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1.
World Neurosurg ; 131: e579-e585, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31404690

RESUMO

BACKGROUND: Spinal arteriovenous malformations (AVM) are an abnormal interconnection of vasculature in the spine than can lead to significant neurologic deficit if left untreated. OBJECTIVE: The objective of this study was to characterize how patients with spinal AVM initially presented, what treatment options were used, and their overall outcomes on a national scale. METHODS: The MarketScan database was queried to identify adult patients diagnosed with a spinal AVM from 2007 to 2015. Trends in management, postoperative complication rates, and costs were determined. RESULTS: In total, 976 patients were identified with having a diagnosis of a spinal AVM. Patients were more commonly treated with an open incision than an embolization (40.1% vs. 15.4%). The overall complication rate was 33.61%. Spinal AVM admissions have been stable over the past decade, and mean cost of hospitalization has risen from of $48,700 in 2007 to $71,292 in 2015. Patients who underwent open surgery had a greater complication rate than those treated with embolization (31.15% vs. 18.25%, P < 0.005); however, this may be strongly influenced by complexity of spinal AVM pathology and not treatment modality. CONCLUSIONS: Costs of spinal AVM management continue to rise, even when treatment modalities have reduced length of stay significantly. Open surgery may lead to more postoperative complications and a greater length of stay than endovascular approaches. Further studies should look to identify the efficacy of endovascular approaches for spinal cord AVMs, particularly in complex spinal AVM traditionally treated with open surgery and to isolate factors leading to the elevated hospitalization costs.


Assuntos
Malformações Arteriovenosas/terapia , Embolização Terapêutica/métodos , Procedimentos Neurocirúrgicos/métodos , Complicações Pós-Operatórias/epidemiologia , Medula Espinal/irrigação sanguínea , Adulto , Idoso , Malformações Arteriovenosas/economia , Malformações Arteriovenosas/epidemiologia , Embolização Terapêutica/economia , Feminino , Custos de Cuidados de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos/economia , Complicações Pós-Operatórias/economia , Estados Unidos/epidemiologia
2.
World J Pediatr Congenit Heart Surg ; 10(4): 407-413, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31307303

RESUMO

BACKGROUND: Plastic bronchitis is a dreaded complication of single ventricle physiology occurring following palliation via Fontan procedure. Medical management of plastic bronchitis often fails, requiring heart transplantation. Percutaneous lymphatic embolization is an emerging treatment for plastic bronchitis. METHODS: To determine the cost-effectiveness of competing management strategies, a modified Markov model was constructed with patients transiting through treatments-medical management, lymphatic embolization, or heart transplantation from a hospital system perspective. Health state transitions were modeled using an institutional review board-approved retrospective review of the Children's Hospital of Pennsylvania's plastic bronchitis cohort. Medication pricing data were obtained from the National Inpatient Sample. Differences in costs and quality-adjusted life years (QALYs) over a five-year horizon for each group were determined. The incremental cost-effectiveness ratio was then calculated. RESULTS: The mean cost of lymphatic embolization from procedure performance was US$340,941, US$385,841 for heart transplantation, and US$594,520 for medical management. The mean quality-adjusted survival of lymphatic embolization yielded an additional 0.66 QALYs (P < .03) relative to heart transplantation and 1.3 (P < .0001) relative to medical management. Orthotopic heart transplantation yielded an additional 0.66 QALYs (P = .06) when comparing heart transplantation to medical management. Compared to medical management, lymphatic embolization generated an incremental cost-effectiveness ratio of US$192,105. Similarly, compared to heart transplantation, lymphatic embolization yielded an incremental cost-effectiveness ratio of US$68,030. CONCLUSIONS: Of the available plastic bronchitis treatments, with a willingness to pay of US$150,000, lymphatic embolization produces an incremental cost-effectiveness ratio within the bounds considered to be cost-effective, potentially causing financial benefits to the health system.


Assuntos
Bronquite/terapia , Cateterismo Periférico/métodos , Embolização Terapêutica/economia , Técnica de Fontan/efeitos adversos , Vasos Linfáticos/diagnóstico por imagem , Complicações Pós-Operatórias , Bronquite/etiologia , Análise Custo-Benefício , Embolização Terapêutica/métodos , Feminino , Humanos , Linfografia , Estudos Retrospectivos
3.
J Neurointerv Surg ; 11(12): 1210-1215, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31239332

RESUMO

BACKGROUND: Endovascular treatment of basilar tip aneurysms is less invasive than microsurgical clipping, but requires closer follow-up. OBJECTIVE: To characterize the additional costs associated with endovascular treatment of basilar tip aneurysms rather than microsurgical clipping. MATERIALS AND METHODS: We obtained clinical records and billing information for 141 basilar tip aneurysms treated with clip ligation (n=48) or endovascular embolization (n=93). Costs included direct and indirect costs associated with index hospitalization, as well as re-treatments, follow-up visits, imaging studies, rehabilitation, and disability. Effectiveness of treatment was quantified by converting functional outcomes (modified Rankin Scale (mRS) score) into quality-adjusted life-years (QALYs). Cost-effectiveness was performed using cost/QALY ratios. RESULTS: Average index hospitalization costs were significantly higher for patients with unruptured aneurysms treated with clip ligation ($71 400 ± $47 100) compared with coil embolization ($33 500 ± $22 600), balloon-assisted coiling ($26 200 ± $11 600), and stent-assisted coiling ($38 500 ± $20 900). Multivariate predictors for higher index hospitalization cost included vasospasm requiring endovascular intervention, placement of a ventriculoperitoneal shunt, longer length of stay, larger aneurysm neck and width, higher Hunt-Hess grade, and treatment-associated complications. At 1 year, endovascular treatment was associated with lower cost/QALY than clip ligation in unruptured aneurysms ($52 000/QALY vs $137 000/QALY, respectively, p=0.006), but comparable rates in ruptured aneurysms ($193 000/QALY vs $233 000/QALY, p=0.277). Multivariate predictors for higher cost/QALY included worse mRS score at discharge, procedural complications, and larger aneurysm width. CONCLUSIONS: Coil embolization of basilar tip aneurysms is associated with a lower cost/QALY. This effect is sustained during follow-up. Clinical condition at discharge is the most significant predictor of overall cost/QALY at 1 year.


