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2.
Mayo Clin Proc ; 94(6): 995-1002, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31079963

RESUMO

OBJECTIVE: To investigate the temporal relationship of hospital charges relative to recorded costs for surgical episodes of care. PATIENTS AND METHODS: This retrospective cohort study selected individuals who underwent any of 8 index urologic surgical procedures at 392 unique institutions from January 1, 2005, through December 31, 2015. For each surgical encounter, cost and charge data reported by hospitals were extracted and adjusted to 2016 US dollars. Trend analysis and multivariable logistic regression modeling were used to assess outcomes. The primary outcome was trend in median charge and cost. Secondary outcomes consisted of hospital characteristics associated with membership in the highest quartile of institutional charge-to-cost ratio. RESULTS: Cohort-level median cost per encounter trended down from $6824 in 2005 to $5586 in 2015 (P for trend<.001), and charges increased from $20,210 to $25,773 during the same period (P for trend<.001). Hospitals in the highest quartile of institutional charge-to-cost ratio were more likely to be safety net, nonteaching, urban, lower surgical volume, smaller, and located outside the Midwest (P<.001 for each characteristic). CONCLUSION: The pricing trends shown herein could indicate some success in cost-containment for surgical episodes of care, although higher hospital charges may be increasingly used to bolster reimbursement from third-party payers and to compensate for escalating costs in other areas.


Assuntos
Cuidado Periódico , Preços Hospitalares/estatística & dados numéricos , Hospitais/estatística & dados numéricos , Procedimentos Cirúrgicos Urológicos/estatística & dados numéricos , Adulto , Bases de Dados Factuais , Feminino , Humanos , Reembolso de Seguro de Saúde , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Procedimentos Cirúrgicos Urológicos/economia
3.
Urology ; 125: 79-85, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30803723

RESUMO

OBJECTIVE: To determine how Medicaid expansion under the Affordable Care Act of 2010 (ACA) has affected hospital pricing practices for surgical episodes of care. METHODS: Given that safety net hospitals would be more vulnerable to decreasing reimbursement due to an increase in proportion of Medicaid patients, we utilized the Premier Healthcare Database to compare institutional charge-to-cost ratio (CCR) in safety net hospitals vs nonsafety net hospitals for 8 index urologic surgery procedures during the period from 2012 to 2015. The effect of Medicaid expansion on CCR was assessed through difference-in-differences analysis. RESULTS: CCR among safety net hospitals increased from 4.06 to 4.30 following ACA-related Medicaid expansion. This did not significantly differ from the change among nonsafety net hospitals, which was from 4.00 to 4.38 (P = .086). The census division with the highest degree of Medicaid expansion experienced a smaller increase in CCR among safety net hospitals relative to nonsafety net (P < .0001). CCR increased by a greater degree in safety net hospitals compared to nonsafety net in the census division where Medicaid expansion was the least prevalent (P < .0001). CONCLUSION: Safety net hospitals have not preferentially increased CCR in response to ACA-related Medicaid expansion. Census divisions where safety net hospitals did increase CCR more than their nonsafety net counterparts do not correspond to those where Medicaid expansion was most prevalent. This could indicate that, despite being more vulnerable to an increased proportion of more poorly reimbursing Medicaid patients, safety net hospitals have not reacted by increasing charges to private payers.


Assuntos
Custos e Análise de Custo , Cuidado Periódico , Hospitalização/economia , Medicaid , Patient Protection and Affordable Care Act , Provedores de Redes de Segurança/economia , Procedimentos Cirúrgicos Urológicos/economia , Humanos , Estados Unidos
4.
J Urol ; 201(2): 393-399, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30053509

