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1.
BJOG ; 127(1): 18-26, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31538709

RESUMO

BACKGROUND: Anterior compartment prolapse is the most common pelvic organ prolapse (POP) with a range of surgical treatment options available. OBJECTIVES: To compare the clinical effectiveness and cost-effectiveness of surgical treatments for the repair of anterior POP. METHODS: We conducted a systematic review of randomised controlled trials comparing surgical treatments for women with POP. Network meta-analysis was possible for anterior POP, same-site recurrence outcome. A Markov model was used to compare the cost-utility of surgical treatments for the primary repair of anterior POP from a UK National Health Service perspective. MAIN RESULTS: We identified 27 eligible trials for the network meta-analysis involving eight surgical treatments tested on 3194 women. Synthetic mesh was the most effective in preventing recurrence at the same site. There was no evidence to suggest a difference between synthetic non-absorbable mesh, synthetic partially absorbable mesh, and biological mesh. The cost-utility analysis, which incorporated effectiveness, complications and cost data, found non-mesh repair to have the highest probability of being cost-effective. The conclusions were robust to model inputs including effectiveness, costs and utility values. CONCLUSIONS: Anterior colporrhaphy augmented with mesh appeared to be cost-ineffective in women requiring primary repair of anterior POP. There is a need for further research on long-term effectiveness and the safety of mesh products to establish their relative cost-effectiveness with a greater certainty. TWEETABLE ABSTRACT: New study finds mesh cost-ineffective in women with anterior pelvic organ prolapse.


Assuntos
Procedimentos Cirúrgicos em Ginecologia/economia , Prolapso de Órgão Pélvico/cirurgia , Telas Cirúrgicas/economia , Análise Custo-Benefício , Feminino , Procedimentos Cirúrgicos em Ginecologia/métodos , Humanos , Meta-Análise em Rede , Prolapso de Órgão Pélvico/economia , Anos de Vida Ajustados por Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Prevenção Secundária/economia , Resultado do Tratamento
2.
Gynecol Oncol ; 155(1): 93-97, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31492539

RESUMO

OBJECTIVE: To compare postoperative outcomes by primary payer status for patients with gynecologic malignancies. METHODS: We retrospectively reviewed patients who underwent elective surgery for gynecologic malignancies between 2015 and 2019. Patient outcomes were compared by payer status using logistic regression. Sociodemographic and clinical covariates were selected a priori and included age, American Society of Anesthesiologists physical status classification, body mass index, smoking status, malignancy site, surgery type, race, estimated income, marital status, and medical interpreter requirement. RESULTS: A total of 1894 patients comprised the study sample. In the multivariate model, compared to patients with private insurance, Medicaid and Medicare patients were more likely to mobilize >24 h after surgery (OR 1.9, p < 0.05 and OR 3.2, p < 0.001, respectively), to require ICU admission (OR 4.0, p < 0.05 and OR 5.0, p < 0.05, respectively), and to have longer lengths of stay (OR 1.8, p < 0.05 and OR 2.2, p < 0.001, respectively). Medicaid patients were also more likely to have higher total hospital costs (OR 1.7, p < 0.05). Payer status was not associated with postoperative pain, postoperative opiate use, or 30-day readmission rates. CONCLUSIONS: Medicaid and Medicare payer status are associated with worse postoperative outcomes in patients with gynecologic malignancies. The poor outcomes of Medicaid patients - a cohort defined by limited income - are noteworthy. The etiology is likely multifactorial, arising from a complex interplay of factors ranging from system issues such as access to care to the unique health status of a population bearing a high burden of disease and socioeconomic adversity.


Assuntos
Neoplasias dos Genitais Femininos/economia , Neoplasias dos Genitais Femininos/cirurgia , Disparidades em Assistência à Saúde/estatística & dados numéricos , Medicaid/estatística & dados numéricos , Medicare/estatística & dados numéricos , Feminino , Procedimentos Cirúrgicos em Ginecologia/economia , Procedimentos Cirúrgicos em Ginecologia/estatística & dados numéricos , Custos Hospitalares , Humanos , Tempo de Internação , Pessoa de Meia-Idade , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/economia , Dor Pós-Operatória/etiologia , Readmissão do Paciente/estatística & dados numéricos , Estudos Retrospectivos , São Francisco , Resultado do Tratamento , Estados Unidos
3.
Gynecol Oncol ; 154(2): 388-393, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31202505

