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1.
Plast Reconstr Surg ; 145(2): 545-554, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31985657

RESUMO

BACKGROUND: Following bariatric surgery, patients develop problems related to lax abdominal skin that may be addressed by contouring procedures. Third-party insurers have subjective requirements for coverage of these procedures that can limit patient access. The authors sought to determine how well third-party payers cover abdominal contouring procedures in this population. METHODS: The authors conducted a cross-sectional analysis of insurance policies for coverage of panniculectomy, lower back excision, and circumferential lipectomy. Abdominoplasty was evaluated as an alternative to panniculectomy. Insurance companies were selected based on their market share and state enrolment. A list of medical necessity criteria was abstracted from the policies that offered coverage. RESULTS: Of the 55 companies evaluated, 98 percent had a policy that covered panniculectomy versus 36 percent who would cover lower back excision (p < 0.0001), and one-third provided coverage for circumferential lipectomy. Of the insurers who covered panniculectomy, only 30 percent would also cover abdominoplasty. Documentation of secondary skin conditions was the most prevalent criterion in panniculectomy policies (100 percent), whereas impaired function and secondary skin conditions were most common for coverage of lower back excision (73 percent and 73 percent, respectively). Frequency of criteria for panniculectomy versus lower back excision differed most notably for (1) secondary skin conditions (100 percent versus 73 percent; p = 0.0030), (2) weight loss (45 percent versus 7 percent; p = 0.0106), and (3) duration of weight stability (82 percent versus 53 percent; p = 0.0415). CONCLUSIONS: For the postbariatric population, panniculectomy was covered more often and had more standardized criteria than lower back excision or circumferential lipectomy. However, all have vast intracompany and interpolicy variations in coverage criteria that may reduce access to procedures, even among patients with established indications.


Assuntos
Abdominoplastia/economia , Cirurgia Bariátrica/economia , Contorno Corporal/economia , Cobertura do Seguro/economia , Seguro Saúde/estatística & dados numéricos , Abdominoplastia/estatística & dados numéricos , Dorso/cirurgia , Estudos Transversais , Humanos , Seguradoras/economia , Seguradoras/estatística & dados numéricos , Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/economia , Lipectomia/economia , Lipectomia/estatística & dados numéricos , Cuidados Pós-Operatórios/economia , Estados Unidos
3.
Am Surg ; 85(9): 1044-1050, 2019 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-31638522

RESUMO

Enhanced recovery after surgery (ERAS) may improve patients' postoperative course. Our center implemented the ERAS protocol for the colorectal service in 2016, and then expanded to multiple service lines over the course of 1.5 years. Our aim was to determine whether broad implementation of ERAS protocols across different service lines could improve patient care. All ERAS patients from 2018 were captured prospectively. For each service line using ERAS, one full year of data preceding ERAS was compared. ERAS service lines included colorectal, gynecology laparoscopic, gynecology open, hepatopancreaticobiliary, urology - nephrectomy and cystectomy, spinal fusion, cardiac surgery-coronary artery bypass grafting. ERAS and pre-ERAS services were compared based on length of stay (LOS), complications, readmission, and mortality rates. In addition, hospital costs were collected during this time frame. ERAS protocols significantly decreased LOS for colorectal, gynecology, and spine. Complications were significantly decreased in colorectal, gynecology, urology, and spine. Readmissions did not significantly increase in any service line except spine. There was no significant change in mortality. ERAS proved to save the hospital 1847 days and cost saving of almost $5 million in 2018. Implementing ERAS broadly improved patient outcomes (LOS, complications, readmission, and mortality) while providing cost savings to the hospital.


Assuntos
Protocolos Clínicos , Procedimentos Cirúrgicos Eletivos/economia , Procedimentos Cirúrgicos Eletivos/normas , Custos Hospitalares , Cuidados Pós-Operatórios/economia , Cuidados Pós-Operatórios/normas , Melhoria de Qualidade , Mortalidade Hospitalar , Humanos , Tempo de Internação/economia , Readmissão do Paciente/economia , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/prevenção & controle
4.
Am Surg ; 85(8): 883-894, 2019 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-31560308

RESUMO

Postoperative laboratory testing is an underrecognized but substantial contributor to health-care costs. We aimed to develop and validate a clinically meaningful laboratory (CML) protocol with individual risk stratification using generalizable and institution-specific predictive analytics to reduce laboratory testing and maximize cost savings for low-risk patients. An institutionally based risk model was developed for pancreaticoduodenectomy and hepatectomy, and an ACS-NSQIP®-based model was developed for distal pancreatectomy. Patients were stratified in each model to the CML by individual risk of major complications, readmission, or death. Clinical outcomes and estimated cost savings were compared with those of a historical cohort with standard of care. Over 34 months, 394 patients stratified to the CML for pancreaticoduodenectomy or hepatectomy saved an estimated $803,391 (44.4%). Over 13 months, 52 patients stratified to the CML for distal pancreatectomy saved an estimated $81,259 (30.5%). Clinical outcomes for 30-day major complications, readmission, and mortality were unchanged after implementation of either model. Predictive analytics can target low-risk patients to reduce laboratory testing and improve cost savings, regardless of whether an institutional or a generalized risk model is implemented. Broader application is important in patient-centered health care and should transition from predictive to prescriptive analytics to guide individual care in real time.