RESUMO

PURPOSE: Transparency of conflicts of interest is essential when assessing publications that address the benefits of robotic surgery over traditional laparoscopic and open operations. We assessed discrepancies between self-reported and actual conflicts of interest as well as whether conflicts of interest are associated with favorable endorsement of robotic surgery. MATERIALS AND METHODS: We searched the Embase® and MEDLINE® databases for articles on robotic surgery within pediatric urology. We included English language articles published since 2013, when data in the Open Payments program (Centers for Medicare and Medicaid Services, Baltimore, Maryland) became available. For all United States based authors Open Payments was used to identify the total amount of financial payment received from Intuitive Surgical®. Chi-square test was used to assess the association between conflicts of interest and favorable endorsement of robotic surgery. RESULTS: A total of 191 articles were initially identified. After exclusion criteria were applied 107 articles remained (267 distinct authors). Of the articles 86 (80.4%) had at least 1 author with a history of payment from Intuitive Surgical, with 79 (91.9%) having at least 1 author who did not declare a conflict of interest despite history of payment. A total of 44 authors (16.5%) had a history of payment from Intuitive Surgical, with an average payment of $3,594.15. Articles with a first and/or last author with a history of payment were more likely to contain a favorable endorsement of robotic surgery compared to articles without a history of payment (85.1% vs 63.6%, p = 0.0124). CONCLUSIONS: Nondisclosure of conflict of interest with Intuitive Surgical is extremely common within pediatric urology. Steps to ensure accurate reporting of conflicts of interest are essential. There appears to be an association between a history of payment and favorable endorsement of robotic surgery.


Assuntos
Conflito de Interesses , Revelação/estatística & dados numéricos , Procedimentos Cirúrgicos Robóticos/métodos , Autorrelato/estatística & dados numéricos , Procedimentos Cirúrgicos Urológicos/métodos , /estatística & dados numéricos , Criança , Revelação/ética , Humanos , Procedimentos Cirúrgicos Robóticos/economia , Procedimentos Cirúrgicos Robóticos/ética , Estados Unidos , Doenças Urológicas/cirurgia , Procedimentos Cirúrgicos Urológicos/economia , Procedimentos Cirúrgicos Urológicos/ética
6.
Urology ; 122: 158-161, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30195010

RESUMO

OBJECTIVE: To assess national and regional practice patterns and rates of pathologic specimen identification sent at time of pyeloplasty, as well as project associated costs, we used a national administrative database. The rate at which the excised ureteropelvic junction obstruction (UPJO) is sent for pathologic identification is variable, arguably without a clear clinical purpose. MATERIALS / METHODS: Utilizing a national administrative database of privately insured patients, 1496 individual cases were identified using international classification of diseases (ICD) and Current Procedural Terminology (CPT) coding. Patients from 0-18 years of age were included whose pyeloplasty was performed during 2010-2014. Patients who were and were not billed for pathologic identification at time of surgery were identified. Regional practice patterns and associated costs were determined. RESULTS: One thousand four hundred and ninety-six pyeloplasty cases were identified (68.2% males). Specimens were sent for pathologic identification in 827 cases (55%). Average age was 5.8 years for those without pathology and 4.6 years for those in whom a specimen was billed. Regionally, the Western United States was least likely to bill for surgical pathology (49%). The parental out-of-pocket payment for the encounter was on average $1518 for cases in which pathology was sent and $1398 for those cases for which no pathology bill was identified. CONCLUSION: Pediatric pyeloplasty is a common surgical procedure for which a pathologic specimen is sent in as many as 55% of cases in this cohort. Regional differences exist across the country and there is an associated slightly higher out-of-pocket cost in cases for which pathologic specimens are sent at time of pyeloplasty.


Assuntos
Padrões de Prática Médica/estatística & dados numéricos , Procedimentos Cirúrgicos Reconstrutivos/métodos , Obstrução Ureteral/cirurgia , Procedimentos Cirúrgicos Urológicos/métodos , Adolescente , Biópsia/economia , Biópsia/métodos , Biópsia/estatística & dados numéricos , Criança , Pré-Escolar , Estudos de Coortes , Bases de Dados Factuais , Feminino , Gastos em Saúde/estatística & dados numéricos , Humanos , Lactente , Recém-Nascido , Pelve Renal/patologia , Pelve Renal/cirurgia , Masculino , Procedimentos Cirúrgicos Reconstrutivos/economia , Procedimentos Cirúrgicos Reconstrutivos/estatística & dados numéricos , Estados Unidos , Ureter/patologia , Ureter/cirurgia , Obstrução Ureteral/economia , Obstrução Ureteral/patologia , Procedimentos Cirúrgicos Urológicos/economia , Procedimentos Cirúrgicos Urológicos/estatística & dados numéricos
9.
J Pediatr Urol ; 14(3): 268.e1-268.e5, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29534861