Assuntos
Aneurisma Roto/economia , Aneurisma Roto/terapia , Análise Custo-Benefício , Aneurisma Intracraniano/economia , Aneurisma Intracraniano/terapia , Adulto , Idoso , Análise Custo-Benefício/tendências , Embolização Terapêutica/economia , Embolização Terapêutica/métodos , Procedimentos Endovasculares/economia , Procedimentos Endovasculares/métodos , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Stents/economia , Instrumentos Cirúrgicos/economia , Resultado do Tratamento
4.
Ann Vasc Surg ; 60: 85-94, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31200030

RESUMO

BACKGROUND: Type II endoleaks are the most common complications after endovascular repair of abdominal aortic aneurysms (EVARs). Some studies have shown the benefit of preventive inferior mesenteric artery (IMA) embolization, but its efficacy and cost-effectiveness continue to be controversial. The aim of this study was to evaluate the efficacy of this procedure on the increase in aneurysmal sac diameter during follow-up. MATERIALS AND METHODS: All consecutive patients who underwent the embolization of the IMA before EVAR in our center, between January 2014 and July 2016, were included. We retrospectively compared the diameter of the aortic aneurysm sac, the rate of endoleak and reinterventions, and the theoretical cost of management between these patients (group 2) and a historical cohort of patients treated for EVAR before January 2014 who did not undergo prior IMA embolization (group 1). RESULTS: Two hundred twenty-four patients were retrospectively analyzed. After exclusion, we compared a group of 37 embolized patients with a control group of 46 patients. The rate of enlargement in the aneurysmal sac diameter was significantly higher in the control group at 2 years (27.9% vs. 4.3%, P = 0.025). The type II endoleak rate at 2 years was significantly higher in the control group (53.1% vs. 18.2%, P = 0.012), as was the aneurysm-related reintervention rate (31.1% vs. 8.1%, P = 0.013). Multivariate analysis confirmed these results. At 2 years of follow-up, there was no difference in the overall cost of patient management between the 2 groups. CONCLUSIONS: Preventive IMA embolization is an effective, reliable, and cost-effective technique that seems to reduce the rate of the aneurysmal sac diameter enlargement, type II endoleak, and reinterventions after EVAR.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular , Embolização Terapêutica/métodos , Endoleak/prevenção & controle , Procedimentos Endovasculares , Artéria Mesentérica Inferior , Idoso , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/economia , Aneurisma da Aorta Abdominal/fisiopatologia , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/economia , Análise Custo-Benefício , Embolização Terapêutica/efeitos adversos , Embolização Terapêutica/economia , Endoleak/diagnóstico por imagem , Endoleak/economia , Endoleak/fisiopatologia , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/economia , Feminino , Custos de Cuidados de Saúde , Humanos , Masculino , Artéria Mesentérica Inferior/diagnóstico por imagem , Artéria Mesentérica Inferior/fisiopatologia , Estudos Retrospectivos , Fatores de Risco , Circulação Esplâncnica , Fatores de Tempo , Resultado do Tratamento
5.
J Vasc Interv Radiol ; 30(3): 293-297, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30819468

RESUMO

PURPOSE: To analyze the cost-effectiveness of radioembolization in the treatment of intrahepatic cholangiocarcinoma (ICC) using the Surveillance, Epidemiology, and End Results (SEER) Medicare cancer database. MATERIALS AND METHODS: Cost as measured by total treatment-related reimbursement in patients diagnosed with ICC who received chemotherapy alone or chemotherapy and yttrium-90 radioembolization was assessed in the SEER Medicare cancer database (1999-2012). Survival analysis was performed, and incremental cost-effectiveness ratios were generated. RESULTS: The study included 585 patients. Average age at diagnosis was 71 years (standard deviation: 9.9), and 52% of patients were male. Twelve percent of patients received chemotherapy with radioembolization (n = 72), and 88% of patients (n = 513) received only chemotherapy. Median survival was 1043 days (95% confidence interval [CI]: 894-1244) for chemotherapy plus radioembolization and 811 days (95% CI: 705-925) for chemotherapy alone (P = .02). Patients who received combination therapy were slightly younger (71 vs 69 years, P = .03). No significant differences were observed between treatment groups in age at treatment, sex, race, or city size. Multivariable analysis showed a hazard ratio for progression for combination therapy versus chemotherapy alone of 0.76 (95% CI: 0.59-0.97, P = .029). The incremental cost-effectiveness ratio, a measure of cost of each added year of life, was $50,058.65 per year (quartiles: $11,454.63, $52,763.28). CONCLUSIONS: Combination therapy of ICC with chemotherapy and radioembolization is associated with higher median survival and can be a cost-effective treatment, with a median cost of $50,058.65 per additional year of survival.