Assuntos
Protocolos Clínicos , Controle de Custos , Testes Diagnósticos de Rotina/economia , Hepatectomia , Preços Hospitalares/estatística & dados numéricos , Pancreatectomia , Pancreaticoduodenectomia , Cuidados Pós-Operatórios/economia , Medição de Risco/métodos , Algoritmos , Feminino , Humanos , Masculino , Estudos Prospectivos , Melhoria de Qualidade , Estados Unidos
5.
Sex Reprod Healthc ; 21: 102-107, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31395227

RESUMO

OBJECTIVE: Many patients may wish to receive contraceptive counseling and services during an abortion visit, but a 2009 study documented challenges faced by abortion clinics, especially independent ones, in providing contraceptive care. Since then, the Affordable Care Act (ACA) has made contraception more accessible by expanding coverage to millions of individuals and by eliminating out of pocket costs. This paper aims to update this previous work and describe recent challenges in providing contraceptive care in independent abortion settings following the ACA, as well as the strategies used to address these challenges. METHODS: We conducted two focus groups and 19 semi-structured interviews with clinic administrators and directors at independent abortion clinics. RESULTS: Challenges to providing contraceptive care in independent abortion clinics included navigating new guidelines under the Affordable Care Act for establishing coverage agreements with health insurance plans and receiving timely and sufficient reimbursement for services provided. Study respondents described strategies related to adjusting clinic flow and protocols to address patient needs regarding receiving contraception during abortion care. CONCLUSION: Staff working in independent abortion clinics in the United States experience a tension between trying to provide holistic, patient-centered care - including contraceptive care - and navigating restrictive political and healthcare contexts for the delivery of abortion care.


Assuntos
Anticoncepção/economia , Aconselhamento , Serviços de Planejamento Familiar/economia , Cobertura do Seguro , Reembolso de Seguro de Saúde , Aborto Induzido , Instituições de Assistência Ambulatorial/organização & administração , Serviços de Planejamento Familiar/legislação & jurisprudência , Feminino , Grupos Focais , Humanos , Entrevistas como Assunto , Patient Protection and Affordable Care Act , Cuidados Pós-Operatórios/economia , Estados Unidos
6.
Plast Reconstr Surg ; 144(2): 507-516, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31348369

RESUMO

BACKGROUND: Telemedicine delivers clinical information and permits discussion between providers and patients at a distance. Postoperative visits may be a burden to patients-many of whom travel long distances and miss work opportunities. By implementing a telehealth opportunity, the authors sought to develop a process that optimizes efficiency and provides optimal patient satisfaction. METHODS: Using quality improvement methods that have been highly effective in the business sector, we developed a testable workflow for patients in the postoperative telehealth setting. Seventy-two patients were enrolled and surveyed. A preoperative survey sought to determine travel distance, comfort with technology, access to the Internet and video-enabled devices, and the patient's interest in telehealth. A postoperative survey focused on patient satisfaction with the experience. RESULTS: Using the Lean Six Sigma methodology, the authors developed a telehealth workflow to optimize clinical efficiency. Preoperative surveys revealed that the majority (73 percent) of patients preferred in-person follow-up visits in the clinic. However, the postoperative survey distributed after the telehealth encounter found that nearly 100 percent of patients were satisfied with the telehealth experience. Ninety-six percent of patients said that their questions were answered, and 97 percent of patients stated that they would use telehealth again in the future. CONCLUSIONS: Telehealth encounters enable real-time clinical decision-making by providing patients and visiting nurses access to providers and decreasing patient transportation needs and wait times. Although initially hesitant to opt for a telehealth encounter in lieu of a traditional visit, the great majority of patients voiced satisfaction with the telehealth experience. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.


Assuntos
Custos de Cuidados de Saúde , Satisfação do Paciente/estatística & dados numéricos , Cuidados Pós-Operatórios/economia , Cirurgia Plástica/economia , Cirurgia Plástica/métodos , Telemedicina/métodos , Adulto , Idoso , Efeitos Psicossociais da Doença , Procedimentos Clínicos , Estética , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Cuidados Pós-Operatórios/métodos , Telemedicina/economia , Resultado do Tratamento , Estados Unidos
7.
Ann Transplant ; 24: 252-259, 2019 May 07.
Artigo em Inglês | MEDLINE | ID: mdl-31061380

