Epidemiological Analysis of 37,424 Carotid Artery Stenosis Intervention Procedures During 11 Years in the Public Health System in Brazil: Stenting has Been More Common Than Endarterectomy.

BACKGROUND: Stroke is a leading cause of death worldwide, with carotid atherosclerosis accounting for 10-20% of cases. In Brazil, the Public Health System provides care for roughly two-thirds of the population. No studies, however, have analysed large-scale results of carotid bifurcation surgery in Brazil. METHODS: This study aimed to describe rates of carotid artery stenting (CAS) and carotid endarterectomy (CEA) performed between 2008 and 2019 in the country through web scraping of publicly available databases. RESULTS: Between 2008 and 2019, 37,424 carotid bifurcation revascularization procedures were performed, of which 22,578 were CAS (60.34%) and 14,846 (39.66%) were CEA. There were 620 in-hospital deaths (1.66%), 336 after CAS (1.48%) and 284 after CEA (1.92%) (P = 0.032). Governmental reimbursement was US$ 77,216,298.85 (79.31% of all reimbursement) for CAS procedures and US$ 20,143,009.63 (20.69%) for CEA procedures. The average cost per procedure for CAS (US$ 3,062.98) was higher than that for CEA (US$ 1,430.33) (P = 0.008). CONCLUSIONS: In Brazil, the frequency of CAS largely surpassed that of CEA. In-hospital mortality rates of CAS were significantly lower than those of CEA, although both had mortality rates within the acceptable rates as dictated by literature. The cost of CAS, however, was significantly higher. This is a pioneering analysis of carotid artery disease management in Brazil that provides, for the first time, preliminary insight into the fact that the low adoption of CEA in the country is in opposition to countries where utilization rates are higher for CEA than for CAS.

Atención a domicilio a ancianos crónicos complejos. Una gran responsabilidad para las enfermeras del presente y del futuro / No disponible

No disponible

Aplicación de un protocolo de manejo de masas anexiales: ahorro en actividad clínicamente innecesaria y costes / Application of a protocol for the management of adnexal masses: savings in clinically unnecessary activity and costs

FUNDAMENTO: Evaluar si la implantación de un protocolo de masas anexiales basado en el sistema GI-RADS permite un correcto manejo de estas, evitando la actividad clínicamente innecesaria derivada del sobrediagnóstico y sobretratamiento, así como un ahorro en los costes. MÉTODO: Estudio de cohortes retrospectivo (julio 2015 - junio 2017). Incluyó mujeres atendidas en la consulta de Ginecología del Hospital Universitario Rey Juan Carlos (Móstoles, Madrid) con hallazgo de una masa anexial en ecografía de alta resolución. La masa anexial se catalogó con el sistema GI-RADS y, junto con la imagen ecográfica y el estatus menopáusico de la paciente, se decidió realizar cirugía o seguimiento. RESULTADOS: Se estudiaron 154 mujeres, el 24 % con imágenes sospechosas de malignidad (G4 y G5). Se intervinieron un 33,1 % de las masas anexiales, el 33,3 % de las cuales fueron cáncer de ovario, principalmente en mujeres postmenopáusicas con una imagen ecográfica sospechosa de malignidad (88,2 %). Un 3,2 % de las pacientes rechazaron la indicación de cirugía. Durante el seguimiento desaparecieron el 21,4 % de las masas anexiales, 61 pacientes (39,6 %) no habían sido intervenidas por presentar una masa anexial estable, y dos (1,3 %) por el riesgo quirúrgico. Al final del estudio se evitaron 96 (62,3 %) cirugías, logrando una reducción de costes de 57.683 euros. CONCLUSIONES: La aplicación de un protocolo basado en el sistema de clasificación GI-RADS evitó cirugías innecesarias y las consecuencias y costes derivados de ellas, por lo que constituye una herramienta útil y práctica en el control y tratamiento de las masas anexiales.Palabras clave. Masa anexial. Clasificación GI-RADS. Cirugías innecesarias. Seguridad del paciente

