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1.
Bone Joint J ; 101-B(8): 995-1001, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31362556

RESUMO

AIMS: The primary aim of this study was to establish the cost-effectiveness of the early fixation of displaced midshaft clavicle fractures. PATIENTS AND METHODS: A cost analysis was conducted within a randomized controlled trial comparing conservative management (n = 92) versus early plate fixation (n = 86) of displaced midshaft clavicular fractures. The incremental cost-effectiveness ratio (ICER) was used to express the cost per quality-adjusted life-year (QALY). The Six-Dimension Short-Form Health Survey (SF-6D) score was used as the preference-based health index to calculate the cost per QALY at 12 months after the injury. RESULTS: The mean 12-month SF-6D was 0.9522 (95% confidence interval (CI) 0.9355 to 0.9689) following conservative management and 0.9607 (95% CI 0.9447 to 0.9767) following fixation, giving an advantage for fixation of 0.0085, which was not statistically significant (p = 0.46). The mean cost per patient was £1322.69 for conservative management and £5405.32 for early fixation. This gave an ICER of £480 309.41 per QALY. For a threshold of £20 000 per QALY, the benefit of fixation would need to be present for 24 years to be cost-effective compared with conservative treatment. Linear regression analysis identified nonunion as the only factor to adversely influence the SF-6D at 12 months (p < 0.001). CONCLUSION: Routine plate fixation of displaced midshaft clavicular fractures is not cost-effective. Nonunion following conservative management has an increased morbidity with comparable expense to early fixation. This may suggest that a targeted approach of fixation in patients who are at higher risk of nonunion would be more cost-effective than the routine fixation of all displaced fractures. Cite this article: Bone Joint J 2019;101-B:995-1001.


Assuntos
Clavícula/lesões , Tratamento Conservador/economia , Análise Custo-Benefício/estatística & dados numéricos , Fixação Interna de Fraturas/economia , Fraturas Ósseas/cirurgia , Custos de Cuidados de Saúde/estatística & dados numéricos , Adulto , Placas Ósseas , Clavícula/cirurgia , Feminino , Seguimentos , Fixação Interna de Fraturas/instrumentação , Fixação Interna de Fraturas/métodos , Fraturas Ósseas/economia , Humanos , Masculino , Estudos Prospectivos , Anos de Vida Ajustados por Qualidade de Vida , Resultado do Tratamento , Reino Unido
2.
Medicine (Baltimore) ; 98(33): e16808, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31415394

RESUMO

Evidence-based studies have revealed outcomes in patients with chronic kidney disease that differed depending on the design of care delivery. This study compared the effects of 3 types of nephrology care: multidisciplinary care (MDC), nephrology care, and non-nephrology care. We studied their effects on the risks of requiring dialysis and the differences between these methods had on long-term medical resource utilization and costs.We conducted a retrospective cohort study involving patients with an estimated glomerular filtration rate of (eGFR) ≤45 mL/min/1.73 m from 2005 to 2007. Patients were divided into MDC, non-MDC, and non-nephrology referral groups. Between-group differences with regard to the risk of requiring dialysis and annual medical utilization and costs were evaluated using a 5-year follow-up period.In total, 661 patients were included. After other covariates and the competing risk of death were taken into account, we observed a significant (56%) reduction in the incidence of dialysis in both the MDC and non-MDC groups relative to the non-nephrology referral group. Costs were markedly lower in the MDC group relative to the other groups (average savings: US$ 830 per year; 95% confidence interval: 367-1295; P < .001).For patients without nephrology referrals, MDC can substantially reduce their risk of developing end-stage renal disease and lower their medical costs. We therefore strongly advocate that all patients with an eGFR of ≤45 mL/min/1.73 m should be referred to a nephrologist and receive MDC.