RESUMO

BACKGROUND Solid organ transplantations lead to improvements in patient survival and patient quality of life, as well as health care system economic benefits. However, over time, health problems can accumulate post-transplantation. Therefore, we hypothesized that in the late post-transplantation period, the costs of patient care increase. MATERIAL AND METHODS We retrospectively calculated costs of patient care in 306 randomly selected kidney transplant recipients who had different follow-up time periods after kidney transplantation (between 1 year and 25 years). Direct costs of inpatient care as well as outpatient care, from the perspective of a transplant center, were considered. RESULTS The mean costs, as well as median costs of post-transplantation care were the highest in the first post-transplantation year. Afterwards, the mean costs and median costs decreased, without an increase in costs of care in the late post-transplantation periods. CONCLUSIONS From the perspective of a transplant center, costs of long-term post-kidney transplantation care did not increase in the late period, even as long as 25 years after transplantation. Our results confirmed that kidney transplantation is a modality of renal replacement therapy that can be associated with economic benefits even when considering long-term post-transplantation care.


Assuntos
Transplante de Rim/economia , Assistência de Longa Duração/economia , Cuidados Pós-Operatórios/economia , Feminino , Custos de Cuidados de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Qualidade de Vida , Estudos Retrospectivos , Transplantados
8.
Ann Vasc Surg ; 59: 167-172, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31077768

RESUMO

BACKGROUND: We analyze the impact of outpatient telemedicine services on the travel burden of vascular surgery patients with regard to distance, time, and cost, as well as the emission of environmental pollutants. METHODS: Retrospective analysis was used to compare the patient travel expenditure and environmental impact associated with telemedicine encounters versus hypothetical in-person traditional consultations for all outpatient virtual care encounters with vascular surgery patients from October 2015 to October 2017. The primary outcomes measured were travel distance saved, travel time saved, travel costs saved, reduction in fuel consumption, and reduction in environmental pollutant emission. RESULTS: Over a two-year period, 146 outpatient telemedicine encounters were conducted among 87 unique patients (61 females, 26 males; mean age, 60 ± 13 years). The average one-way distance saved by the utilization of telemedicine services was 15.6 ± 6.3 miles, with an average roundtrip savings of 31.2 miles. The average one-way travel time saved was 19.5 ± 9.2 minutes, with an average roundtrip savings of 39 minutes. By using telemedicine services, these vascular surgery patients saved an average of $4.26 in gas and parking costs at each telemedicine encounter. The total reduction in passenger vehicle emission of environmental pollutants, including carbon dioxide, carbon monoxide, nitric oxides, and volatile organic compounds was 1632 kg, 42,867 g, 3160 g, and 4715 g, respectively, with a total of 194 gallons of gas saved from driving. CONCLUSIONS: Utilization of telemedicine services reduces the travel distance, time, and costs for vascular surgery patients. Outpatient telemedicine programs may also provide environmental benefit through the reduction of greenhouse gas and pollutant emissions.


Assuntos
Poluentes Atmosféricos/efeitos adversos , Assistência Ambulatorial/economia , Custos de Cuidados de Saúde , Gastos em Saúde , Cuidados Pós-Operatórios/economia , Telemedicina/economia , Poluição Relacionada com o Tráfego/prevenção & controle , Transporte de Pacientes/economia , Procedimentos Cirúrgicos Vasculares/economia , Emissões de Veículos/prevenção & controle , Idoso , Assistência Ambulatorial/métodos , Redução de Custos , Análise Custo-Benefício , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Cuidados Pós-Operatórios/métodos , Estudos Retrospectivos , Telemedicina/métodos , Fatores de Tempo
9.
Spine (Phila Pa 1976) ; 44(20): 1449-1455, 2019 Oct 15.
Artigo em Inglês | MEDLINE | ID: mdl-31145379

RESUMO

STUDY DESIGN: Retrospective analysis of data extracted from the MarketScan database (2000-2016) using International Classification of Diseases (ICD)-9, ICD-10, and Current Procedural Terminology-4 codes. OBJECTIVE: Evaluate the economic costs and health care utilization associated with spine infections. SUMMARY OF BACKGROUND DATA: Spinal infections (SI) are associated with significant morbidity and mortality. A recent spike in SI is attributed to the drug abuse epidemic. Management of SI represents a large burden on the health care system. METHODS: We assessed payments and outcomes at the index hospitalization, 1-, 3-, 6-, and 12-month follow up. Outcomes assessed included length of stay, complications, operation rates, and health care utilization. Outcomes were compared between cohorts with spinal infections: (1) with prior surgery, (2) drug abuse, and (3) without previous exposure to surgery or drug abuse, denoted as control. RESULTS: We identified 43,972 patients; 15.6% (N = 6847) of patients underwent prior surgery, 3.8% (N = 1,668) were previously expose to drug abuse while 80.6% fell into the control group. Both the postsurgical and drug abuse groups longer hospital stay compared with the control cohort (5 d vs. 4 d, P < 0.0001). Exposure to IV drug abuse was associated with increased risk of complications compared with the control group (43% vs. 38%, P < 0.0001). Payments at 1-month follow-up were significantly (P < 0.0001) higher among the postsurgical group compared with both groups. However, at 12-months follow-up, payments were significantly (P < 0.0001) higher in the drug abuse group compared with both groups. Only postsurgical infections were associated with higher number of surgical interventions both at presentation and 1 year follow up. CONCLUSION: SI following surgery or IV drug abuse are associated with higher payments, complication rates, and longer hospital stays. Drug abuse related SI are associated with the highest complication rates, readmissions, and overall payments at 1 year of follow up despite the lower rate of surgical interventions. LEVEL OF EVIDENCE: 3.