BACKGROUND: Evaluate whether the implementation of an adnexal masses protocol, based on the GI-RADS system, allows a correct management of these masses, avoiding unnecessary clinical activity produced by overdiagnosis and overtreatment, as well as cost savings. METHODS: Retrospective cohort study (July 2015 - June 2017) including women treated at the Gynaecology clinic of the Hospital Universitario Rey Juan Carlos (Móstoles, Madrid), with detection of an adnexal mass in high resolution echography. Adnexal masses were classified by the GI-RADS system, and together with the echographic image and menopausal status, surgery or follow-up was decided. RESULTS: A total of 154 women were studied, 24 % with images suggesting malignancy (G4 and G5). Surgery was performed on 33.1 % of adnexal masses; 33.3 % of them were ovarian carcinoma, mainly (88.2 %) in postmenopausal women with echographic images suggesting malignancy. Three point two percent of patients rejected the recommended surgery. During follow-up 21.4 % of the masses disappeared, 61 patients were only monitored due to a stable mass and two (1.3 %) due to surgical risk. Eventually, 96 (62.3 %) surgeries were avoided, achieving a 57,683 Euro saving. CONCLUSIONS: The application of a protocol based on the GI-RADS classification system avoided unnecessary surgeries, as well as the consequences and economical cost produced by them. Thus, this protocol is a useful and practical tool for the monitoring and treatment of adnexal masses

Real-World Budget Impact of the Adoption of Insulin Glargine Biosimilars in Primary Care in England (2015-2018).

BACKGROUND: Lantus, the reference insulin glargine used for the treatment of diabetes, lost its patent protection in 2014, opening the market to biosimilar competitors. OBJECTIVE: First, to analyze the adoption rates of insulin glargine biosimilars in primary care in England and estimate the savings realized and missed, since an insulin glargine biosimilar was first used, and second, to assess potential variations in adoption rates across Clinical Commissioning Groups (CCGs). RESEARCH DESIGN AND METHODS: Data sets capturing information on all insulin glargine items prescribed by all general practitioners up to December 2018 were used. Total costs of insulin glargine and uptake rates of biosimilars were calculated. The real-world budget impact was estimated assuming the cost of reference insulin glargine for all items and comparing the total costs in this scenario with the total costs in the real world. The missed savings were estimated assuming the cost of biosimilars for all insulin glargine items. Choropleth maps were generated to assess potential variations in uptake across CCGs. RESULTS: Insulin glargine biosimilars generated savings of £900,000 between October 2015 (time of first prescription) and December 2018. The missed savings amounted to £25.6 million in this period, indicating that only 3.42% of the potential savings were achieved. The analyses demonstrated a large level of variation in the uptake of insulin glargine biosimilars across CCGs, with market shares ranging from 0 to 53.3% (December 2018). CONCLUSIONS: These results may encourage decision makers in England to promote the use of best-value treatments in primary care and to reevaluate variation across CCGs.

La perspectiva de personas migrantes sobre el acceso a la atención sanitaria en el contexto de políticas de austeridad en Andalucía / The perspective of migrants on access to health care in the context of austerity policies in Andalusia (Spain)

OBJETIVO: Conocer la valoración de personas migrantes sobre su acceso al sistema sanitario tras la entrada en vigor del Real Decreto-Ley16/2012 y sobre el efecto que han podido producir los recortes económicos en dicho acceso. MÉTODO: Estudio cualitativo fenomenológico con entrevistas semiestructuradas, realizado en Andalucía, en dos fases (2009-2010 y 2012-2013), con 36 participantes. Se segmentó la muestra por tiempo de estancia, nacionalidad y ámbito de residencia. Las nacionalidades de las personas migrantes son Bolivia, Marruecos y Rumanía. RESULTADOS: Como elementos facilitadores del acceso en ambas fases se identifican la situación administrativa regular, la posesión de tarjeta sanitaria individual, el conocimiento del idioma, las redes sociales y la información. Los resultados muestran diferencias en el acceso a la atención sanitaria de las personas migrantes antes y después de la aplicación del RDL 16/2012, en el marco de las políticas de austeridad. En la segunda fase se agravan algunas barreras de acceso, como los tiempos de espera y la incompatibilidad de horarios, y empeoran las condiciones socioeconómicas y administrativas de las personas participantes. CONCLUSIONES: El diseño de políticas económicas y de regulación de la atención sanitaria debería tener en cuenta las barreras y los facilitadores de acceso como ejes fundamentales de la protección de la salud de las personas migrantes y, por ende, de la población general