Assuntos
Assistência à Saúde/economia , Custos de Cuidados de Saúde/estatística & dados numéricos , Nefrologia/economia , Diálise Renal/economia , Insuficiência Renal Crônica/economia , Idoso , Assistência à Saúde/métodos , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Nefrologia/métodos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Equipe de Assistência ao Paciente/economia , Encaminhamento e Consulta/economia , Estudos Retrospectivos
4.
Bone Joint J ; 101-B(8): 984-994, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31362557

RESUMO

AIMS: The aim of the Scaphoid Magnetic Resonance Imaging in Trauma (SMaRT) trial was to evaluate the clinical and cost implications of using immediate MRI in the acute management of patients with a suspected fracture of the scaphoid with negative radiographs. PATIENTS AND METHODS: Patients who presented to the emergency department (ED) with a suspected fracture of the scaphoid and negative radiographs were randomized to a control group, who did not undergo further imaging in the ED, or an intervention group, who had an MRI of the wrist as an additional test during the initial ED attendance. Most participants were male (52% control, 61% intervention), with a mean age of 36.2 years (18 to 73) in the control group and 38.2 years (20 to 71) in the intervention group. The primary outcome was total cost impact at three months post-recruitment. Secondary outcomes included total costs at six months, the assessment of clinical findings, diagnostic accuracy, and the participants' self-reported level of satisfaction. Differences in cost were estimated using generalized linear models with gamma errors. RESULTS: The mean cost up to three months post-recruitment per participant was £542.40 (sd £855.20, n = 65) for the control group and £368.40 (sd £338.60, n = 67) for the intervention group, leading to an estimated cost difference of £174 (95% confidence interval (CI) -£30 to £378; p = 0.094). The cost difference per participant increased to £266 (95% CI £3.30 to £528; p = 0.047) at six months. Overall, 6.2% of participants (4/65, control group) and 10.4% of participants (7/67, intervention group) had sustained a fracture of the scaphoid (p = 0.37). In addition, 7.7% of participants (5/65, control group) and 22.4% of participants (15/67, intervention group) had other fractures diagnosed (p = 0.019). The use of MRI was associated with higher diagnostic accuracy both in the diagnosis of a fracture of the scaphoid (100.0% vs 93.8%) and of any other fracture (98.5% vs 84.6%). CONCLUSION: The use of immediate MRI in the management of participants with a suspected fracture of the scaphoid and negative radiographs led to cost savings while improving the pathway's diagnostic accuracy and patient satisfaction. Cite this article: Bone Joint J 2019;101-B:984-994.


Assuntos
Análise Custo-Benefício , Fraturas Ósseas/diagnóstico por imagem , Custos de Cuidados de Saúde/estatística & dados numéricos , Imagem por Ressonância Magnética/economia , Osso Escafoide/lesões , Traumatismos do Punho/diagnóstico por imagem , Adolescente , Adulto , Idoso , Redução de Custos/estatística & dados numéricos , Serviço Hospitalar de Emergência , Feminino , Seguimentos , Fraturas Ósseas/economia , Humanos , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Satisfação do Paciente/estatística & dados numéricos , Estudos Prospectivos , Radiografia , Osso Escafoide/diagnóstico por imagem , Reino Unido , Traumatismos do Punho/economia , Adulto Jovem
5.
N Engl J Med ; 381(5): 407-419, 2019 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-31365799

RESUMO

BACKGROUND: The World Health Organization recommends not performing transfusions in African children hospitalized for uncomplicated severe anemia (hemoglobin level of 4 to 6 g per deciliter and no signs of clinical severity). However, high mortality and readmission rates suggest that less restrictive transfusion strategies might improve outcomes. METHODS: In this factorial, open-label, randomized, controlled trial, we assigned Ugandan and Malawian children 2 months to 12 years of age with uncomplicated severe anemia to immediate transfusion with 20 ml or 30 ml of whole-blood equivalent per kilogram of body weight, as determined in a second simultaneous randomization, or no immediate transfusion (control group), in which transfusion with 20 ml of whole-blood equivalent per kilogram was triggered by new signs of clinical severity or a drop in hemoglobin to below 4 g per deciliter. The primary outcome was 28-day mortality. Three other randomizations investigated transfusion volume, postdischarge supplementation with micronutrients, and postdischarge prophylaxis with trimethoprim-sulfamethoxazole. RESULTS: A total of 1565 children (median age, 26 months) underwent randomization, with 778 assigned to the immediate-transfusion group and 787 to the control group; 984 children (62.9%) had malaria. The children were followed for 180 days, and 71 (4.5%) were lost to follow-up. During the primary hospitalization, transfusion was performed in all the children in the immediate-transfusion group and in 386 (49.0%) in the control group (median time to transfusion, 1.3 hours vs. 24.9 hours after randomization). The mean (±SD) total blood volume transfused per child was 314±228 ml in the immediate-transfusion group and 142±224 ml in the control group. Death had occurred by 28 days in 7 children (0.9%) in the immediate-transfusion group and in 13 (1.7%) in the control group (hazard ratio, 0.54; 95% confidence interval [CI], 0.22 to 1.36; P = 0.19) and by 180 days in 35 (4.5%) and 47 (6.0%), respectively (hazard ratio, 0.75; 95% CI, 0.48 to 1.15), without evidence of interaction with other randomizations (P>0.20) or evidence of between-group differences in readmissions, serious adverse events, or hemoglobin recovery at 180 days. The mean length of hospital stay was 0.9 days longer in the control group. CONCLUSIONS: There was no evidence of differences in clinical outcomes over 6 months between the children who received immediate transfusion and those who did not. The triggered-transfusion strategy in the control group resulted in lower blood use; however, the length of hospital stay was longer, and this strategy required clinical and hemoglobin monitoring. (Funded by the Medical Research Council and Department for International Development; TRACT Current Controlled Trials number, ISRCTN84086586.).