Assuntos
Reembolso de Seguro de Saúde/economia , Aceitação pelo Paciente de Cuidados de Saúde , Cuidados Pós-Operatórios/economia , Complicações Pós-Operatórias/economia , Doenças da Coluna Vertebral/economia , Transtornos Relacionados ao Uso de Substâncias/economia , Adulto , Idoso , Estudos de Coortes , Assistência à Saúde/economia , Feminino , Hospitalização/economia , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Doenças da Coluna Vertebral/epidemiologia , Doenças da Coluna Vertebral/cirurgia , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Fatores de Tempo
10.
Seizure ; 69: 245-250, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31121549

RESUMO

PURPOSE: To prospectively assess the feasibility of establishing low cost epilepsy surgery programs in resource poor settings. METHOD: We started epilepsy surgery centers in Tier 2 and Tier 3 cities in India in private hospitals. This model is based on the identifying and operating ideal epilepsy surgery candidates on the basis of clinical history, interictal and ictal video-EEG data, and 1.5 T MRI without other investigations and without regular involvement of other specialists. Trained epileptologists formed the fulcrum of this program who identified ideal candidates, offered them counseling, and read video-EEG and MRI. We also spread epilepsy awareness among locals and physicians and established focused epilepsy clinics. The expenses were subsidized for deserving patients and policies were devised to keep video-EEG duration and staff requirement to minimum. Difficult epilepsy surgery cases were referred to established centers. Initial surgeries were performed by invited epilepsy surgeons and subsequently by local neurosurgeons. RESULTS: A total of 125 epilepsy surgeries were performed at three centers since 2012. This included 81(64.8%) temporal lobe resections, 26 (20.8%) extratemporal focal resections, and 13 (10.4%) hemispherotomies. Of the 93 patients with more than 1 year of postoperative followup, 86 (92.5%) had Engel class IA outcome. There were minor complications in 5% patients. Average cost of presurgical evaluation and surgery was Rs. 92,707 (USD 1,324). CONCLUSIONS: It is possible to establish successful epilepsy surgery programs in resource poor setting with reasonable costs. This low cost model can be replicated in other parts of world to reduce the surgical treatment gap.


Assuntos
Epilepsia Resistente a Medicamentos/economia , Epilepsia Resistente a Medicamentos/cirurgia , Procedimentos Neurocirúrgicos/economia , Adolescente , Adulto , Encéfalo/diagnóstico por imagem , Encéfalo/fisiopatologia , Encéfalo/cirurgia , Países em Desenvolvimento , Epilepsia Resistente a Medicamentos/diagnóstico por imagem , Epilepsia Resistente a Medicamentos/fisiopatologia , Eletroencefalografia , Estudos de Viabilidade , Feminino , Humanos , Índia , Imagem por Ressonância Magnética , Masculino , Procedimentos Neurocirúrgicos/métodos , Seleção de Pacientes , Cuidados Pós-Operatórios/economia , Cuidados Pós-Operatórios/métodos , Complicações Pós-Operatórias/economia , Estudos Prospectivos , Especialização , Gravação em Vídeo , Adulto Jovem
11.
J Orthop Surg Res ; 14(1): 93, 2019 Apr 02.
Artigo em Inglês | MEDLINE | ID: mdl-30940168

RESUMO

BACKGROUND: Venous thromboembolism (VTE) is a complication following surgery. Low-molecular-weight heparin (LMWH) or direct oral anticoagulants (DOACs) are efficacious but come with inherent bleeding risk. Mechanical prophylaxis, such as intermittent pneumatic compression (IPC), does not induce bleeding but may be difficult to implement beyond the immediate post-operative period. This study compared the cost and quality-adjusted life years (QALYs) saved of commonly used VTE prophylaxis regimens after lower limb arthroplasty. METHODS: A previously published cost-utility model considering major efficacy and safety endpoints was updated to estimate the 1-year cost-effectiveness of different VTE prophylaxis regimens. The VTE strategies assessed included apixaban, dabigatran, rivaroxaban, LMWH, IPC, IPC + LMWH and IPC + apixaban. Efficacy data were derived from studies in PubMed, and cost data came from the 2017 Australian AR-DRG and PBS pricing schemes. RESULTS: Costs for VTE prophylaxis including treatment of its associated complications over the first year after surgery ranged from AUD $644 (IPC) to AUD $956 (rivaroxaban). Across 500 simulations, IPC was the cheapest measure in 73% of simulations. In 97% of simulations, a DOAC was associated with the highest resulting QALYs. Compared to IPC, apixaban was cost-effective in 76.4% of simulations and apixaban + IPC in 87.8% of simulations. For VTE events avoided, the DOACs and IPC were on par. LMWH and LMWH + IPC were negatively dominated. CONCLUSIONS: Apixaban, IPC or a sequential/simultaneous combination of both is currently the most cost-effective VTE prophylaxis regimens. The choice between them is best guided by the relative VTE and bleeding risks of individual patients.