OBJECTIVE: To conduct an assessment of migrant people regarding their access to the health system following entry into force of Royal Decree-Law 16/2012 along with the impact of economic cuts on such access. METHOD: Qualitative phenomenological study with semi-structured interviews, conducted in Andalusia (Spain), in two phases (2009-2010 and 2012-2013), with 36 participants. The sample was segmented by length of stay, nationality and area of residence. The nationalities of origin are Bolivia, Morocco and Romania. RESULTS: Elements facilitating access in both periods: regular administrative situation, possession of Individual Health Card, knowledge of the language, social networks and information. The results show differences in access to health care for migrants before and after the enforcement of the RDL 16/2012, within austerity policies. In the second period, access barriers such as waiting times or incompatibility of schedules are aggravated and the socio-economic and administrative conditions of participants worsen. CONCLUSIONS: The design of policies, economic and regulatory health care, should take into account barriers and facilitators of access as fundamental main points of health protection for migrants and, therefore, for the general population

Room Costs for Common Pediatric Hospitalizations and Cost-Reducing Quality Initiatives.

BACKGROUND: Improvement initiatives promote safe and efficient care for hospitalized children. However, these may be associated with limited cost savings. In this article, we sought to understand the potential financial benefit yielded by improvement initiatives by describing the inpatient allocation of costs for common pediatric diagnoses. METHODS: This study is a retrospective cross-sectional analysis of pediatric patients aged 0 to 21 years from 48 children's hospitals included in the Pediatric Health Information System database from January 1, 2017, to December 31, 2017. We included hospitalizations for 8 common inpatient pediatric diagnoses (seizure, bronchiolitis, asthma, pneumonia, acute gastroenteritis, upper respiratory tract infection, other gastrointestinal diagnoses, and skin and soft tissue infection) and categorized the distribution of hospitalization costs (room, clinical, laboratory, imaging, pharmacy, supplies, and other). We summarized our findings with mean percentages and percent of total costs and used mixed-effects models to account for disease severity and to describe hospital-level variation. RESULTS: For 195 436 hospitalizations, room costs accounted for 52.5% to 70.3% of total hospitalization costs. We observed wide hospital-level variation in nonroom costs for the same diagnoses (25%-81% for seizure, 12%-51% for bronchiolitis, 19%-63% for asthma, 19%-62% for pneumonia, 21%-78% for acute gastroenteritis, 21%-63% for upper respiratory tract infection, 28%-69% for other gastrointestinal diagnoses, and 21%-71% for skin and soft tissue infection). However, to achieve a cost reduction equal to 10% of room costs, large, often unattainable reductions (>100%) in nonroom cost categories are needed. CONCLUSIONS: Inconsistencies in nonroom costs for similar diagnoses suggest hospital-level treatment variation and improvement opportunities. However, individual improvement initiatives may not result in significant cost savings without specifically addressing room costs.

Prevalence of pulmonary arterial hypertension in the Camerino area of central Italy and savings resulting from generic bosentan.