Assuntos
Neoplasias dos Ductos Biliares/economia , Neoplasias dos Ductos Biliares/radioterapia , Quimiorradioterapia/economia , Colangiocarcinoma/economia , Colangiocarcinoma/radioterapia , Embolização Terapêutica/economia , Custos de Cuidados de Saúde , Medicare/economia , Compostos Radiofarmacêuticos/administração & dosagem , Compostos Radiofarmacêuticos/economia , Radioisótopos de Ítrio/administração & dosagem , Radioisótopos de Ítrio/economia , Idoso , Idoso de 80 Anos ou mais , Antineoplásicos/administração & dosagem , Antineoplásicos/economia , Neoplasias dos Ductos Biliares/patologia , Quimiorradioterapia/efeitos adversos , Colangiocarcinoma/patologia , Análise Custo-Benefício , Bases de Dados Factuais , Custos de Medicamentos , Embolização Terapêutica/efeitos adversos , Feminino , Humanos , Masculino , Compostos Radiofarmacêuticos/efeitos adversos , Estudos Retrospectivos , Programa de SEER , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , Radioisótopos de Ítrio/efeitos adversos
6.
Ann Otol Rhinol Laryngol ; 128(5): 401-405, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30739476

RESUMO

OBJECTIVE: Multidisciplinary vascular anomaly clinics (VACs) offer important value to pediatric patients with complex vascular anomalies whose care overlaps specialties. These clinics are labor intensive and costly to operate since providers see fewer patients compared to their individual specialty clinic. Our North American tertiary care institution's VAC specialists include a pediatric otolaryngologist, pediatric surgeon, pediatric plastic surgeon, pediatric dermatologist, and interventional radiologist. To assess financial feasibility, we conducted a cost analysis of our VACs comprised of 2 half-day multidisciplinary physician attended clinics (5 specialists at our main campus and 2 specialists at a satellite clinic) and a half-day nurse practitioner clinic. METHOD: Assessment of net revenue based on net collections for clinic, professional, operative, hospital setting, and facility charges generated during 12 consecutive monthly VACs beginning July 1, 2015. Expense calculations included provider and staff salaries, benefits, supply costs, and clinic leasing costs. RESULTS: There were 469 clinic visits, of which 202 were new patient evaluations. Sixty-eight patients underwent 93 procedures under general anesthesia, including procedures performed by our interventional radiologist, most commonly sclerotherapy or embolization (n = 37), surgical interventions including endoscopy (n = 36), or laser procedures (n = 20). Three patients were admitted. Fifty-seven patients received a new diagnosis different from that for which they were referred. Gross revenue was $1 810 525, and net revenue was 42.5%, or $783 152. Expenses totaled $453 415 for a net positive revenue of $329 737. CONCLUSION: When including direct downstream revenue, particularly from operative procedures, our VAC program operates on a net positive margin, making the program financially feasible.


Assuntos
Instituições de Assistência Ambulatorial/economia , Malformações Vasculares/terapia , Anestesia Geral/estatística & dados numéricos , Custos e Análise de Custo , Embolização Terapêutica/economia , Embolização Terapêutica/estatística & dados numéricos , Endoscopia/economia , Endoscopia/estatística & dados numéricos , Estudos de Viabilidade , Pessoal de Saúde/economia , Humanos , Terapia a Laser/economia , Terapia a Laser/estatística & dados numéricos , América do Norte , Admissão do Paciente/economia , Admissão do Paciente/estatística & dados numéricos , Pediatria , Mecanismo de Reembolso , Estudos Retrospectivos , Salários e Benefícios/economia , Escleroterapia/economia , Escleroterapia/estatística & dados numéricos
7.
World Neurosurg ; 125: 461-468, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30743038

RESUMO

OBJECTIVES: Rupture of unruptured intracranial aneurysms (UIA) is the main cause for subarachnoid hemorrhage. UIA are widespread among the population. Advanced technology enables us to diagnose UIAs with increasing reliability and subsequently treat them. There are 2 main treatment options: surgical clipping and endovascular treatment of the aneurysm. This article aims to analyze costs of neurosurgical clipping and the endovascular approach to treat UIA, and to give an overview over the existing literature. METHODS: A systematic literature search was conducted using the databases Ovid MEDLINE, PubMed, and NHS EED. Articles were divided into 2 groups based on the perspective from which costs were evaluated (health care provider or payer). Costs were inflated to the year 2015 and converted to international dollars. RESULTS: The literature search yielded 137 different articles out of which 15 have been considered relevant and have been included in this review. Not only absolute numbers but also the cost ratio of both treatment modalities showed substantial variations. The coiling procedure tends to be more expensive for health care providers but cheaper for cost bearers. Without any exception, the authors determined shorter lengths of stay for patients who underwent the coiling procedure. CONCLUSIONS: Due to different definitions of hospital costs and hardly reproducible calculations, comparability of the stated numbers is limited. Besides the economic impact, outcomes must be considered when making a treatment decision. The 2 treatment modalities are not equally suitable in every patient nor for every aneurysm location.


Assuntos
Embolização Terapêutica/métodos , Procedimentos Endovasculares/métodos , Aneurisma Intracraniano/terapia , Procedimentos Neurocirúrgicos/métodos , Cuidados Críticos/economia , Embolização Terapêutica/economia , Procedimentos Endovasculares/economia , Procedimentos Endovasculares/instrumentação , Custos Hospitalares , Humanos , Aneurisma Intracraniano/economia , Tempo de Internação/economia , Procedimentos Neurocirúrgicos/economia , Procedimentos Neurocirúrgicos/instrumentação , Hemorragia Subaracnóidea/economia , Hemorragia Subaracnóidea/terapia , Instrumentos Cirúrgicos
8.
Cardiovasc Intervent Radiol ; 42(4): 520-527, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30506168

RESUMO

PURPOSE: Minimally invasive alternatives to transurethral resection of the prostate (TURP) such as prostate arterial embolization (PAE) and photoselective vaporization of the prostate (PVP) are being explored as adjuncts in the care of patients with benign prostatic hyperplasia. However, there are conflicting reports of the costs of these procedures. The purpose of this study was to compare the direct and indirect hospital costs of TURP, PAE and PVP. MATERIALS AND METHODS: A chart review was performed in patients who underwent TURP, PVP and PAE from April 2015 to March 2017. All hospital costs were collected in accordance with the Ontario Case Costing Initiative, a standardized medical case costing system. Costs were characterized as direct or indirect and fixed or variable. Probabilistic sensitivity analysis was conducted to study cost uncertainty. RESULTS: During the study period, a total of 209 men underwent TURP, 28 PVP and 21 PAE. Mean age (years) was as follows: TURP 71.43; PVP 73.66; PAE 70.77 (p = 0.366). Mean length of stay (days) was as follows: TURP 1.63; PVP 1.55; PAE 1 (p = 0.076). Total costs of the PAE group ($3829, SD $1582) were less than both PVP ($5719, SD $1515) and TURP groups ($5034, SD $1997, p < 0.001). There was no significant difference in direct costs between the groups. Monte Carlo simulation demonstrated that PAE was the least costly alternative majority of the time. CONCLUSIONS: The total hospital costs of PAE at our institution are significantly lower than those of PVP and TURP.