Assuntos
Anemia/terapia , Transfusão de Sangue , Hemoglobinas/análise , Tempo para o Tratamento , Anemia/complicações , Anemia/mortalidade , Transfusão de Sangue/economia , Criança , Pré-Escolar , Análise Custo-Benefício , Feminino , Seguimentos , Custos de Cuidados de Saúde , Humanos , Lactente , Tempo de Internação/economia , Malária/complicações , Malaui/epidemiologia , Masculino , Readmissão do Paciente/estatística & dados numéricos , Reação Transfusional/epidemiologia , Uganda/epidemiologia
6.
N Engl J Med ; 381(5): 420-431, 2019 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-31365800

RESUMO

BACKGROUND: Severe anemia (hemoglobin level, <6 g per deciliter) is a leading cause of hospital admission and death in children in sub-Saharan Africa. The World Health Organization recommends transfusion of 20 ml of whole-blood equivalent per kilogram of body weight for anemia, regardless of hemoglobin level. METHODS: In this factorial, open-label trial, we randomly assigned Ugandan and Malawian children 2 months to 12 years of age with a hemoglobin level of less than 6 g per deciliter and severity features (e.g., respiratory distress or reduced consciousness) to receive immediate blood transfusion with 20 ml per kilogram or 30 ml per kilogram. Three other randomized analyses investigated immediate as compared with no immediate transfusion, the administration of postdischarge micronutrients, and postdischarge prophylaxis with trimethoprim-sulfamethoxazole. The primary outcome was 28-day mortality. RESULTS: A total of 3196 eligible children (median age, 37 months; 2050 [64.1%] with malaria) were assigned to receive a transfusion of 30 ml per kilogram (1598 children) or 20 ml per kilogram (1598 children) and were followed for 180 days. A total of 1592 children (99.6%) in the higher-volume group and 1596 (99.9%) in the lower-volume group started transfusion (median, 1.2 hours after randomization). The mean (±SD) volume of total blood transfused per child was 475±385 ml and 353±348 ml, respectively; 197 children (12.3%) and 300 children (18.8%) in the respective groups received additional transfusions. Overall, 55 children (3.4%) in the higher-volume group and 72 (4.5%) in the lower-volume group died before 28 days (hazard ratio, 0.76; 95% confidence interval [CI], 0.54 to 1.08; P = 0.12 by log-rank test). This finding masked significant heterogeneity in 28-day mortality according to the presence or absence of fever (>37.5°C) at screening (P=0.001 after Sidak correction). Among the 1943 children (60.8%) without fever, mortality was lower with a transfusion volume of 30 ml per kilogram than with a volume of 20 ml per kilogram (hazard ratio, 0.43; 95% CI, 0.27 to 0.69). Among the 1253 children (39.2%) with fever, mortality was higher with 30 ml per kilogram than with 20 ml per kilogram (hazard ratio, 1.91; 95% CI, 1.04 to 3.49). There was no evidence of differences between the randomized groups in readmissions, serious adverse events, or hemoglobin recovery at 180 days. CONCLUSIONS: Overall mortality did not differ between the two transfusion strategies. (Funded by the Medical Research Council and Department for International Development, United Kingdom; TRACT Current Controlled Trials number, ISRCTN84086586.).