Objective: Pulmonary arterial hypertension is a rare and progressive respiratory disease characterised by high blood pressure and vascular resistance producing right ventricular fatigue. In Italy, pulmonary hypertension can be treated with different drugs available on the market at different costs, and in the Marche region distributed exclusively by hospital pharmacies. The present study examined in an area of the Marche region the use of drugs specifically indicated for pulmonary hypertension, and evaluated how the introduction of the generic bosentan might lower pharmaceutical costs for the healthcare budget. Methods: The study examined oral administration prescriptions and costs using data from the Apotheke Gold (Record Data) database from 1 January 2012 to 31 August 2017. Results: Annually (from 1 January 2012 to 31 August 2017), an average of 4.83 patients were treated (prevalence of 102.35 cases per 1 million residents) with ambrisentan (Volibris), bosentan (Tracleer), macitentan (Opsumit), tadalafil (Adcirca) or sildenafil (Revatio). The total expenditure during the 5-year 8-month period was €472 405. Ambrisentan was by far the most expensive product overall, with a total expenditure of €222 380 for the period studied (a daily cost of €67.39), even though Tracleer had the highest cost for a day of treatment (a daily cost of €94.48, but a total expenditure of €163 976 for the period, due to its more recent marketing). Providing patients with the generic form bosentan in place of Tracleer would lower the costs dramatically. A very significant annual savings per patient of approximately €31 879 would be achieved, a striking 92.4% reduction in costs. Conclusion: The prevalence of pulmonary arterial hypertension reported for Camerino and its surrounding area in the Marches region is quite high compared with that reported by other authors for France and Scotland. The introduction of the generic bosentan would cut costs drastically. It is to be hoped that centralised procurement at the regional level would bring further savings.

Trends in cancer mortality in Spain: the influence of the financial crisis / Evolución de la mortalidad por cáncer en España: influencia de la crisis económica

Objective: To determine if the onset of the economic crisis in Spain affected cancer mortality and mortality trends. Method: We conducted a longitudinal ecological study based on all cancer-related deaths and on specific types of cancer (lung, colon, breast and prostate) in Spain between 2000 and 2013. We computed age-standardised mortality rates in men and women, and fit mixed Poisson models to analyse the effect of the crisis on cancer mortality and trends therein. Results: After the onset of the economic crisis, cancer mortality continued to decline, but with a significant slowing of the yearly rate of decline (men: RR = 0.987, 95%CI = 0.985-0.990, before the crisis, and RR = 0.993, 95%CI = 0.991-0.996, afterwards; women: RR = 0.990, 95%CI = 0.988-0.993, before, and RR = 1.002, 95%CI = 0.998-1.006, afterwards). In men, lung cancer mortality was reduced, continuing the trend observed in the pre-crisis period; the trend in colon cancer mortality did not change significantly and continued to increase; and the yearly decline in prostate cancer mortality slowed significantly. In women, lung cancer mortality continued to increase each year, as before the crisis; colon cancer continued to decease; and the previous yearly downward trend in breast cancer mortality slowed down following the onset of the crisis. Conclusions: Since the onset of the economic crisis in Spain the rate of decline in cancer mortality has slowed significantly, and this situation could be exacerbated by the current austerity measures in healthcare

Objetivo: Determinar si el inicio de la crisis económica en España afectó a la mortalidad por cáncer y sus tendencias. Método: Estudio ecológico longitudinal que analiza todas las muertes por cáncer y por tipos específicos de cáncer (pulmón, colon, mama y próstata) en España entre 2000 y 2013. Se estimaron las tasas de mortalidad estandarizadas por edad en hombres y mujeres, y se ajustaron modelos mixtos de Poisson para analizar el efecto de la crisis sobre la mortalidad por cáncer y sus tendencias. Resultados: Después del inicio de la crisis económica, la mortalidad por cáncer continuó su tendencia a la baja, pero con una disminución significativa del decrecimiento anual (hombres: riesgo relativo [RR] = 0,987, intervalo de confianza del 95% [IC95%] = 0,985-0,990, antes de la crisis, y RR = 0,993, IC95% = 0,991-0,996 después; mujeres: RR = 0,990, IC95% = 0,988-0,993, antes, y RR = 1,002, IC95% = 0,998-1,006 después). En los hombres, la mortalidad por cáncer de pulmón se redujo, continuando la tendencia observada en el periodo anterior a la crisis; la tendencia en la mortalidad por cáncer de colon no cambió significativamente y siguió aumentando; y la disminución anual de la mortalidad por cáncer de próstata se desaceleró significativamente. En las mujeres, la mortalidad por cáncer de pulmón continuó aumentando cada año, como antes de la crisis; el cáncer de colon continuó disminuyendo; y la tendencia a la disminución de la mortalidad por cáncer de mama se desaceleró después del inicio de la crisis. Conclusiones: Desde el inicio de la crisis económica en España, la disminución de la tasa de mortalidad por cáncer se ha desacelerado significativamente y esta situación podría verse exacerbada por las actuales medidas de austeridad en el sistema sanitario

Cohort Study of Albumin versus Lactated Ringer's for Postoperative Cardiac Surgery Fluid Resuscitation in the Intensive Care Unit.