Assuntos
Análise Custo-Benefício/economia , Embolização Terapêutica/economia , Custos Hospitalares/estatística & dados numéricos , Terapia a Laser/economia , Hiperplasia Prostática/terapia , Ressecção Transuretral da Próstata/economia , Idoso , Humanos , Masculino , Hiperplasia Prostática/economia , Resultado do Tratamento
9.
BJU Int ; 123(6): 1055-1060, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30578705

RESUMO

OBJECTIVES: To perform a post hoc analysis of in-hospital costs incurred in a randomized controlled trial comparing prostatic artery embolization (PAE) and transurethral resection of the prostate (TURP). PATIENTS AND METHODS: In-hospital costs arising from PAE and TURP were calculated using detailed expenditure reports provided by the hospital accounts department. Total costs, including those arising from surgical and interventional procedures, consumables, personnel and accommodation, were analysed for all of the study participants and compared between PAE and TURP using descriptive analysis and two-sided t-tests, adjusted for unequal variance within groups (Welch t-test). RESULTS: The mean total costs per patient (±sd) were higher for TURP, at €9137 ± 3301, than for PAE, at €8185 ± 1630. The mean difference of €952 was not statistically significant (P = 0.07). While the mean procedural costs were significantly higher for PAE (mean difference €623 [P = 0.009]), costs apart from the procedure were significantly lower for PAE, with a mean difference of €1627 (P < 0.001). Procedural costs of €1433 ± 552 for TURP were mainly incurred by anaesthesia, whereas €2590 ± 628 for medical supplies were the main cost factor for PAE. CONCLUSIONS: Since in-hospital costs are similar but PAE and TURP have different efficacy and safety profiles, the patient's clinical condition and expectations - rather than finances - should be taken into account when deciding between PAE and TURP.


Assuntos
Embolização Terapêutica/economia , Custos Hospitalares , Doenças Prostáticas/cirurgia , Ressecção Transuretral da Próstata/economia , Idoso , Hospitalização/economia , Humanos , Masculino , Pessoa de Meia-Idade , Doenças Prostáticas/economia , Suíça , Resultado do Tratamento
10.
Neurocirugia (Astur) ; 29(6): 267-274, 2018.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-30145034

RESUMO

OBJECTIVE: to evaluate the results and costs of surgical treatment against endovascular in non ruptured aneurysms. MATERIAL AND METHODS: retrospective study of a consecutive series non ruptured aneurysms from a single-center treated endovascularly (EV) and surgically (SC). A descriptive study of demographic (age, sex) charqacteristics of the patients and the radiological aspects of the aneurysms have been carried out. Clinical results (GOS at 6 months), angiographic data (occlusion classification) and economic costs have been evaluated in both globally, and in each of the groups. RESULTS: 89 patients treated between 2010 and 2015 were reviewed. Most of them were treated endovascularly (74%). There were no statiscally significant differences between EV and SC groups. 89% of the patients presented favourable GOS (4-5) at six months, being this percentage similar in both groups. Complete occlusion was much higher in SC group (96%) than in EV (55%). Retreatment rate was 24% in EV group and 0% in SC group. The retreatments were more frequent in anterior circulation aneurysms and bigger aneurysms (> 10 mm). The expenses in the SC group come mainly from hospital stay, meanwhile in the EV group is due to embolisation materials. The average length of stay (ALOS) are higher in SC group but costs of first admission are higher in EV group (14% more). When the costs of retreatments and follow up are included the costs of endovascular treatment is much higher than the surgical (61% more expensive). CONCLUSIONS: results of both types of treatment are comparable. The grade of aneurysmal occlusion of the SC group was higher than the EV, as well as the stability of the treatment, requiring fewer retreatments. Althoug the ALOS in SC group were longer, the costs of the EV group were significantly higher than the SC group due to the costs of embolisation materials, follow up that they need and the rate of retreatment. Adequate selection of candidates for endovascular coiling could improve angiographic outcomes, reduce retraction rates, and save costs.


Assuntos
Craniotomia , Embolização Terapêutica , Procedimentos Endovasculares , Aneurisma Intracraniano/terapia , Adulto , Idoso , Cateteres/economia , Angiografia Cerebral/economia , Craniotomia/economia , Custos Diretos de Serviços , Embolização Terapêutica/economia , Embolização Terapêutica/instrumentação , Procedimentos Endovasculares/economia , Procedimentos Endovasculares/instrumentação , Feminino , Humanos , Achados Incidentais , Aneurisma Intracraniano/economia , Aneurisma Intracraniano/cirurgia , Tempo de Internação , Angiografia por Ressonância Magnética/economia , Masculino , Pessoa de Meia-Idade , Neuroimagem/economia , Estudos Retrospectivos , Espanha/epidemiologia , Stents/economia , Resultado do Tratamento
11.
BMC Cancer ; 18(1): 715, 2018 Jul 05.
Artigo em Inglês | MEDLINE | ID: mdl-29976149