Assuntos
Artroplastia de Quadril/efeitos adversos , Artroplastia do Joelho/efeitos adversos , Custos de Cuidados de Saúde/estatística & dados numéricos , Tromboembolia Venosa/prevenção & controle , Idoso , Anticoagulantes/efeitos adversos , Anticoagulantes/economia , Anticoagulantes/uso terapêutico , Austrália , Terapia Combinada/economia , Análise Custo-Benefício , Feminino , Humanos , Dispositivos de Compressão Pneumática Intermitente/economia , Masculino , Pessoa de Meia-Idade , Modelos Econométricos , Cuidados Pós-Operatórios/economia , Cuidados Pós-Operatórios/métodos , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/prevenção & controle , Anos de Vida Ajustados por Qualidade de Vida , Tromboembolia Venosa/economia , Tromboembolia Venosa/etiologia
12.
J Pediatr Surg ; 54(5): 1013-1018, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30826120

RESUMO

BACKGROUND/PURPOSE: The purpose of the study was to determine variables associated with attending postoperative clinic follow-up (POFU) in pediatric surgical patients, predictors of clinical value, and visit cost estimates. METHODS: POFU patterns of children undergoing eight common pediatric surgical procedures over one year at a tertiary pediatric hospital were examined retrospectively. Variables associated with attending POFU and associated with predetermined measures of clinical value and cost were determined. Driving distance to hospital was chosen as a proxy measure of cost to the family. RESULTS: Six-hundred-thirty-three patients were included, and 58% attended POFU. Variables independently associated with attending follow-up included: procedure type (orchidopexy, complicated appendicitis), living close to the hospital, having a defined follow-up order, individual surgeon attending. Clinical value was identified in 16.4% of patient visits and associated with orchidopexies, having required an earlier urgent postoperative visit and longer cases considered "complex". Significant costs to the health care system (~$125,000) and families (~$15,000) could be estimated from follow-up cases that had no clinical issues identified nor required an intervention. CONCLUSION: POFU of common pediatric surgical procedures may have limited clinical value while coming at significant costs to families and the health care system. Further study is needed to define optimal needs and means of follow-up of these common pediatric surgical procedures. LEVEL OF EVIDENCE: Level III.


Assuntos
Cooperação do Paciente/estatística & dados numéricos , Cuidados Pós-Operatórios , Adolescente , Canadá , Criança , Pré-Escolar , Feminino , Seguimentos , Custos de Cuidados de Saúde/estatística & dados numéricos , Humanos , Lactente , Modelos Logísticos , Masculino , Razão de Chances , Cuidados Pós-Operatórios/economia , Estudos Retrospectivos
13.
J Med Econ ; 22(7): 684-690, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30841773

RESUMO

Background: Fast-tracking is an approach adopted by Mayo Clinic in Florida's (MCF) liver transplant (LT) program, which consists of early tracheal extubation and transfer of patients to surgical ward, eliminating a stay in the intensive care unit in select patients. Since adopting this approach in 2002, MCF has successfully fast-tracked 54.3% of patients undergoing LT. Objectives: This study evaluated the reduction in post-operative length of stay (LOS) that resulted from the fast-tracking protocol and assessed the potential cost saving in the case of nationwide implementation. Methods: A propensity score for fast-tracking was generated based on MCF liver transplant databases during 2011-2013. Various propensity score matching algorithms were used to form control groups from the United Network of Organ Sharing Standard Analysis and Research (STAR) file that had comparable demographic characteristics and health status to the treatment group identified in MCF. Multiple regression and matching estimators were employed for evaluation of the post-surgery LOS. The algorithm generated from the analysis was also applied to the STAR data to determine the proportion of patients in the US who could potentially be candidates for fast-tracking, and the potential savings. Results: The effect of the fast-tracking on the post-transplant LOS was estimated at approximately from 2.5 (p-value = 0.001) to 3.2 (p-value < 0.001) days based on various matching algorithms. The cost saving from a nationwide implementation of fast-tracking of liver transplant patients was estimated to be at least $78 million during the 2-year period. Conclusion: The fast-track program was found to be effective in reducing post-transplant LOS, although the reduction appeared to be less than previously reported. Nationwide implementation of fast-tracking could result in substantial cost savings without compromising the patient outcome.