PURPOSE: A new postcardiac surgery fluid resuscitation strategy was implemented in our cardiovascular intensive care unit (CVICU) to implement evidence-based practice. We transitioned from a primarily albumin fluid-based strategy to a lactated Ringer's fluid-based strategy. We sought to determine whether a new postoperative fluid resuscitation strategy significantly altered the fluid composition for postcardiac surgery patients and what effect that would have on fluid resuscitation costs. Secondary outcomes included various clinical parameters. METHODS: This was a retrospective, before-and-after cohort study of postcardiac surgery patients in an academic quaternary care intensive care unit (ICU) during two different 3-month time intervals. A total of 192 patients were studied: 108 pre-intervention and 84 post intervention. The intervention consisted of surveying stakeholders regarding potential concerns of reducing albumin use, an educational intervention addressing those concerns, and removing albumin from the routine postcardiac surgery ICU admission order set. RESULTS: In the post intervention time period, albumin use decreased significantly compared to pre-invention (p<0.01), and lactated Ringer's volume increased significantly (p<0.01). However, total volume administered for resuscitation was not significantly different pre- and post intervention (1129 ml vs. 1369 ml, p=0.136). There were a net-cost savings between the pre-intervention and post intervention period (3 mo) of $30,549.20, with the albumin reduction accounting for most of those savings. Secondary outcomes were not significantly different between groups. CONCLUSIONS: An albumin fluid reduction strategy was successful in reducing the amount of albumin fluid used for postcardiac surgery patients and resulted in substantial cost savings.

Patient Activation Changes as a Potential Signal for Changes in Health Care Costs: Cohort Study of US High-Cost Patients.

BACKGROUND: Programs to improve quality of care and lower costs for the highest utilizers of health services are proliferating, yet such programs have difficulty demonstrating cost savings. OBJECTIVE: In this study, we explore the degree to which changes in Patient Activation Measure (PAM) levels predict health care costs among high-risk patients. PARTICIPANTS: De-identified claims, demographic data, and serial PAM scores were analyzed on 2155 patients from multiple medical groups engaged in an existing Center for Medicare and Medicaid Innovation-funded intervention over 3 years designed to activate and improve care coordination for high-risk patients. DESIGN: In this prospective cohort study, four levels of PAM (from low to high) were used as the main predictor variable. We fit mixed linear models for log10 of allowed charges in follow-up periods in relation to change in PAM, controlling for baseline PAM, baseline costs, age, sex, income, and baseline risk score. MAIN MEASURES: Total allowed charges were derived from claims data for the cohort. PAM scores were from a separate database managed by the local practices. KEY RESULTS: A single PAM level increase was associated with 8.3% lower follow-up costs (95% confidence interval 2.5-13.2%). CONCLUSIONS: These findings contribute to a growing evidence base that the change in PAM score could serve as an early signal indicating the impact of interventions designed for high-cost, high-needs patients.

Collaborative practice agreement in solid organ transplantation.

Background Given the complexity of solid organ transplant recipients, a multidisciplinary approach is required. To promote medication safety and enable providers to focus on the medical and surgical needs of these patients, our department of pharmacy created a collaborative practice agreement between physicians and pharmacists. Through this agreement, credentialed pharmacists are empowered to provide inpatient services including initiation and adjustment of medications through independent review of laboratory results after multidisciplinary rounds. Objective To evaluate the effect of our collaborative practice agreement on clinical care and institutional finances. Setting An inpatient setting at a large academic medical center. Methods Three transplant pharmacists entered all clinical interventions made on abdominal transplant recipients between September and October 2013 into Quantifi®, a software application that categorizes and assigns a cost savings value based on impact and type of intervention. Main outcome measure The main outcome measures in this study were number and categorization of interventions, as well as estimated cost savings to the institution. Results There were 1060 interventions recorded, an average of 20 interventions per pharmacist per day. The most common interventions were pharmacokinetic evaluations (36%) and dose adjustments (19%). Over the time period, these interventions translated into an estimated savings of $107,634.00, or an annual cost savings of $373,131.20 per pharmacist, or a cost-benefit ratio of 2.65 to the institution. Conclusions Based on our study, implementation of a collaborative practice agreement enables credentialed pharmacists to make clinically and financially meaningful interventions in a complex patient population.