RESUMO

BACKGROUND: Trans-arterial radio-embolization (TARE) is an emerging treatment for the management of hepatocellular carcinoma (HCC). TARE may compete with systemic chemotherapy, sorafenib, in intermediate stage patients with prior chemoembolization failure or advanced patients with tumoral macrovascular invasion with no extra-hepatic spread and good liver function. We performed a budget impact analysis (BIA) evaluating the expected changes in the expenditure for the Italian Healthcare Service within scenarios of increased utilization of TARE in place of sorafenib over the next five years. METHODS: Starting from patient level data from three oncology centres in Italy, a Markov model was developed to project on a lifetime horizon survivals and costs associated to matched cohorts of intermediate-advanced HCC patients treated with TARE or sorafenib. The initial model has been integrated with epidemiological data to perform a BIA comparing the current scenario with 20 and 80% utilization rates for TARE and sorafenib, respectively, with increasing utilization rates of TARE of 30, 40 and 50% over the next 1, 3 and 5 years. RESULTS: Compared to the current scenario, progressively increasing utilization rates of TARE over sorafenib in the next 5 years is expected to save globally about 7 million Euros. CONCLUSIONS: Radioembolization can be considered a valuable treatment option for patients with intermediate-advanced HCC. These findings enrich the evidence about the economic sustainability of TARE in comparison to standard systemic chemotherapy within the context of a national healthcare service.


Assuntos
Carcinoma Hepatocelular/terapia , Embolização Terapêutica/métodos , Neoplasias Hepáticas/terapia , Embolização Terapêutica/economia , Custos de Cuidados de Saúde , Recursos em Saúde , Humanos , Cadeias de Markov
12.
World Neurosurg ; 115: 393-399, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-29656151

RESUMO

OBJECTIVE: Comparison of feasibility and safety between endovascular coiling versus neurosurgical clipping for the management of unruptured intracranial aneurysms (UIAs) has been incrementally reported. However, economic comparison has been rarely reported. This meta-analysis aims at qualitatively and quantitatively analyzing the difference of hospital costs and length of stay between endovascular versus neurosurgical treatment in UIA. METHODS: MEDLINE, the Cochrane database, EMBASE, and Web of Science database were searched for cohort studies describing economic hospital cost or length of stay in patients with UIA. Two authors independently assessed study eligibility and rated quality using the Newcastle Ottawa Scale. Ravmen 5.2 was used to perform forest plot analysis. RESULTS: Nine studies describing 24,856 UIAs treated with neurosurgical clipping and 31,309 UIAs treated with endovascular coiling were included. Meta-analysis revealed that the total hospital costs (THCs) were similar between coiling and clipping in UIA patients (standard mean difference [SMD]: -0.33, 95% confidence interval: -0.68 to 0.02, I2 = 99%, P = 0.07). Subgroup analysis showed that THCs of coiling were significantly lower than clipping in the United States but opposite in South Korea. One-year medical costs of coiling were similar in both groups (SMD: -0.04, 95% CI: -0.08 to 0.00, I2 = 0%, P = 0.07). In addition, the length of stay of coiling were significantly shorter than that of clipping (SMD: 0.69, 95% CI: 0.56-0.81, I2 = 95%, P < 0.001). CONCLUSION: Generally, no significant difference in THCs and 1-year medical costs between coiling versus clipping in UIAs was observed. However, the length of stay of endovascular coiling was much shorter than neurosurgical clipping and decreased over time.


Assuntos
Procedimentos Endovasculares/economia , Custos Hospitalares , Aneurisma Intracraniano/economia , Tempo de Internação/economia , Procedimentos Neurocirúrgicos/economia , Embolização Terapêutica/economia , Embolização Terapêutica/tendências , Procedimentos Endovasculares/tendências , Custos Hospitalares/tendências , Humanos , Aneurisma Intracraniano/cirurgia , Tempo de Internação/tendências , Procedimentos Neurocirúrgicos/tendências
13.
J Neurointerv Surg ; 10(6): 602-605, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-28916562

RESUMO

BACKGROUND: Endovascular treatment of aneurysms with coils is among the most frequent treatments in interventional neuroradiology, and represents an important expense. Each manufacturer has created several types of coils, with prices varying among brands and coil types. The objective of this study was to assess the impact of cost awareness of the exact price of each coil by the operating physician on the total cost of aneurysm coiling. MATERIALS AND METHODS: This was a comparative study conducted over 1 year in a single tertiary care center. The reference cohort and the experimental cohort consisted of all aneurysm embolization procedures performed during the first 6 months and the last 6 months, respectively. During the second period, physicians were given an information sheet with the prices of all available coils and were requested to look at the sheet during each procedure with the instruction to try to reduce the total cost of the coils used. Expenses related to the coiling procedures during each period were compared. RESULTS: 77 aneurysms (39 ruptured) in the reference cohort and 73 aneurysms (36 ruptured) in the experimental cohort were treated, respectively. There was no statistically significant difference regarding aneurysm location and mean size. The overall cost of the coiling procedures, the mean number of coils used per procedure, and the median cost of each procedure did not differ significantly between the two cohorts. CONCLUSION: Awareness of the precise price of coils by operators without any additional measure did not have a scientifically proven impact on the cost of aneurysm embolization.