RESUMO

INTRODUCTION: Endoscopic injection of a bulking agent is a common first-line approach to the treatment of vesicoureteral reflux (VUR). While early outcomes are comparable to open ureteroneocystotomy, 5-25% of children will eventually develop recurrent reflux necessitating repeat injections or open ureteral reimplantation. OBJECTIVE: To determine whether prior endoscopic injection of a bulking agent impacts outcomes of subsequent open ureteral reimplantation. STUDY DESIGN: Using a retrospective cohort design, radiographic and clinical outcomes of open ureteral reimplantation were compared between patients with and without prior endoscopic correction of reflux. Surgical and hospitalization data were also compared between groups and a cost comparison was performed to assess differences in healthcare costs between the two cohorts. Units of analysis included total ureters or total patients. For certain variables, subanalysis of unilateral versus bilateral reimplantation was included. RESULTS: A total of 258 patients underwent open reimplantation for VUR between 2007 and 2016 by five pediatric urologists. Final analysis (see Summary Table) included 192 patients with pre-operative and postoperative voiding cystourethrogram (VCUG) and follow-up data at a median 4.95 months. Among 317 reimplanted refluxing ureters, radiographic resolution was reached in 26/27 (96.3%) patients with and 279/290 (96.2%) without prior endoscopic treatment (P = 0.981). Clinical success was achieved in 17/17 (100%) patients with and 174/175 (99.4%) without prior endoscopic treatment (P = 0.755). There were no statistically significant differences between duration of surgery or length of hospital stay. There were no statistically significant differences between total charges, total costs, and operating room (OR) costs between groups. DISCUSSION: This study indicated that prior endoscopic injection of a bulking agent did not impact the outcomes or costs of subsequent open ureteroneocystotomy. While prior studies have demonstrated tissue changes associated with injection of a bulking agent, these did not seem to significantly impact the difficulty of later open surgery or the success rates compared to patients who proceeded directly to open correction of reflux. CONCLUSION: Open ureteral reimplantation for recurrent VUR after failed endoscopic injection of a bulking agent was safe and effective, with comparable outcomes and costs to open surgery in patients without prior endoscopic correction.


Assuntos
Custos Hospitalares , Reimplante/métodos , Ureter/cirurgia , Procedimentos Cirúrgicos Urológicos/métodos , Refluxo Vesicoureteral/cirurgia , Adolescente , Criança , Pré-Escolar , Custos e Análise de Custo , Cistografia , Cistoscopia , Feminino , Seguimentos , Humanos , Lactente , Masculino , Reimplante/economia , Estudos Retrospectivos , Procedimentos Cirúrgicos Urológicos/economia , Refluxo Vesicoureteral/diagnóstico , Refluxo Vesicoureteral/economia , Adulto Jovem
10.
J Pediatr Urol ; 14(4): 336.e1-336.e8, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29530407

RESUMO

INTRODUCTION: Since 2010, there have been few new data comparing perioperative outcomes and cost between open (OP) and robotic pyeloplasty (RP). In a post-adoption era, the value of RP may be converging with that of OP. OBJECTIVE: To 1) characterize national trends in pyeloplasty utilization through 2015, 2) compare adjusted outcomes and median costs between OP and RP, and 3) determine the primary cost drivers for each procedure. STUDY DESIGN: We performed a retrospective cohort study using the Premier database, which provides a nationally representative sample of U.S. hospitalizations between 2003 and 2015. ICD9 codes and itemized billing were used to abstract our cohorts. Trends in utilization and cost were calculated and then stratified by age. We used propensity scores to weight our cohorts and then applied regression models to measure differences in the probability of prolonged operative time (pOT), prolonged length of stay (pLOS), complications, and cost. RESULTS: During the study period 11,899 pyeloplasties were performed: 75% open, 10% laparoscopic, and 15% robotic. The total number of pyeloplasty cases decreased by 7% annually; OP decreased by a rate of 10% while RP grew by 29% annually. In 2015, RP accounted for 40% of cases. The largest growth in RPs was among children and adolescents. The average annual rate of change in cost for RP and OP was near stagnant: -0.5% for open and -0.2% for robotic. The summary table provides results from our regression analyses. RP conferred an increased likelihood of pOT, but a reduced likelihood of pLOS. The odds of complications were equivalent. RP was associated with a significantly higher median cost, but the absolute difference per case was $1060. DISCUSSION: Despite advantages in room and board costs for RP, we found that the cost of equipment and OR time continue to make it more expensive. Although the absolute difference may be nominal, we likely underestimate the true cost because we did not capture amortization, hidden or down-stream costs. In addition, we did not measure patient satisfaction and pain control, which may provide the non-monetary data needed for comparative value. CONCLUSION: Despite an overall decline in pyeloplasties, RP utilization continues to increase. There has been little change in cost over time, and RP remains more expensive because of equipment and OR costs. The robotic approach confers a reduced likelihood of pLOS, but an increased likelihood of pOT. Complication rates are low and similar in each cohort.