Assuntos
Anemia/terapia , Transfusão de Sangue , Hemoglobinas/análise , Anemia/complicações , Anemia/mortalidade , Transfusão de Sangue/economia , Criança , Pré-Escolar , Análise Custo-Benefício , Feminino , Febre/complicações , Seguimentos , Custos de Cuidados de Saúde , Humanos , Lactente , Tempo de Internação/economia , Malária/complicações , Malaui/epidemiologia , Masculino , Readmissão do Paciente/estatística & dados numéricos , Reação Transfusional/epidemiologia , Uganda/epidemiologia
7.
J Water Health ; 17(4): 499-516, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31313990

RESUMO

Harmful algal blooms (HABs) damage human activities and health. While there is wide literature on economic losses, little is known about the economic impact on human health. In this review, we systematically retrieved papers which presented health costs following exposure to HABs. A systematic review was conducted up to January 2019 in databases such as ScienceDirect and PubMed, and 16 studies were selected. Health costs included healthcare and medication expenses, loss of income due to illness, cost of pain and suffering, and cost of death. Two categories of illness (digestive and respiratory) were considered for health costs. For digestive illness cost, we found $86, $1,015 and $12,605, respectively, for mild, moderate and severe cases. For respiratory illness, costs were $86, $1,235 and $14,600, respectively, for mild, moderate and severe cases. We used Quality-Adjusted Life Years (QALYs) to access the loss of well-being due to illness caused by HABs. We found that breathing difficulty causes the most loss of QALYs, especially in children, with a loss of between 0.16 and 0.771 per child. Having gastroenteritis could cause a loss of between 2.2 and 7.1 QALYs per 1,000 children. Misleading symptoms of illness following exposure to HABs could cause bias in health costs estimations.


Assuntos
Efeitos Psicossociais da Doença , Proliferação Nociva de Algas , Criança , Custos de Cuidados de Saúde , Humanos , Renda , Anos de Vida Ajustados por Qualidade de Vida
8.
Medicine (Baltimore) ; 98(28): e16169, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31305399

RESUMO

We aim to examine temporal trends of orthopedic operations and opioid-related hospital stays among seniors in the nation and states of Oregon and Washington where marijuana legalization was accepted earlier than any others.As aging society advances in the United States (U.S.), orthopedic operations and opioid-related hospital stays among seniors increase in the nation.A serial cross-sectional cohort study using the healthcare cost and utilization project fast stats from 2006 through 2015 measured annual rate per 100,000 populations of orthopedic operations by age groups (45-64 vs 65 and older) as well as annual rate per 100,000 populations of opioid-related hospital stays among 65 and older in the nation, Oregon and Washington states from 2008 through 2017. Orthopedic operations (knee arthroplasty, total or partial hip replacement, spinal fusion or laminectomy) and opioid-related hospital stays were measured. The compound annual growth rate (CAGR) was used to quantify temporal trends of orthopedic operations by age groups as well as opioid-related hospital stays and was tested by Rao-Scott correction of χ for categorical variables.The CAGR (4.06%) of orthopedic operations among age 65 and older increased (P < .001) unlike the unchanged rate among age 45 to 64. The CAGRs of opioid-related hospital stays among age 65 and older were upward trends among seniors in general (6.79%) and in Oregon (10.32%) and Washington (15.48%) in particular (all P < .001).Orthopedic operations and opioid-related hospital stays among seniors increased over time in the U.S. Marijuana legalization might have played a role of gateway drug to opioid among seniors.


Assuntos
Analgésicos Opioides/uso terapêutico , Controle de Medicamentos e Entorpecentes , Artropatias/tratamento farmacológico , Idoso , Estudos Transversais , Custos de Cuidados de Saúde , Hospitalização/tendências , Humanos , Artropatias/economia , Artropatias/cirurgia , Uso da Maconha/legislação & jurisprudência , Pessoa de Meia-Idade , Oregon , Procedimentos Ortopédicos , Aceitação pelo Paciente de Cuidados de Saúde , Estudos Retrospectivos , Washington
9.
N Engl J Med ; 381(6): 543-551, 2019 08 08.
Artigo em Inglês | MEDLINE | ID: mdl-31291511