Assuntos
Aneurisma Roto/economia , Análise Custo-Benefício/métodos , Embolização Terapêutica/economia , Conhecimentos, Atitudes e Prática em Saúde , Aneurisma Intracraniano/economia , Papel do Médico , Adulto , Idoso , Aneurisma Roto/terapia , Estudos de Coortes , Embolização Terapêutica/instrumentação , Embolização Terapêutica/métodos , Feminino , Humanos , Aneurisma Intracraniano/terapia , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento
14.
J Vasc Surg ; 67(1): 134-141, 2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-28666823

RESUMO

BACKGROUND: Endovascular aneurysm repair of aortoiliac or iliac aneurysms is often performed with stent graft coverage of the origin of the hypogastric artery (HA) to ensure adequate distal seal. It is considered common practice to perform adjunctive coiling of the HA to prevent a type II endoleak. Our objective was to question the necessity of pre-emptive coiling by comparing the outcomes of HA coverage with and without prior coil embolization. METHODS: Data from the Endurant Stent Graft Natural Selection Global Postmarket Registry (ENGAGE), which prospectively enrolled 1263 endovascular aneurysm repair patients between March 2009 and April 2011 from multiple centers worldwide, were used for this study. We identified patients in whom the Endurant stent graft (Medtronic Vascular, Santa Rosa, Calif) covered one or both HAs and grouped them into cases in which prior HA embolization-coils or plugs-was performed (CE) and cases in which HA embolization was not performed (NE). The occurrence of covered HA-related endoleak and secondary interventions were compared between groups. RESULTS: In 197 patients, 225 HAs were covered. Ninety-one HAs were covered after coil embolization (CE group), and 134 HAs were covered without prior coil embolization (NE group). Both groups were similar at baseline and had comparable length of follow-up to last image (665.2 ± 321.7 days for CE patients; 641.6 ± 327.6 days for NE patients; P = .464). Importantly, both groups showed equivalent iliac morphology concerning common iliac artery proximal, mid, and distal dimensions and tortuosity, making them suitable for comparative analysis. During follow-up, HA-related endoleaks were sparse and occurred equally often in both groups (CE 5.5% vs NE 3.0%; P = .346). Secondary intervention to resolve an HA-related endoleak was performed twice in the CE group and three times in the NE group. Late non-HA-related endoleaks occurred more often in the CE group compared with the NE group, (25.0% vs 15.0%; P = .080). Secondary interventions for other reasons than HA-related endoleaks occurred in 7.5% of NE cases and 15.4% of CE cases (P = .057), mostly for occlusions in the ipsilateral iliac limb. During follow-up, 19 NE patients and 9 CE patients died, which is not significantly different (P = .225), and no deaths were related directly or indirectly to HA coverage. Also, no reports of gluteal necrosis and bowel ischemia were made. CONCLUSIONS: This study shows that HA coverage with the Endurant endograft without prior coil embolization does not increase the incidence of endoleak or related secondary interventions. These findings together with the already available evidence suggest that omission of coil embolization may be a more resource-effective strategy whenever HA coverage is required.


Assuntos
Aneurisma da Aorta Abdominal/terapia , Implante de Prótese Vascular/métodos , Embolização Terapêutica/estatística & dados numéricos , Endoleak/epidemiologia , Procedimentos Endovasculares/métodos , Aneurisma Ilíaco/terapia , Sistema de Registros/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Aorta Abdominal/diagnóstico por imagem , Aorta Abdominal/cirurgia , Aneurisma da Aorta Abdominal/mortalidade , Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/economia , Implante de Prótese Vascular/instrumentação , Angiografia por Tomografia Computadorizada , Análise Custo-Benefício , Embolização Terapêutica/economia , Embolização Terapêutica/instrumentação , Embolização Terapêutica/métodos , Endoleak/etiologia , Endoleak/prevenção & controle , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/economia , Procedimentos Endovasculares/instrumentação , Feminino , Seguimentos , Humanos , Aneurisma Ilíaco/mortalidade , Artéria Ilíaca/diagnóstico por imagem , Artéria Ilíaca/cirurgia , Incidência , Masculino , Estudos Prospectivos , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Stents/efeitos adversos , Resultado do Tratamento
15.
Neurosurgery ; 82(4): 497-505, 2018 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-28541411

RESUMO

BACKGROUND: The benefit of surgical treatment of ruptured aneurysms is well established. OBJECTIVE: To determine whether ultra-early ruptured aneurysm treatment leads to not only improved outcomes but also reduced hospitalization cost. METHODS: Using 2008-2011 Nationwide Inpatient Sample data, we analyzed demographic, clinical, and hospital factors for nontraumatic subarachnoid hemorrhage (SAH) patients who were "directly" admitted to the treating hospital where they underwent intervention (clipping/coiling). Patients treated on the day of admission (day 0) formed the ultra-early cohort; others formed the deferred treatment cohort. All Patient Refined Diagnosis-Related Groups were also included in regression analyses. RESULTS: A total of 17 412 patients were directly admitted to a hospital following nontraumatic SAH where they underwent intervention (clipping/coiling). Mean patient age was 53.87 yr (median 53.00, standard deviation 14.247); 68.3% were women (n = 11 893). A total of 6338 (36.4%) patients underwent treatment on the day of admission (ultra-early). Patients who underwent treatment on day 0 had significantly more routine discharge dispositions than those treated >admission day 0 (P < .0001). In regression analysis, treatment on day 0 was protective against other than routine discharge disposition outcome (P < .0001; odds ratio 0.657; 95% confidence interval 0.614-0.838). Total cost incurred by hospitals was $4.36 billion. Mean cost of hospital charges in the ultra-early cohort was $239 126.05, which was significantly lower than that for the cohort treated >day 0 ($272 989.56, P < .001), Mann-Whitney U-test). Performance of an intervention on admission day 0 was protective against higher hospitalization cost (P < .0001; odds ratio 0.811; 95% confidence interval 0.732-0.899). CONCLUSION: Ultra-early treatment of ruptured aneurysms is significantly associated with better discharge disposition and decreased hospitalization cost.