Assuntos
Custos e Análise de Custo , Pelve Renal/cirurgia , Laparoscopia/economia , Laparoscopia/métodos , Utilização de Procedimentos e Técnicas/estatística & dados numéricos , Utilização de Procedimentos e Técnicas/tendências , Procedimentos Cirúrgicos Robóticos/economia , Procedimentos Cirúrgicos Robóticos/estatística & dados numéricos , Obstrução Ureteral/cirurgia , Adolescente , Criança , Pré-Escolar , Estudos de Coortes , Feminino , Humanos , Lactente , Masculino , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , Procedimentos Cirúrgicos Urológicos/economia , Procedimentos Cirúrgicos Urológicos/métodos
11.
Neurourol Urodyn ; 37(6): 1931-1936, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29488654

RESUMO

AIM: To identify the costs of replacing an entire malfunctioning AUS device versus an individual component at the time of device malfunction. METHODS: Decision analysis was performed by analyzing the costs associated with revising a malfunctioning artificial urinary sphincter using one of two techniques: either individual or entire device replacement. Costs were determined by including actual institutional costs. Model assumptions were based on a summary of published literature and were created based on a time horizon of 0-5 years since the original, primary AUS was placed, and models were created for malfunction of each individual component. Sensitivity analysis was done adjusting for costs of the device and failure rates. RESULTS: Total costs to replace an individual component were $8330 for the pump, $7611 for the cuff, and $5599 for the balloon, while entire device replacement cost $15 069. Over a 5-year time horizon the cost per patient for replacement of a balloon, pump, or cuff were $14 407, $17 491, and $15 212, respectively, versus $18 001 if the entire device was replaced. To be less costly to replace the entire device, balloon, pump, and cuff failure rates would need to be >55%, >25%, or >37.5% during the first 2 years after placement. CONCLUSION: In the event of failure of the artificial urinary sphincter, cost analysis demonstrates that removal and replacement of the entire device is more expensive than replacement of a malfunctioning component at any point up to 5 years after initial AUS placement.


Assuntos
Remoção de Dispositivo/economia , Remoção de Dispositivo/métodos , Esfíncter Urinário Artificial/economia , Procedimentos Cirúrgicos Urológicos/economia , Tomada de Decisão Clínica , Custos e Análise de Custo , Falha de Equipamento/economia , Humanos , Estimativa de Kaplan-Meier , Reoperação/economia , Estudos Retrospectivos
12.
Int J Surg ; 53: 18-23, 2018 May.
Artigo em Inglês | MEDLINE | ID: mdl-29432971

RESUMO

BACKGROUND: The management of disposable and reusable supplies might have an impact on the cost efficiency of the Operating Room (OR). This study aimed to evaluate the cost and reasons for wasted supplies in the OR during surgical procedures. METHODS: We conducted an observational and prospective study in a French university hospital. We assessed the cost of wasted supplies in the OR (defined by opened unused devices), the reasons for the wastage, and the circulator retrievals. At the end, we assessed the perception of surgeons and nurses relative to the supply wastage. RESULTS: Fifty routine procedures and five non-scheduled procedures were observed in digestive (n = 20), urologic (n = 20) and gynecologic surgery (n = 15). The median cost [IQR] of open unused devices was €4.1 [0.5; 10.5] per procedure. Wasted supplies represented up to 20.1% of the total cost allocated to surgical supplies. Considering the 8000 surgical procedures performed in these three surgery departments, the potential annual cost savings were 100 000€. The most common reason of wastage was an anticipation of the surgeon's needs. The circulating nurse spent up to 26.3% of operative time outside of the OR, mainly attending to an additional demand from the surgeon (30%). Most of the survey respondents (68%) agreed that knowing supply prices would change their behavior. CONCLUSIONS: This study showed the OR is a major source of wasted hospital expenditure and an area wherein an intervention would have a significant impact. Reducing wasted supplies could improve the cost efficiency of the OR and also decrease its ecological impact.