RESUMO

BACKGROUND: The Centers for Medicare and Medicaid Services (CMS) developed the Accountable Care Organization (ACO) Investment Model (AIM) to encourage the growth of Medicare Shared Savings Program (MSSP) ACOs in rural and underserved areas. AIM provides financial support to eligible MSSP ACOs by means of prepayment of shared savings. Estimation of the performance of AIM ACOs on measures of spending and utilization in their first performance year would be useful for understanding the viability of ACOs located in these areas. METHODS: We analyzed Medicare claims and enrollment data for a group of fee-for-service beneficiaries who had been attributed to 41 AIM ACOs and for a comparable group of beneficiaries who resided in the ACO markets but were served primarily by non-ACO providers. We used a difference-in-differences study design to compare changes in outcomes from the baseline period (2013 through 2015) to the performance period (2016) among beneficiaries attributed to AIM ACOs with concurrent changes among beneficiaries in the comparison group. The primary outcome of interest was total Medicare Part A and B spending. RESULTS: Provider participation in AIM was associated with a differential reduction in total Medicare spending of $28.21 per beneficiary per month relative to the comparison group, which amounted to an aggregate decrease of $131.0 million. Over the same period, CMS made $76.2 million in prepayments and paid an additional $6.2 million in shared savings to ACOs in which shared savings exceeded the prepayments. After we accounted for this $82.4 million in CMS spending, the aggregate net reduction was $48.6 million, which corresponded to a net reduction of $10.46 per beneficiary per month. Decreases in the number of hospitalizations and use of institutional post-acute care contributed to the observed reduction in overall spending. CONCLUSIONS: With up-front investments, participation in ACO shared savings contracts by providers serving rural and underserved areas was associated with lower Medicare spending than that among non-ACO providers. (Funded by the Centers for Medicare and Medicaid Services.).


Assuntos
Organizações de Assistência Responsáveis/economia , Gastos em Saúde , Área Carente de Assistência Médica , Medicare/economia , Serviços de Saúde Rural/economia , Idoso , Idoso de 80 Anos ou mais , Redução de Custos , Feminino , Custos de Cuidados de Saúde , Humanos , Revisão da Utilização de Seguros , Masculino , Poupança para Cobertura de Despesas Médicas , Pessoa de Meia-Idade , Estados Unidos
10.
Artigo em Alemão | MEDLINE | ID: mdl-31297549

RESUMO

BACKGROUND: Currently, there are 1.7 million people living with dementia (PwD) in Germany. This number is expected to double within the next decades. Estimates of the total societal economic burden of dementia are currently missing. OBJECTIVES: The aim was to estimate the current and future total cost and excess cost of dementia from a public payer and societal perspective. METHODS: Studies demonstrating the healthcare resource utilization of PwD in Germany were identified. Utilization data were aggregated using the sample size of different studies as a weight. Annual per capita costs of PwD and excess cost of dementia were calculated using standardized unit costs. Current and future costs were calculated based on published prevalence and population forecasts. RESULTS: PwD living at home had lower costs from a payer perspective compared to those who are institutionalized, but higher total societal cost due to the higher informal care time. The total cost for PwD from a payer perspective was 34 billion € in 2016. These costs could reach 90 billion € by 2060. The excess cost of dementia was 18 billion € in 2016 and is estimated to become 49 billion € by 2060 from a payer perspective, representing 54% of the total cost of PwD and up to 15% of the total costs associated with the elderly population. The total societal cost was 73 billion € in 2016 and is estimated to become 194 billion € by 2060. The excess cost of dementia was 54 billion € in 2016 and is estimated to become 145 billion € by 2060, representing 74% of the total societal cost of PwD and 36% of the total societal cost of the elderly. CONCLUSION: Dementia diseases represent a tremendous social and economic burden. Without a cure, supporting caregivers and implementing interventions that delay the functional and cognitive decline will be crucial to relieving the increasing costs.