Assuntos
Aneurisma Roto/cirurgia , Embolização Terapêutica/economia , Embolização Terapêutica/métodos , Aneurisma Intracraniano/cirurgia , Tempo para o Tratamento/economia , Adulto , Idoso , Estudos de Coortes , Feminino , Custos Hospitalares , Humanos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Resultado do Tratamento
16.
Neurosurg Focus ; 42(6): E6, 2017 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-28565986

RESUMO

OBJECTIVE Rupture of large or giant intracranial aneurysms leads to significant morbidity, mortality, and health care costs. Both coiling and the Pipeline embolization device (PED) have been shown to be safe and clinically effective for the treatment of unruptured large and giant intracranial aneurysms; however, the relative cost-to-outcome ratio is unknown. The authors present the first cost-effectiveness analysis to compare the economic impact of the PED compared with coiling or no treatment for the endovascular management of large or giant intracranial aneurysms. METHODS A Markov model was constructed to simulate a 60-year-old woman with a large or giant intracranial aneurysm considering a PED, endovascular coiling, or no treatment in terms of neurological outcome, angiographic outcome, retreatment rates, procedural and rehabilitation costs, and rupture rates. Transition probabilities were derived from prior literature reporting outcomes and costs of PED, coiling, and no treatment for the management of aneurysms. Cost-effectiveness was defined, with the incremental cost-effectiveness ratios (ICERs) defined as difference in costs divided by the difference in quality-adjusted life years (QALYs). The ICERs < $50,000/QALY gained were considered cost-effective. To study parameter uncertainty, 1-way, 2-way, and probabilistic sensitivity analyses were performed. RESULTS The base-case model demonstrated lifetime QALYs of 12.72 for patients in the PED cohort, 12.89 for the endovascular coiling cohort, and 9.7 for patients in the no-treatment cohort. Lifetime rehabilitation and treatment costs were $59,837.52 for PED; $79,025.42 for endovascular coiling; and $193,531.29 in the no-treatment cohort. Patients who did not undergo elective treatment were subject to increased rates of aneurysm rupture and high treatment and rehabilitation costs. One-way sensitivity analysis demonstrated that the model was most sensitive to assumptions about the costs and mortality risks for PED and coiling. Probabilistic sampling demonstrated that PED was the cost-effective strategy in 58.4% of iterations, coiling was the cost-effective strategy in 41.4% of iterations, and the no-treatment option was the cost-effective strategy in only 0.2% of iterations. CONCLUSIONS The authors' cost-effective model demonstrated that elective endovascular techniques such as PED and endovascular coiling are cost-effective strategies for improving health outcomes and lifetime quality of life measures in patients with large or giant unruptured intracranial aneurysm.


Assuntos
Aneurisma Roto/economia , Aneurisma Roto/terapia , Análise Custo-Benefício , Embolização Terapêutica , Aneurisma Intracraniano/economia , Aneurisma Intracraniano/terapia , Adolescente , Adulto , Idoso , Aneurisma Roto/complicações , Criança , Embolização Terapêutica/economia , Embolização Terapêutica/instrumentação , Embolização Terapêutica/métodos , Feminino , Humanos , Aneurisma Intracraniano/complicações , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento , Adulto Jovem
17.
Cardiovasc Intervent Radiol ; 40(11): 1694-1697, 2017 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-28560549

RESUMO

PURPOSE: Prostatic arterial embolization (PAE) has emerged as a minimally invasive alternative to TURP; however, there are limited cost comparisons reported. The purpose of this study was to compare in-hospital direct costs of elective PAE and TURP in a hospital setting. MATERIALS AND METHODS: Institutional Review Board-approved retrospective review was performed on patients undergoing PAE and TURP from January to December 2014. Inclusion criteria included male patients greater than 40 years of age who presented for ambulatory TURP or PAE with no history of prior surgical intervention for BPH. Direct costs were categorized into the following categories: nursing and operating room or interventional room staffing, operating room or interventional supply costs, anesthesia supplies, anesthesia staffing, hospital room cost, radiology, and laboratory costs. Additionally, length of stay was evaluated for both groups. RESULTS: The mean patient age for the TURP (n = 86) and PAE (n = 70) cohorts was 71.3 and 64.4 years, respectively (p < 0.0001). Intra-procedural supplies for PAE were significantly more costly than TURP ($1472.77 vs $1080.84, p < 0.0001). When including anesthesia supplies and nursing/staffing, costs were significantly more expensive for TURP than PAE ($2153.64 vs $1667.10 p < 0.0001). The average length of stay for the TURP group was longer at 1.38 versus 0.125 days for the PAE group. Total in-hospital costs for the TURP group ($5338.31, SD $3521.17) were significantly higher than for PAE ($1678.14, SD $442.0, p < 0.0001). CONCLUSIONS: When compared to TURP, PAE was associated with significantly lower direct in-hospital costs and shorter hospital stay.


Assuntos
Embolização Terapêutica/economia , Embolização Terapêutica/métodos , Hiperplasia Prostática/terapia , Ressecção Transuretral da Próstata/economia , Ressecção Transuretral da Próstata/métodos , Idoso , Humanos , Masculino , Pessoa de Meia-Idade , Próstata/irrigação sanguínea , Próstata/cirurgia , Hiperplasia Prostática/economia , Hiperplasia Prostática/cirurgia , Estudos Retrospectivos , Resultado do Tratamento
18.
Ann Vasc Surg ; 44: 119-127, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-28479464

