are cost-saving if the screening initiation age is greater than 65 years.