Assuntos
Cuidadores/economia , Efeitos Psicossociais da Doença , Demência/economia , Demência/psicologia , Custos de Cuidados de Saúde/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Envelhecimento , Cuidadores/estatística & dados numéricos , Alemanha , Humanos , Aceitação pelo Paciente de Cuidados de Saúde , Alocação de Recursos
11.
Vasc Health Risk Manag ; 15: 187-208, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31308682

RESUMO

Peripheral arterial disease is a chronic vascular disease characterized by impaired circulation to the lower extremities. Its most severe stage, known as critical limb ischemia (CLI), puts patients at an increased risk of cardiovascular events, amputation, and death. The objective of this literature review is to describe the burden of disease across a comprehensive set of domains-epidemiologic, clinical, humanistic, and economic-focusing on key studies published in the last decade. CLI prevalence in the United States is estimated to be approximately 2 million and is likely to rise in the coming years given trends in important risk factors such as age, diabetes, and smoking. Hospitalization for CLI patients is common and up to 60% are readmitted within 6 months. Amputation rates are unacceptably high with a disproportionate risk for certain demographic and socioeconomic groups. In addition to limb loss, CLI patients also have reduced life expectancy with mortality typically exceeding 50% by 5 years. Given the poor clinical prognosis, it is unsurprising that the quality of life burden associated with CLI is significant. Studies assessing quality of life in CLI patients have used a variety of generic and disease-specific measures and all document a substantial impact of the disease on the patient's physical, social, and emotional health status compared to population norms. Finally, the poor clinical outcomes and increased medical resource use lead to a considerable economic burden for national health care systems. However, published cost studies are not comprehensive and, therefore, likely underestimate the true economic impact of CLI. Our summary documents a sobering assessment of CLI burden-a poor clinical prognosis translating into diminished quality of life and high costs for millions of patients. Continued prevention efforts and improved treatment strategies are the key to ameliorating the substantial morbidity and mortality associated with this disease.


Assuntos
Efeitos Psicossociais da Doença , Custos de Cuidados de Saúde , Isquemia/economia , Isquemia/terapia , Extremidade Inferior/irrigação sanguínea , Doença Arterial Periférica/economia , Doença Arterial Periférica/terapia , Amputação/economia , Estado Terminal , Humanos , Incidência , Isquemia/diagnóstico , Isquemia/epidemiologia , Salvamento de Membro , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/epidemiologia , Prevalência , Qualidade de Vida , Fatores de Risco , Resultado do Tratamento , Estados Unidos/epidemiologia
13.
BMJ ; 366: l4134, 2019 07 10.
Artigo em Inglês | MEDLINE | ID: mdl-31292124

RESUMO

OBJECTIVE: To determine whether 30 day mortality, 30 day readmissions, and inpatient spending vary according to whether physicians were exposed to work hour reforms during their residency. DESIGN: Retrospective observational study. SETTING: US Medicare. PARTICIPANTS: 20% random sample (n=485 685) of Medicare beneficiaries aged 65 years or more admitted to hospital and treated by a general internist during 2000-12. MAIN OUTCOME MEASURES: 30 day mortality, 30 day readmissions, and inpatient Medicare Part B spending among patients treated by first year internists who were fully exposed to the 2003 Accreditation Council for Graduate Medical Education (ACGME) work hour reforms during their residency (completed residency after 2006) compared with first year internists with partial or no exposure to reforms (completed residency before 2006). Senior internists not exposed to reforms during their residency served as a control group (10th year internists) for general trends in hospital care: a difference-in-difference analysis. RESULTS: Exposure of physicians to work hour reforms during their residency was not associated with statistically significant differences in 30 day mortality, 30 day readmissions, or inpatient spending. Among 485 685 hospital admissions, 30 day mortality rates during 2000-06 and 2007-12 for patients of first year internists were 10.6% (12 567 deaths/118 014 hospital admissions) and 9.6% (13 521/140 529), respectively, and for 10th year internists were 11.2% (11 018/98 811) and 10.6% (13 602/128 331), for an adjusted difference-in-difference effect of -0.1 percentage points (95% confidence interval -0.8% to 0.6%, P=0.68). 30 day readmission rates for first year internists during 2000-06 and 2007-12 were 20.4% (24 074/118 014) and 20.4% (28 689/140 529), respectively, and for 10th year internists were 20.1% (19 840/98 811) and 20.5% (26 277/128 331), for an adjusted difference-in-difference effect of 0.1 percentage points (-0.9% to 1.1%, P=0.87). Medicare Part B inpatient spending for first year internists during 2000-06 and 2007-12 was $1161 (£911; €1024) and $1267 per hospital admission, respectively, and for 10th year internists was $1331 and $1599, for an adjusted difference-in-difference effect of -$46 (95% confidence interval -$94 to $2, P=0.06). CONCLUSIONS: Exposure of internists to work hour reforms during their residency was not associated with post-training differences in patient mortality, readmissions, or costs of care.