Assuntos
Equipamentos Descartáveis/economia , Salas Cirúrgicas/economia , Equipamentos Cirúrgicos/economia , Procedimentos Cirúrgicos Operatórios/economia , Redução de Custos , Procedimentos Cirúrgicos do Sistema Digestório/economia , Procedimentos Cirúrgicos do Sistema Digestório/instrumentação , Procedimentos Cirúrgicos em Ginecologia/economia , Procedimentos Cirúrgicos em Ginecologia/instrumentação , Hospitais Universitários , Humanos , Recursos Humanos de Enfermagem no Hospital/psicologia , Duração da Cirurgia , Estudos Prospectivos , Cirurgiões/psicologia , Procedimentos Cirúrgicos Urológicos/economia , Procedimentos Cirúrgicos Urológicos/instrumentação
14.
J Pediatr Urol ; 14(1): 50.e1-50.e6, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-28917602

RESUMO

PURPOSE: The need for mechanical inpatient bowel preparation (IBP) in reconstructive pediatric urology has come under scrutiny, secondary to literature demonstrating little benefit regarding outcomes. Starting in 2013, a majority of patients undergoing reconstructive procedures at our institution no longer underwent IBP. We hypothesized that outpatient bowel preparation (OBP) would reduce length of stay (LOS) without increasing postoperative complications after appendicovesicostomy surgery. MATERIALS AND METHODS: An institutional database of patients undergoing lower urinary tract reconstruction between May 2010 and December 2014 was reviewed. Starting in 2013, a departmental decision was made to replace IBP with OBP. Patients undergoing an augmentation cystoplasty or continent ileovesicostomy were excluded because of insufficient numbers undergoing OBP. Patients undergoing IBP were admitted 1 day prior to surgery and received polyethylene glycol/electrolyte solution. A personalized preoperative OBP was introduced in 2013. Cost data were obtained from the Pediatric Health Information System. RESULTS: Sixty-seven patients met the inclusion criteria, with 30 (44.8%) undergoing IBP. There were no differences with respect to gender, age, presence of ventriculoperitoneal shunt, body mass index, glomerular filtration rate, preoperative diagnosis, operative time, and prior or simultaneous associated surgeries (p ≥ 0.07). Patients undergoing an IBP had a longer median LOS (7 vs. 5 days, p = 0.0002) and a higher median cost (US$4,288, p = 0.01). Postoperative complications in both groups were uncommon and were classified as Clavien-Dindo grade 1-2, with no statistical difference (IBP 20.0% vs. OBP 5.4%, p = 0.13). No serious postoperative complication occurred, such as a dehiscence, bowel obstruction, or shunt infection. DISCUSSION: This is the first analysis of hospitalization costs and IBP, showing a higher median cost of US$4288 compared with OBP. The LOS was shorter with an OBP (figure), similar to a previous report. Similar complication rates between the groups add to the growing body of literature that avoidance of IBP is safe in pediatric lower urinary tract reconstruction. Being a retrospective review of a practice change, differences in care that influenced cost and LOS may be missing. Also, as the surgeons do not know if a usable appendix is initially present, our data may not extrapolate to all patients. Despite these potential limitations, our data support the safety of utilizing OBP in patients with a high likelihood of a usable appendix, including those undergoing a synchronous Malone antegrade continence enema via a split-appendix technique. CONCLUSION: In patients undergoing an appendicovesicostomy, preoperative IBP led to longer LOS and higher costs of hospitalization. OBP was not associated with increased risks of postoperative complications.


Assuntos
Pacientes Internados/estatística & dados numéricos , Pacientes Ambulatoriais/estatística & dados numéricos , Cuidados Pré-Operatórios/métodos , Irrigação Terapêutica/métodos , Bexiga Urinaria Neurogênica/cirurgia , Procedimentos Cirúrgicos Urológicos/métodos , Adolescente , Apêndice/cirurgia , Criança , Pré-Escolar , Estudos de Coortes , Bases de Dados Factuais , Feminino , Custos Hospitalares , Humanos , Tempo de Internação/economia , Masculino , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/fisiopatologia , Estudos Retrospectivos , Medição de Risco , Resultado do Tratamento , Bexiga Urinária/cirurgia , Derivação Urinária/métodos , Procedimentos Cirúrgicos Urológicos/economia
15.
Int J Urol ; 25(2): 86-93, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-28734037