RESUMO

BACKGROUND: Intraprocedural aneurysm sac embolization (embo-EVAR) during endovascular abdominal aneurysm repair (EVAR) using coils and fibrin glue is a technique for preventing type II endoleak (EII). Our aim is to evaluate feasibility, safety and clinical outcome of this promising approach. MATERIALS AND METHODS: A retrospective clinical case analysis of 72 patients who underwent EVAR during the period 2011-2014. Two groups were compared at 6 and 12 months follow-up with contrast media computed tomography scan and contrast-enhanced ultrasound (CEUS) imaging: consecutively, 36 patients (group A) treated with classic EVAR and 36 patients (group B) treated with embo-EVAR. Coils were released filling better as possible the aneurysm sac; the embolization was completed by injecting fibrin glue. Device and materials used, differential systemic and sac pressures, presence of any endoleak, and complication were registered. RESULTS: In our experience, we had 100% technical success without surgical conversion. Embo-EVAR was performed, after endograft deployment, in group B patients, all with ratio of Δ-pressures (obtained from Δ-sac pressure/Δ-differential pressure) > 0.16. No early or late complications occurred and mortality was nil. Follow-up was performed with computed tomography-angiography and CEUS at 6 and 12 months. We observed 9 type II and 1 type Ia endoleak in group A and 2 type II and 1 type Ib endoleaks in group B. Mean radiation exposure time was 30.3 min in group A and 43.3 min in group B. EVAR procedure average cost was 9,000 €. The average cost of sac embolization was 1,500€. CONCLUSIONS: Although a randomized study is necessary, embo-EVAR may be a valid approach to prevent type II endoleaks and further complications. Mild costs and exposure-dose increase could be accepted to avoid reinterventions, and in our experience, it could be routinely performed with excellent results.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Implante de Prótese Vascular/métodos , Embolização Terapêutica , Endoleak/prevenção & controle , Procedimentos Endovasculares/métodos , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/economia , Aneurisma da Aorta Abdominal/mortalidade , Aortografia/métodos , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/economia , Implante de Prótese Vascular/mortalidade , Angiografia por Tomografia Computadorizada , Meios de Contraste/administração & dosagem , Embolização Terapêutica/efeitos adversos , Embolização Terapêutica/economia , Embolização Terapêutica/mortalidade , Endoleak/diagnóstico por imagem , Endoleak/etiologia , Endoleak/mortalidade , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/economia , Procedimentos Endovasculares/mortalidade , Estudos de Viabilidade , Feminino , Custos Hospitalares , Humanos , Itália , Masculino , Pessoa de Meia-Idade , Doses de Radiação , Exposição à Radiação , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia
19.
Eur Radiol ; 27(11): 4730-4736, 2017 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-28484825

RESUMO

OBJECTIVES: To characterise the safety, efficacy and cost of direct carotid-cavernous fistula (CCF) treatment using polyvinyl alcohol copolymer or detachable balloons. METHODS: We reviewed retrospectively patients with direct CCFs treated with either a detachable balloon or polyvinyl alcohol copolymer at our hospital from 2005 to 2015 and identified 94 patients with 105 CCFs. All patients had follow-up angiograms. The CCF occlusion rate, procedure complication rate, treatment expense and operation time were recorded. RESULTS: With a mean of 5.4 months of angiographic follow-up, the complete occlusion rate and recanalisation rate of the polyvinyl alcohol copolymer group was not significantly different from that of the detachable balloon group. The treatment expense was much higher and the operation time was much longer in the polyvinyl alcohol copolymer group than the detachable balloon group (P < 0.001). CONCLUSIONS: Embolisation of CCF with polyvinyl alcohol copolymer is as safe and effective as detachable balloon but has a much higher cost and longer operation time. KEY POINTS: • Carotid-cavernous fistula results from a damaged carotid artery. • Detachable balloons have been used with success for many years. • Some reported excellent outcomes after embolisation with polyvinyl alcohol copolymer. • Treatment expense is much higher in the polyvinyl alcohol copolymer group.


Assuntos
Fístula Carotidocavernosa/terapia , Embolização Terapêutica/métodos , Polímeros/administração & dosagem , Álcool de Polivinil/administração & dosagem , Adolescente , Adulto , Idoso , Angiografia , Artéria Carótida Primitiva , Fístula Carotidocavernosa/diagnóstico por imagem , Custos e Análise de Custo , Embolização Terapêutica/efeitos adversos , Embolização Terapêutica/economia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
20.
Value Health ; 20(3): 336-344, 2017 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-28292478

RESUMO

OBJECTIVES: To perform a cost-effectiveness analysis comparing the use of transarterial radioembolization (TARE) with that of sorafenib in the treatment of patients with intermediate or advanced hepatocellular carcinoma (HCC) according to the Barcelona Clinic Liver Cancer staging system. METHODS: Patient-level data were consecutively recorded and collected at three oncology centers in Italy. A propensity score matching was performed to compare patients with similar clinical characteristics who underwent TARE or sorafenib treatment. Clinical data from the matched cohorts were used to populate a Markov model to project, on a lifetime horizon, life years, quality-adjusted life years, and economic outcomes associated with TARE and sorafenib for both intermediate and advanced HCC stages. RESULTS: Starting from data covering 389 and 241 patients who underwent TARE and sorafenib treatment, respectively, the propensity score matching yielded a total of 308 matched patients. For intermediate-stage patients, the model estimated for TARE versus sorafenib an incremental cost-utility ratio of €3,302/QALY (incremental cost-effectiveness ratio of €1,865 per life year gained), whereas for patients in advanced stage TARE dominated (lower costs and greater health improvements) compared with sorafenib. CONCLUSIONS: From an Italian health care service perspective, TARE could be a cost-effective strategy in comparison with sorafenib for patients with intermediate or advanced HCC. The results from forthcoming randomized controlled trials comparing TARE with sorafenib will be able to confirm or reject the validity of this preliminary evaluation. In the meantime, decision makers can use these results to control and coordinate the diffusion of the technology.


Assuntos
Antineoplásicos/economia , Antineoplásicos/uso terapêutico , Carcinoma Hepatocelular/terapia , Embolização Terapêutica/economia , Neoplasias Hepáticas/terapia , Niacinamida/análogos & derivados , Compostos de Fenilureia/economia , Compostos de Fenilureia/uso terapêutico , Idoso , Institutos de Câncer , Carcinoma Hepatocelular/patologia , Estudos de Coortes , Análise Custo-Benefício , Embolização Terapêutica/métodos , Feminino , Humanos , Itália , Estimativa de Kaplan-Meier , Neoplasias Hepáticas/patologia , Masculino , Cadeias de Markov , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Niacinamida/economia , Niacinamida/uso terapêutico , Anos de Vida Ajustados por Qualidade de Vida , Sorafenibe , Sobrevida
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