Assuntos
Custos de Cuidados de Saúde/normas , Mortalidade Hospitalar , Hospitalização/economia , Internato e Residência , Readmissão do Paciente/economia , Garantia da Qualidade dos Cuidados de Saúde , Jornada de Trabalho em Turnos , Idoso , Idoso de 80 Anos ou mais , Feminino , Mortalidade Hospitalar/tendências , Hospitalização/tendências , Humanos , Internato e Residência/normas , Masculino , Medicare/economia , Readmissão do Paciente/normas , Readmissão do Paciente/tendências , Estudos Retrospectivos , Estados Unidos
15.
Urol Clin North Am ; 46(3): 353-362, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31277730

RESUMO

Experience demonstrates multiple paths to cure for patients with clinical stage I testicular cancer. Because all options should provide a long-term disease-free rate near 100%, overall survival is no longer relevant in decision making, allowing practitioners to factor in quality of life, toxicity, cost, and impact on compliance. Surveillance for clinical stage I seminoma and clinical stage I nonseminoma has become the preferred option. The contrarian view is that a risk-adapted approach should persist, with surveillance for low-risk individuals and active therapy high-risk individuals. However, results obtained in unselected patients provide a strong argument against the need for such an approach.


Assuntos
Neoplasias Embrionárias de Células Germinativas/patologia , Neoplasias Embrionárias de Células Germinativas/terapia , Neoplasias Testiculares/patologia , Neoplasias Testiculares/terapia , Biomarcadores Tumorais/metabolismo , Intervalo Livre de Doença , Custos de Cuidados de Saúde , Humanos , Masculino , Estadiamento de Neoplasias , Qualidade de Vida
16.
Urol Clin North Am ; 46(3): 363-376, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31277731

RESUMO

There are several treatment approaches for stage II germ cell tumors (GCTs), and a thorough understanding of the staging classification and histologic differences in tumor biology and therapeutic responsiveness is critical to determine an effective, multimodal management strategy that involves urologists, medical oncologists, and radiation oncologists. This article discusses contemporary management strategies for stage II GCTs, including chemotherapy, radiotherapy, retroperitoneal lymph node dissection (RPLND), and surveillance. Patient selection, histology, and extent of lymphadenopathy drive management, and, as both treatment and detection strategies continue to emerge and be refined, the management of patients with stage II GCT continues to evolve.


Assuntos
Neoplasias Embrionárias de Células Germinativas/patologia , Neoplasias Embrionárias de Células Germinativas/terapia , Neoplasias Testiculares/patologia , Neoplasias Testiculares/terapia , Intervalo Livre de Doença , Custos de Cuidados de Saúde , Humanos , Excisão de Linfonodo , Metástase Linfática , Masculino , Estadiamento de Neoplasias , Qualidade de Vida
17.
Rev. argent. salud publica ; 39(9): 25-30, Julio 2019. Tab
Artigo em Espanhol | LILACS, BINACIS, ARGMSAL | ID: biblio-1007193

RESUMO

INTRODUCCIÓN: Las lesiones asociadas al tránsito(LAT) constituyen un serio problema en hospitales públicos.Para mejorar la administración y distribución de recursos,es importante conocer el costo de hospitalización por esta causa. El objetivo del estudio fue caracterizar a los pacientes hospitalizados por LAT y estimar los costos directos de la asistencia entre enero y junio de 2017 en un hospital público de referencia de la provincia de Tucumán. MÉTODOS: Se realizó un estudio de estimación de costos de hospitalización por LAT, con seguimiento retrospectivo y sumatoria de variables contempladas. Se estimaron promedios, se compararon proporciones. Se consideró significativo p<0,05. Se empleó el programa estadístico Stata 11.2. RESULTADOS: Hubo 458 pacientes hospitalizados por LAT, el 79% fueron varones y y la mediana de edad fue de 27 años en ambos sexos. Las motos representaron el 77% de los vehículos utilizados. Los pacientes graves (25%) permanecieron más de 30 días en servicios quirúrgicos (costo promedio: USD 7.252). El costo promedio de estudios complementarios por paciente fue de USD 180, el de cirugías USD 823 y el de internación USD 1320. CONCLUSIONES: Las hospitalizaciones por LAT fueron principalmente en varones, jóvenes adultos y motociclistas. El mayor costo se observó en pacientes graves, que requirieron cirugía y un promedio de 35 días de internación en servicios quirúrgico