Assuntos
Redução de Custos , Deambulação Precoce/economia , Unidades de Terapia Intensiva/economia , Tempo de Internação/economia , Transplante de Fígado/métodos , Centros Médicos Acadêmicos , Fatores Etários , Estudos de Coortes , Bases de Dados Factuais , Deambulação Precoce/métodos , Feminino , Florida , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Transplante de Fígado/efeitos adversos , Transplante de Fígado/economia , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Cuidados Pós-Operatórios/economia , Cuidados Pós-Operatórios/métodos , Estudos Retrospectivos , Fatores de Risco , Viés de Seleção
14.
Clin Rehabil ; 33(6): 1003-1014, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30747010

RESUMO

OBJECTIVE: To assess the costs, effects, and cost-utility of an accelerated physiotherapy programme versus a standard physiotherapy programme following resurfacing hip arthroplasty. DESIGN: A cost-utility analysis alongside a randomized controlled trial. SETTING: A UK National Health Service hospital and patients' homes. SUBJECTS: A total of 80 male resurfacing hip arthroplasty patients randomized post procedure to one of the two programmes. INTERVENTIONS: The accelerated physiotherapy programme commenced in hospital with patients being fully weight bearing, without hip precautions, and following a range of exercises facilitating gait re-education, balance, and lower limb strength. Standard physiotherapy commenced in hospital, but hip precautions were used and exercises were only partially weight bearing. In both groups, patients continued with their exercises at home for an eight-week period. MAIN MEASURES: Data on healthcare contacts were collected from patients to 12 months and costed using unit costs from national sources. Information was also collected on patients' costs. Health-related quality of life was measured using the EuroQol EQ-5D questionnaire and used to estimate quality-adjusted life years (QALYs) to 12 months. Mean costs and QALYs for each trial arm were compared. RESULTS: On average, the accelerated physiotherapy programme was less expensive (mean cost difference -£200; 95% confidence interval: -£656 to £255) and more effective (mean QALY difference 0.13; 95% confidence interval: 0.05 to 0.21) than standard physiotherapy and had a high probability of being cost-effective. CONCLUSION: From the National Health Service perspective, an accelerated physiotherapy programme for male patients undergoing revision of total hip arthroplasty (RHA) is very likely to be cost-effective when compared to a standard physiotherapy programme.


Assuntos
Artroplastia de Quadril/reabilitação , Análise Custo-Benefício , Modalidades de Fisioterapia/economia , Artroplastia de Quadril/métodos , Marcha , Humanos , Extremidade Inferior , Masculino , Pessoa de Meia-Idade , Força Muscular , Cuidados Pós-Operatórios/economia , Equilíbrio Postural , Anos de Vida Ajustados por Qualidade de Vida , Reino Unido
15.
Scott Med J ; 64(3): 86-90, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30621515

RESUMO

BACKGROUND: Increased availability of routine investigations results in significant over-investigation, burdening patients with unnecessary tests as well as increasing cost. We aimed to identify the extent of monitoring of liver function tests in lung resections, and to ascertain whether any impact on clinical decision-making occurred. METHODS: Cases were identified using theatre records coded as "lobectomy/bilobectomy" in the three-month period 20 June 2017 to 20 September 2017. Electronic records were used to collect patient data. RESULTS: A total of 91 cases were included; 77 (85%) patients had 1 set of pre-operative LFTs, 12 (13%) patients had 2 sets, and 2 (2%) patients had 0 sets; 69 (76%) had normal LFTs pre-operatively; 298 sets of LFTs were measured post-operatively, with a median of 3 sets per patient; 61 (67%) patients had either normal or static LFTs post-operatively, 13 (14%) had isolated rise in GGT, 16 (17%) had derangement of ALT and AST, and 1 patient (1%) had deranged ALP. Altered clinical decision-making due to LFTs derangement was recorded in two cases (2%). CONCLUSION: Clinicians have an obligation to justify expense, and practise in a cost-effective manner. Our data suggest that the routine perioperative monitoring of LFTs in thoracic surgery does not give any clear benefit to patient care.