RESUMO

Implementing a robotic urological surgery program requires institutional support, and necessitates a comprehensive, detail-oriented plan that accounts for training, oversight, cost and case volume. Given the prevalence of robotic surgery in adult urology, in many instances it might be feasible to implement a pediatric robotic urology program within the greater context of adult urology. This involves, from an institutional standpoint, proportional distribution of equipment cost and operating room time. However, the pediatric urology team primarily determines goals for volume expansion, operative case selection, resident training and surgical innovation within the specialty. In addition to the clinical model, a robust economic model that includes marketing must be present. This review specifically highlights these factors in relationship to establishing and maintaining a pediatric robotic urology program. In addition, we share our data involving robot use over the program's first nine years (December 2007-December 2016).


Assuntos
Implementação de Plano de Saúde/organização & administração , Procedimentos Cirúrgicos Robóticos/educação , Centros de Atenção Terciária/organização & administração , Doenças Urológicas/cirurgia , Procedimentos Cirúrgicos Urológicos/educação , Criança , Alocação de Recursos para a Atenção à Saúde/economia , Alocação de Recursos para a Atenção à Saúde/organização & administração , Implementação de Plano de Saúde/economia , Humanos , Internato e Residência/economia , Internato e Residência/organização & administração , Procedimentos Cirúrgicos Robóticos/economia , Procedimentos Cirúrgicos Urológicos/economia
16.
F1000Res ; 72018.
Artigo em Inglês | MEDLINE | ID: mdl-30613380

RESUMO

Modern robotics is an advanced minimally invasive technology with the advantages of wristed capability, three-dimensional optics, and tremor filtration compared with conventional laparoscopy. Urologists have been early adopters of robotic surgical technology: robotics have been used in urologic oncology for more than 20 years and there has been an increasing trend for utilization in benign urologic pathology in the last couple of years. The continuing development and interest in robotics are aimed at surgical efficiency as well as patient outcomes. However, despite its advantages, improvements in haptics, system size, and cost are still desired. This article explores the current use of robotics in urology as well as future improvements on the horizon.


Assuntos
Robótica/métodos , Procedimentos Cirúrgicos Urológicos/métodos , Urologia/métodos , Humanos , Laparoscopia/instrumentação , Laparoscopia/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Robótica/economia , Robótica/instrumentação , Cirurgia Assistida por Computador/economia , Procedimentos Cirúrgicos Urológicos/economia , Procedimentos Cirúrgicos Urológicos/instrumentação , Urologia/economia , Urologia/instrumentação
17.
Int Braz J Urol ; 44(1): 109-113, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29135411

RESUMO

INTRODUCTION: Surgical treatment of urinary incontinence progressed significantly with the introduction of synthetic slings. However, in some public Brazilian hospitals, the costs of these materials prevent their routine use. OBJECTIVE: To compare the costs of ambulatory synthetic sling surgery with an historical series of patients submitted to Burch surgery in a Brazilian public hospital. MATERIALS AND METHODS: Twenty nine incontinent patients were selected to synthetic sling surgery. Demographic data were prospectively collected and also the costs of the procedure, including drugs and materials, use of surgical and recovery wards, medical staff and hospitalization. These data were compared to the costs of 29 Burch surgeries performed before the introduction of synthetic slings. RESULTS: Demographic data were similar, although median age was lower in the group submitted to Burch surgery (46.3±8.6 versus 56.2±11.3 (p<0.001)). Cost was significantly lower in patients submitted to sling in all items, except for time spent in recovery ward. Total value of 29 Burch surgeries was R$ 217.766.12, and of R$ 68.049.92 of 29 patients submitted to sling surgery (p<0.001). CONCLUSION: Burch surgery was more expensive than ambulatory synthetic transobturator sling surgery, even when the cost of the synthetic sling was considered.