NTRODUCTION: Traffic-related injuries (TRI) are a major problem in public hospitals. For better resource management and distribution, it is important to know the cost of hospitalizations. The objective of this study was to characterize patients hospitalized due to TRI and to estimate the direct costs of the care provided between January and June 2017in a public hospital ofTucumán Province in Argentina. METHODS: A study of costs of patients hospitalized due to TRI was conducted, with retrospective follow-up and summation of the variables considered for the analysis. Averages were estimated and proportions were compared. A p value <0.05 was considered significant. Statistical software Stata 11.2 was used. RESULTS: A total of 458 patients were hospitalized due to TRI, 79% were men, and the median age was 27 for both sexes. Motorcycles accounted for 77% of all vehicles used. Severely injured patients (25%) stayed more than 30 days in surgical facilities (average cost: USD 7252). The average cost per patient of complementary studies, in surgeries and hospitalization was USD 180, USD 823 and USD 1320, respectively. CONCLUSIONS: Patients hospitalized due to TRI were mainly males, young adults and motorcyclists. The highest cost was in the group of patients with serious injuries, who required surgery, with an average stay of 35 days of hospitalization in surgical facilitie


Assuntos
Humanos , Masculino , Feminino , Adulto , Traumatismo Múltiplo , Acidentes de Trânsito , Custos de Cuidados de Saúde
20.
BMC Infect Dis ; 19(1): 552, 2019 Jun 24.
Artigo em Inglês | MEDLINE | ID: mdl-31234784

RESUMO

BACKGROUND: Human papillomavirus (HPV) is the most widespread sexually transmitted infection worldwide. It causes several health consequences, in particular accounting for the majority of cervical cancer cases in women. In the United Kingdom, a vaccination campaign targeting 12-year-old girls started in 2008; this campaign has been successful, with high uptake and reduced HPV prevalence observed in vaccinated cohorts. Recently, attention has focused on vaccinating both sexes, due to HPV-related diseases in males (particularly for high-risk men who have sex with men) and an equity argument over equalising levels of protection. METHODS: We constructed an epidemiological model for HPV transmission in the UK, accounting for nine of the most common HPV strains. We complemented this with an economic model to determine the likely health outcomes (healthcare costs and quality-adjusted life years) for individuals from the epidemiological model. We then tested vaccination with the three HPV vaccines currently available, vaccinating either girls alone or both sexes. For each strategy we calculated the threshold price per vaccine dose, i.e. the maximum amount paid for the added health benefits of vaccination to be worth the cost of each vaccine dose. We calculated results at 3.5% discounting, and also 1.5%, to consider the long-term health effects of HPV infection. RESULTS: At 3.5% discounting, continuing to vaccinate girls remains highly cost-effective compared to halting vaccination, with threshold dose prices of £56-£108. Vaccination of girls and boys is less cost-effective (£25-£53). Compared to vaccinating girls only, adding boys to the programme is not cost-effective, with negative threshold prices (-£6 to -£3) due to the costs of administration. All threshold prices increase when using 1.5% discounting, and adding boys becomes cost-effective (£36-£47). These results are contingent on the UK's high vaccine uptake; for lower uptake rates, adding boys (at the same uptake rate) becomes more cost effective. CONCLUSIONS: Vaccinating girls is extremely cost-effective compared with no vaccination, vaccinating both sexes is less so. Adding boys to an already successful girls-only programme has a low cost-effectiveness, as males have high protection through herd immunity. If future health effects are weighted more heavily, threshold prices increase and vaccination becomes cost-effective.


Assuntos
Análise Custo-Benefício , Modelos Econômicos , Infecções por Papillomavirus/prevenção & controle , Vacinas contra Papillomavirus/imunologia , Vacinação/economia , Adolescente , Feminino , Custos de Cuidados de Saúde , Humanos , Imunidade Coletiva , Masculino , Papillomaviridae/imunologia , Infecções por Papillomavirus/epidemiologia , Infecções por Papillomavirus/imunologia , Vacinas contra Papillomavirus/administração & dosagem , Anos de Vida Ajustados por Qualidade de Vida , Reino Unido/epidemiologia , Neoplasias do Colo do Útero/prevenção & controle
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