Potential cost savings to be made by slowing cognitive decline in mild Alzheimer's disease dementia using a model derived from the UK GERAS observational study.

BACKGROUND: Given the high costs associated with the care of those with Alzheimer's disease (AD) dementia, we examined the likely impact of a reduction in the rate of cognitive decline upon cost outcomes associated with this disease. METHODS: Using the group of patients with mild AD dementia from the GERAS study, generalised linear modelling (GLM) was used to explore the relationship between change in cognition as measured using the Mini-Mental State Examination (MMSE) and UK overall costs (health care and social care costs, and total societal costs) associated with AD dementia. RESULTS: A total of 200 patients with mild AD dementia were identified. Least squares mean (LSM) ± standard error (SE) reduction in MMSE score was 3.6 ± 0.4 points over 18 months. Using GLM it was possible to calculate that this worsening in cognition was associated with an 8.7% increase in total societal costs, equating to an increase of approximately £2200 per patient over an 18-month period. If the rate of decline in cognition was reduced by 30% or 50%, the associated savings in total societal costs over 18 months would be approximately £670 and £1100, respectively, of which only £110 and £180, respectively, could be attributed to a saving of health care costs. CONCLUSION: This study demonstrates that there are potential savings to be made in the care of patients with AD dementia through reducing the rate of cognitive decline. A reduction in wider societal costs is likely to be the main contributor to these potential savings, and need to be further evaluated when intervention costs and cost offsets can be measured.

Potential savings in the diagnosis of vestibular schwannoma.

INTRODUCTION: Magnetic resonance imaging (MRI) is used to screen patients at risk for vestibular schwannoma (VS). These MRIs are costly and have an extremely low yield; only 3% of patients in the screening population has an actual VS. It might be worthwhile to develop a test to predict VS and refer only a subset of all patients for MRI. OBJECTIVE: To examine the potential savings of such a hypothetical diagnostic test before MRI. DESIGN: We built a decision analytical model of the diagnostic strategy of VS. Input was derived from literature and key opinion leaders. The current strategy was compared to hypothetical new strategies, assigning MRI to the following: (i) all patients with pathology, (ii) all patients with important pathology and (iii) only patients with VS. This resulted in potential cost savings for each strategy. We conducted a budget impact analysis to predict nationwide savings for the Netherlands and the United Kingdom (UK), and a probabilistic sensitivity analysis to address uncertainty. RESULTS: Mean savings ranged from €256 (95%CI €250 - €262) or approximately US$284 (95%CI US$277 - US$291) per patient for strategy 1 to €293 (95%CI €290 - €296) or approximately US$325 (95%CI US$322 - US$328) per patient for strategy 3. Future diagnostic strategies can cost up to these amounts per patient and still be cost saving. Annually, for the Netherlands, €2.8 to €3.2 million could be saved and €10.8 to €12.3 million for the UK. CONCLUSIONS: The model shows that substantial savings could be generated if it is possible to further optimise the diagnosis of VS.

Evaluation of pegfilgrastim use at an academic medical center.