Assuntos
Slings Suburetrais/economia , Incontinência Urinária por Estresse/economia , Incontinência Urinária por Estresse/cirurgia , Procedimentos Cirúrgicos Urológicos/economia , Procedimentos Cirúrgicos Urológicos/métodos , Adolescente , Adulto , Idoso , Brasil , Feminino , Custos de Cuidados de Saúde , Hospitais Públicos , Humanos , Pessoa de Meia-Idade , Adulto Jovem
18.
BMJ Open ; 7(8): e015111, 2017 08 11.
Artigo em Inglês | MEDLINE | ID: mdl-28801396

RESUMO

INTRODUCTION: Single-incision mini-slings (SIMS) represent the third generation of midurethral slings. They have been developed with the aim of offering a true ambulatory procedure for treatment of female stress urinary incontinence (SUI) with reduced morbidity and earlier recovery while maintaining similar efficacy to standard midurethral slings (SMUS). The aim of this study is to determine the clinical and cost-effectiveness of adjustable anchored SIMS compared with tension-free SMUS in the surgical management of female SUI, with 3-year follow-up. METHODS AND ANALYSIS: A pragmatic, multicentre, non-inferiority randomised controlled trial. PRIMARY OUTCOME MEASURE: The primary outcome measure is the patient-reported success rate measured by the Patient Global Impression of Improvement at 12 months. The primary economic outcome will be incremental cost per quality-adjusted life year gained at 12 months. SECONDARY OUTCOME MEASURES: The secondary outcomes measures include adverse events, objective success rates, impact on other lower urinary tract symptoms, health-related quality of life profile and sexual function, and reoperation rates for SUI. Secondary economic outcomes include National Health Service and patient primary and secondary care resource use and costs, incremental cost-effectiveness and incremental net benefit. STATISTICAL ANALYSIS: The statistical analysis of the primary outcome will be by intention-to-treat and also a per-protocol analysis. Results will be displayed as estimates and 95% CIs. CIs around observed differences will then be compared with the prespecified non-inferiority margin. Secondary outcomes will be analysed similarly. ETHICS AND DISSEMINATION: The North of Scotland Research Ethics Committee has approved this study (13/NS/0143). The dissemination plans include HTA monograph, presentation at international scientific meetings and publications in high-impact, open-access journals. The results will be included in the updates of the National Institute for Health and Care Excellence and the European Association of Urology guidelines; these two specific guidelines directly influence practice in the UK and worldwide specialists, respectively. In addition, plain English-language summary of the main findings/results will be presented for relevant patient organisations. TRIAL REGISTRATION NUMBER: ISRCTN93264234. The SIMS study is currently recruiting in 20 UK research centres. The first patient was randomised on 4 February 2014, with follow-up to be completed at the end of February 2020.


Assuntos
Anestesia/métodos , Complicações Pós-Operatórias/fisiopatologia , Reoperação/estatística & dados numéricos , Slings Suburetrais , Incontinência Urinária por Estresse/cirurgia , Procedimentos Cirúrgicos Urológicos/métodos , Coito/fisiologia , Análise Custo-Benefício , Feminino , Humanos , Qualidade de Vida , Fatores de Risco , Slings Suburetrais/economia , Resultado do Tratamento , Reino Unido , Incontinência Urinária por Estresse/economia , Incontinência Urinária por Estresse/fisiopatologia , Micção/fisiologia , Procedimentos Cirúrgicos Urológicos/economia
19.
World J Urol ; 35(11): 1799-1805, 2017 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-28664240

RESUMO

OBJECTIVES: To understand how prioritization of treatment attributes and treatment choice varies by patient characteristics, we sought to specifically determine how demographic variables affect patient treatment preference. PATIENTS AND METHODS: Male patients with urethral stricture disease participated in a choice-based conjoint (CBC) analysis exercise evaluating six treatment attributes associated with internal urethrotomy and urethroplasty. Demographic and past symptom data were collected. Stratified analysis of demographic variables, including age, education, income, was conducted using a mixed effect logistic regression model to evaluate the coefficient size and confidence intervals between the treatments attribute preferences of each strata. RESULTS: 169 patients completed the CBC exercise and were included in our analysis. Overall success of the procedure is the most important treatment attribute to patients and this persists across strata. Older patients (≥65) express preferences for better success rates and fewer future procedures, whereas younger patients prefer a less invasive approach and are more willing to accept additional procedures if needed. Patients with lower levels of education preferred open reconstruction and had a stronger preference against multiple future procedures, whereas those with higher levels of education preferred endoscopic treatment and had a less strong preference against multiple future procedures. Low-income individuals express statistically significant stronger negative preferences against high copay costs compared to high-income individuals. CONCLUSION: These results can help to inform physicians' counseling about surgical management of urethral stricture disease to better align patient preferences with treatment selection and encourage shared decision making.