Assuntos
Hepatectomia , Testes de Função Hepática/métodos , Neoplasias Pulmonares/cirurgia , Cuidados Pós-Operatórios/métodos , Idoso , Análise Custo-Benefício , Feminino , Humanos , Testes de Função Hepática/economia , Neoplasias Pulmonares/fisiopatologia , Masculino , Cuidados Pós-Operatórios/economia , Período Pós-Operatório , Estudos Retrospectivos
17.
Plast Reconstr Surg ; 143(1S Management of Surgical Incisions Utilizing Closed-Incision Negative-Pressure Therapy): 36S-40S, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30586102

RESUMO

BACKGROUND: Breast cancer accounts for 30% of all new cancer diagnoses in women. Although more options are now available regarding breast reconstruction, the risk of complications (eg, infection, dehiscence, and expander exposure) is also prevalent and must be considered when choosing a reconstruction option because the cost for complications can be substantial. METHODS: A hypothetical cost model was applied to clinical outcomes of a previous retrospective study comparing the use of closed-incision negative-pressure therapy (ciNPT) and standard of care (SOC) over breast incisions after immediate reconstruction. The adjusted complication cost for a mastectomy with reconstruction was a mean of $10,402 and was calculated using a database of inpatient, outpatient, and carrier claims. RESULTS: The previous retrospective study included data on 665 breasts (ciNPT = 331, SOC = 334) and 356 female patients (ciNPT = 177, SOC = 179) and reported on complication rates at the breast level: 8.5% (28/331) for the ciNPT breast group versus 15.9% (53/334) for the SOC group (P = 0.0092). In the ciNPT group, 24/177 patients (13.6%) had a complication, whereas in the SOC group, 38/179 patients (21.2%) had a complication. Based on the adjusted mean complication cost of $10,402, total complication cost for the ciNPT group was $250,000 versus $395,000 for the SOC group with a per-patient cost savings of $218.00 with ciNPT. CONCLUSION: The authors' preliminary findings show potential cost savings with the use of ciNPT over breast incisions and warrant further study regarding the cost-effectiveness of ciNPT compared with standard of care after immediate breast reconstruction.


Assuntos
Análise Custo-Benefício , Custos de Cuidados de Saúde/estatística & dados numéricos , Mamoplastia/economia , Tratamento de Ferimentos com Pressão Negativa/economia , Cuidados Pós-Operatórios/economia , Complicações Pós-Operatórias/prevenção & controle , Ferida Cirúrgica/terapia , Neoplasias da Mama/economia , Neoplasias da Mama/cirurgia , Redução de Custos/estatística & dados numéricos , Feminino , Humanos , Mastectomia/economia , Modelos Econômicos , Cuidados Pós-Operatórios/métodos , Complicações Pós-Operatórias/economia , Estudos Retrospectivos , Ferida Cirúrgica/economia , Estados Unidos
18.
J Robot Surg ; 13(1): 129-140, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-29948875

RESUMO

The objectives of this study are to evaluate if robotic cystectomy demonstrates reduced complications, readmissions, and cost-to-patient compared to open approach 30-day post-operatively, and to identify predictors of complication, readmission, and cost-to-patient. This retrospective cohort study analyzed 249 patients who underwent open (n = 149) or robotic (n = 100) cystectomy from 2009 to 2015 at our institution. Outcomes included 30-day post-operative complication, readmission, and cost-to-patient charges. We used modified Clavien-Dindo/MSKCC classifications. Multivariable logistic and linear regression models were used to evaluate associations to outcomes and to build predictive models. Patient, clinical, and surgical characteristics differed by open and robotic groups, respectively, only for estimated blood loss (median: 600 versus 150 cc, p < 0.01), operative time (mean: 6.19 versus 6.85 h, p < 0.01), and length of stay (median: 7 versus 5 days, p < 0.01). Complication: frequency of patients with at least one 30-day complication was 85% compared to 66% (p < 0.01). Minor gastrointestinal and bleeding complications were increased in the open group (50% versus 41%, p = 0.01; 52% versus 11%, p < 0.01, respectively). Fifty percent of patients required blood transfusion in open compared to 11% (p < 0.01). Patients in the open group experienced more major complications (19% versus 10%, p = 0.04). Robotic approach was a predictor for fewer complications (OR 0.44, 95% CI 0.20-0.99, p = 0.049). Readmission: no significant difference in number of patients readmitted was found. Cost-to-patient: Robotic approach predicted an 18% reduction in total cost-to-patient compared to open approach (p < 0.01). Robotic cystectomy demonstrated reduced total cost-to-patient when taking into account all 30-day post-operative services with fewer complications compared to open cystectomy.


Assuntos
Cistectomia/economia , Cistectomia/métodos , Custos de Cuidados de Saúde , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Procedimentos Cirúrgicos Robóticos/economia , Procedimentos Cirúrgicos Robóticos/métodos , Idoso , Idoso de 80 Anos ou mais , Análise de Variância , Perda Sanguínea Cirúrgica/prevenção & controle , Perda Sanguínea Cirúrgica/estatística & dados numéricos , Estudos de Coortes , Redução de Custos , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Cuidados Pós-Operatórios/economia , Cuidados Pós-Operatórios/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Tempo
19.
Zhonghua Zhong Liu Za Zhi ; 40(10): 787-792, 2018 Oct 23.
Artigo em Chinês | MEDLINE | ID: mdl-30392345