PURPOSE: Pegfilgrastim is indicated to reduce the risk of febrile neutropenia. As a cost-savings initiative, Pegfilgrastim Process Guidelines were developed and implemented at a large, academic teaching institution to improve appropriate use of pegfilgrastim and to decrease costs of outpatient infusion center administration by deferring doses to home self-administration for eligible patients. METHODS: A retrospective medical record review was conducted post-implementation of the Pegfilgrastim Process Guideline to evaluate the use of pegfilgrastim and to assess the safety and efficacy of transferring pegfilgrastim orders from outpatient infusion center to home administration for eligible patients. RESULTS: Fifty-nine patients were included in the study, with 35 patients receiving pegfilgrastim in the outpatient infusion center, 13 patients self-injecting at home, and 11 patients receiving doses in both settings. The total wholesale cost avoidance for pegfilgrastim orders transferred to self-administration at home during this time period totaled $205,163. The revenue from outpatient prescriptions of pegfilgrastim totaled $291,111.93. The percentage of febrile neutropenia admissions was 11.4%, 0%, and 9.1% in the outpatient infusion, home, and outpatient/home group, respectively. CONCLUSION: Implementation of the Pegfilgrastim Process Guidelines demonstrated decreased total pegfilgrastim orders to be dispensed by the infusion center and a cost avoidance of $205,163 in four months without any perceivable changes in patient outcomes. This represents a significant cost-savings opportunity.

Topical Vancomycin Reduces Surgical-Site Infections After Craniotomy: A Prospective, Controlled Study.

BACKGROUND: Surgical-site infections (SSIs) are an important cause of morbidity and mortality in neurosurgical patients. Topical antibiotics are one potential method to reduce the incidence of these infections. OBJECTIVE: To examine the efficacy of topical vancomycin applied within the wound during craniotomy in a large prospective cohort study at a major academic center. METHODS: Three hundred fifty-five patients were studied prospectively in this cohort study; 205 patients received 1 g of topical vancomycin powder in the subgaleal space while 150 matched control patients did not. Patients otherwise received identical care. The primary outcome variable was SSI rate factored by cohort. Secondary analysis examined cost savings from vancomycin usage estimated from hospital costs associated with SSI in craniotomy patients. RESULTS: The addition of topical vancomycin was associated with a significantly lower rate of SSI than standard of care alone (0.49% [1/205] vs 6% [9/150], P = .002). Based on the costs of revision surgery for infections, topical vancomycin usage was estimated to save $1367 446 per 1000 craniotomy patients. No adverse reactions occurred. CONCLUSION: Topical vancomycin is a safe, effective, and cost-saving measure to prevent SSIs following craniotomy. These results have broad implications for standard of care in craniotomy.

Budget Impact Analysis of Brivaracetam Adjunctive Therapy for Partial-Onset Epileptic Seizures in Valencia Community, Spain.

BACKGROUND AND OBJECTIVE: More than 30% of patients with epilepsy have inadequate control of seizures with drug therapy. The goal of this study is to determine the budget impact (BI) of the introduction of brivaracetam to the portfolio of approved drugs in Spain as adjunctive therapy for the treatment of partial-onset epilepsy in patients over 16 years old with a 5-year time horizon in the Valencia Community, a Spanish region with a population of 5 million. METHODS: The BI model compares the pharmaceutical expenditure on antiepileptics in two scenarios: with and without brivaracetam. It assumes that the introduction and increased use of brivaracetam will lead to a proportional decrease in consumption of coexisting adjunctive antiepileptics and calculates the evolution of the consumption of brivaracetam over 5 years (2016-2020). The model was designed from the perspective of the Spanish National Health System. Data on the candidate population, consumption of antiepileptics, market share and pharmaceutical expenditure were obtained from real-world data. Finally, a sensitivity analysis was carried out on the set of variables involved in the evolution of costs using a Monte-Carlo simulation. RESULTS: The model estimates that the target population eligible for adjunctive antiepileptics will hold at around 2352 between 2016 and 2020. Annual expenditure on antiepileptics is approximately €3.6 million. The number of patients eligible for treatment with brivaracetam would increase from 42 to 179 and annual savings of 0.09-0.37% would be created, representing €41,873 over 5 years (0.23% of the total budget). The sensitivity analysis corroborates that the probability of achieving savings with brivaracetam is around 84%. CONCLUSIONS: Brivaracetam is a therapeutic alternative that allows savings for the health system in patients with non-controlled epilepsy in monotherapy, having a fixed, predictable annual cost (independent of dose) from the first day of treatment as the lack of need for titration means the patient is within a range of therapeutic doses from the first dose.