Assuntos
Tomada de Decisões , Preferência do Paciente , Estreitamento Uretral/cirurgia , Procedimentos Cirúrgicos Urológicos/métodos , Adulto , Fatores Etários , Idoso , Comportamento de Escolha , Custo Compartilhado de Seguro , Escolaridade , Endoscopia/economia , Endoscopia/métodos , Gastos em Saúde , Humanos , Renda , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Pobreza , Fatores Socioeconômicos , Procedimentos Cirúrgicos Urológicos/economia
20.
J Sex Med ; 14(8): 1059-1065, 2017 08.
Artigo em Inglês | MEDLINE | ID: mdl-28709874

RESUMO

BACKGROUND: The surgical treatment of urinary incontinence and erectile dysfunction by prosthetic devices has become part of urologic practice, although sparse data exist at a national level on readmissions and hospital costs. AIM: To assess causes and costs of early (≤30 days) and late (31-90 days) readmissions after implantation of penile prostheses (PPs), artificial urinary sphincters (AUSs), or PP + AUS. METHODS: Using the 2013 and 2014 US Nationwide Readmission Databases, sociodemographic characteristics, hospital costs, and causes of readmission were compared among PP, AUS and AUS + PP surgeries. Multivariable logistic regression models tested possible predictors of hospital readmission (early, late, and 90 days), increased hospital costs, and prolonged length of stay at initial hospitalization and readmission. OUTCOME: Outcomes were rates, causes, hospital costs, and predictive factors of early, late, and any 90-day readmissions. RESULTS: Of 3,620 patients, 2,626 (73%) had PP implantation, 920 (25%) had AUS implantation, and 74 (2%) underwent PP + AUS placement. In patients undergoing PP, AUS, or PP + AUS placement, 30-day (6.3% vs 7.9% vs <15.0%, P = .5) and 90-day (11.6% vs 12.8% vs <15.0%, P = .8) readmission rates were comparable. Early readmissions were more frequently caused by wound complications compared with late readmissions (10.9% vs <4%, P = .03). Multivariable models identified longer length of stay, Charlson Comorbidity Index score higher than 0, complicated diabetes, and discharge not to home as predictors of 90-day readmissions. Notably, hospital volume was not a predictor of early, late, or any 90-day readmissions. However, within the subset of high-volume hospitals, each additional procedure was associated with increased risk of late (odds ratio = 1.06, 95% CI = 1.03-1.09, P < .001) and 90-day (odds ratio = 1.03 95% CI = 1.02-1.05, P < .001) readmissions. AUS and PP + AUS surgeries had higher initial hospitalization costs (P < .001). A high hospital prosthetic volume decreased costs at initial hospitalization. Mechanical complications led to readmission of all patients receiving PP + AUS. CLINICAL IMPLICATIONS: High-volume hospitals showed a weaker association with increased initial hospitalization costs. Charlson Comorbidity Index, diabetes, and length of stay were predictors of 90-day readmission, showing that comorbidity status is important for surgical candidacy. STRENGTHS AND LIMITATIONS: This is the first study focusing on readmissions and costs after PP, AUS, and PP + AUS surgeries using a national database, which allows ascertainment of readmissions to hospitals that did not perform the initial surgery. Limitations are related to the limited geographic coverage of the database and lack of surgery- and surgeon-specific variables. CONCLUSIONS: Analysis of readmissions can provide better care for urologic prosthetic surgeries through better preoperative optimization, counseling, and resource allocation. Pederzoli F, Chappidi MR, Collica S, et al. Analysis of Hospital Readmissions After Prosthetic Urologic Surgery in the United States: Nationally Representative Estimates of Causes, Costs, and Predictive Factors. J Sex Med 2017;14:1059-1065.


Assuntos
Disfunção Erétil/cirurgia , Readmissão do Paciente/economia , Prótese de Pênis/economia , Complicações Pós-Operatórias/economia , Incontinência Urinária/cirurgia , Idoso , Estudos de Coortes , Disfunção Erétil/economia , Custos Hospitalares , Hospitalização/economia , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Alta do Paciente/economia , Prótese de Pênis/efeitos adversos , Complicações Pós-Operatórias/etiologia , Fatores de Tempo , Estados Unidos , Incontinência Urinária/economia , Procedimentos Cirúrgicos Urológicos/efeitos adversos , Procedimentos Cirúrgicos Urológicos/economia
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