RESUMO

Objective: To investigate the clinical effectiveness of postoperative nutritional support in patients undergoing hepatectomy for hepatocellular carcinoma (HCC). Methods: A total of 379 HCC patients who received partial hepatectomy from January 2010 to December 2013 in Department of Hepatobiliary Surgery of Cancer Hospital, Chinese Academy of Medical Sciences were selected. Based on the nutritional method, all of the enrolled patients were divided into two group: 142 patients who received early enteral nutrition (EEN) combined with parenteral nutrition (PN) were identified as EEN+ PN group; 237 patients who received total parenteral nutrition (TPN) were identified as TPN group. These two groups were even divided into two subgroups, centrally located HCC (cl-HCC) and non-centrally located HCC (ncl-HCC). The clinical effectiveness of different groups was assessed and compared. Results: The age, gender, body mass index (BMI), the maximum diameter of the tumor, the amount of operative bleeding and postoperative infective rate did not show statistically significant differences between EEN+ PN group and TPN group (P>0.05). On the seventh postoperative day (7(th) POD), aspartate transaminase (AST) of EEN+ PN group and TPN group were (41.6±2.0) IU/L and (50.4±3.2) IU/L respectively, and the difference was statistically significant (P<0.05). Alkaline phosphatase (ALP) of these two groups were (80.8±2.4) IU/L and (90.2±2.3) IU/L, respectively, and the difference was statistically significant (P<0.05). Total bilirubin (TBIL) of these two groups were (15.8±0.7) µmol/L and (19.1±0.7) µmol/L, respectively, and the difference was statistically significant (P<0.05). On the 7(th) POD, AST in cl-HCC subgroups of EEN+ PN group and TPN group were (39.6±2.6) IU/L and (61.0±7.0) IU/L, respectively, and the difference was statistically significant (P<0.05). TBIL in cl-HCC subgroups of these two groups were (14.4±0.9) µmol/L and (20.7±1.3) µmol/L, respectively, and the difference was statistically significant (P<0.05). On the 7(th) POD, ALP in ncl-HCC subgroups of these two groups were (79.3±3.0) IU/L and (89.9±3.1) IU/L, respectively, and the difference was statistically significant (P<0.05). The total length of stay (t-LOS) of these two groups were (15.8±0.4) days and (17.1±0.4) days, respectively, and the difference was statistically significant (P<0.05). Postoperative LOS (postop-LOS) of these two groups were (8.6±0.2) days and (10.1±0.3) days, respectively, and the difference was statistically significant (P<0.05). Total length of stay (t-LOS) in ncl-HCC subgroups of these two groups were (15.1±0.5) days and (16.6±0.3) days, respectively, and the difference was statistically significant (P<0.05). Postoperative LOS (postop-LOS) in ncl-HCC subgroups of these two groups were (8.4±0.2) days and (9.5±0.2) days, respectively, and the difference was statistically significant (P<0.05). Postoperative LOS (postop-LOS) in cl-HCC subgroups of these two groups were (8.7±0.2) days and (11.0±0.8) days, respectively, and the difference was statistically significant (P<0.05). Postoperative hospitalization expenses of these two groups were (20 855.0±549.8) yuan and (23 373.0±715.5) yuan, respectively, and the difference was statistically significant (P<0.05). Postoperative hospitalization expenses in cl-HCC subgroups of these two groups were (21 012.0±748.5) yuan and (24 697.0±1 409.0) yuan, respectively, and the difference was statistically significant (P<0.05). Conclusion: EEN+ PN can improve the liver function, shorten the postoperative hospitalization time and reduce the postoperative hospitalization expenses of HCC patients in need of nutritional support.


Assuntos
Carcinoma Hepatocelular/cirurgia , Nutrição Enteral , Hepatectomia , Neoplasias Hepáticas/cirurgia , Nutrição Parenteral , Cuidados Pós-Operatórios , Nutrição Enteral/economia , Humanos , Tempo de Internação/economia , Apoio Nutricional , Nutrição Parenteral/economia , Cuidados Pós-Operatórios/economia , Cuidados Pós-Operatórios/métodos , Período Pós-Operatório , Resultado do Tratamento
20.
Pharmacotherapy ; 38(12): 1241-1249, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30403299

RESUMO

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.


Assuntos
Procedimentos Cirúrgicos Cardíacos/tendências , Unidades de Terapia Intensiva/tendências , Cuidados Pós-Operatórios/métodos , Lactato de Ringer/administração & dosagem , Albumina Sérica Humana/administração & dosagem , Idoso , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/economia , Estudos de Coortes , Redução de Custos/métodos , Redução de Custos/tendências , Feminino , Hidratação/economia , Hidratação/métodos , Hidratação/tendências , Humanos , Unidades de Terapia Intensiva/economia , Masculino , Pessoa de Meia-Idade , Cuidados Pós-Operatórios/economia , Estudos Retrospectivos , Lactato de Ringer/economia , Albumina Sérica Humana/economia
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