RESUMO

OBJECTIVES: Enhanced recovery after surgery (ERAS) programs has shown clinical benefits in gynecologic surgery. The aim of the present study was to compare costs before and after implementation of an ERAS program for gynecologic surgery. METHODS: Retrospective study comparing perioperative costs between consecutive patient groups undergoing gynecologic surgery (benign, staging or debulking) (I, 2012-13) prior, (II) immediately after, and (III, 2014-16) the three years after ERAS implementation. Preoperative, intraoperative, and postoperative real costs were collected for each patient via hospital administration. A bootstrap independent t-test was used for comparison. RESULTS: Demographics and preoperative characteristics were similar between group I (n = 42), II (n = 51), and III (ERAS I; n = 122, II; n = 134, III; n = 90). Average ERAS-specific costs were $687 per patient. Total mean individual costs per patient were $13'329 (95% confidence interval (CI): 11'301-15'213) and $17'710 (95% CI: 14'452-21'605) in the ERAS and pre-ERAS groups respectively, resulting in net savings of $4'381 (95% CI: 549-8'752, p = 0.043) in favour of ERAS group. Cost savings were explained by lower pre- and postoperative costs (difference: $5'011 95% CI: 1'587-8'998, p = 0.019). Total costs continued to decrease by $2'520 (mean: $15'190, 95% CI: 13'791-16'631) in year 1, by $3'077 (mean: $14'633, 95% CI: 13'378-16'250) and $5'070 (mean: $12'640, 95% CI: 11'460-14'015) (p = 0.03) respectively, in year 2 and 3 after implementation. CONCLUSION: Based on real costs and including specific costs due to ERAS implementation, ERAS program in gynecologic surgery induced significant decrease of overall costs by $4'381 per patient. Total costs continued to decrease in the three years after implementation.


Assuntos
Análise Custo-Benefício , Procedimentos Cirúrgicos em Ginecologia/economia , Assistência Perioperatória/economia , Adulto , Idoso , Redução de Custos/estatística & dados numéricos , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Pessoa de Meia-Idade , Assistência Perioperatória/métodos , Avaliação de Programas e Projetos de Saúde , Estudos Retrospectivos
4.
J Obstet Gynaecol Res ; 45(6): 1091-1095, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30977214

RESUMO

AIM: To clarify the status of minimally invasive gynecologic surgery (MIGS) in the Asia/Oceania region. METHODS: Survey questionnaires were sent out to the representative of AOFOG countries. They consisted of questions on the general status of MIGS, the clinical indication of MIGS, cost coverage, company support, training and certification for MIGS, patient preference for MIGS and requirements for the AOFOG. RESULTS: Developmental stage of MIGS in this region was roughly divided into three categories: fully developed countries, countries in the developmental stage and countries in the rudimentary stage. Clinical indication of MIGS and training opportunity of young doctors were correlated with the developmental stage. CONCLUSION: Support by AOFOG should be considered according to the developmental stage of each country. Collecting updated information on MIGS in each member country is important to provide adequate support.


Assuntos
Procedimentos Cirúrgicos em Ginecologia , Procedimentos Cirúrgicos Minimamente Invasivos , Sociedades Médicas , Ásia , Países Desenvolvidos/estatística & dados numéricos , Países em Desenvolvimento/estatística & dados numéricos , Procedimentos Cirúrgicos em Ginecologia/economia , Procedimentos Cirúrgicos em Ginecologia/educação , Procedimentos Cirúrgicos em Ginecologia/normas , Procedimentos Cirúrgicos em Ginecologia/estatística & dados numéricos , Pesquisas sobre Serviços de Saúde/estatística & dados numéricos , Humanos , Procedimentos Cirúrgicos Minimamente Invasivos/economia , Procedimentos Cirúrgicos Minimamente Invasivos/educação , Procedimentos Cirúrgicos Minimamente Invasivos/normas , Procedimentos Cirúrgicos Minimamente Invasivos/estatística & dados numéricos , Oceania , Sociedades Médicas/normas , Sociedades Médicas/estatística & dados numéricos
5.
Minerva Ginecol ; 71(1): 4-17, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30318878

RESUMO

Over the past two decades, minimally invasive surgery (MIS) abdominal surgery has increasingly been used to treat pelvic organ prolapse. Besides the several advantages associated with minimal invasiveness, this approach bridged the gap between the benefits of vaginal surgery and the surgical success rates of open abdominal procedures. The most commonly performed procedure for suspension of the vaginal apex for postoperative vaginal prolapse by robotic-assisted laparoscopy is the sacrocolpopexy. Conventional laparoscopic application of this procedure was first reported in 1994 by Nezhat et al. and had not gained widespread adoption due to lengthy learning curve associated with laparoscopic suturing. Since FDA approval of the da Vinci® robot for gynecologic surgery in 2005, minimally invasive abdominal surgery for pelvic organ prolapse has become increasingly popular, as robotic-assisted laparoscopic sacrocolpopexy is an option for those surgeons without experience or training in the conventional route. Robotic surgery has made its way into the armamentarium of POP treatment and has allowed pelvic surgeons to adapt the "gold standard" technique of abdominal sacrocolpopexy to a minimally invasive approach with improved intraoperative morbidity and decreased convalescence. In fact, repair of pelvic organ prolapse can be performed robotically, and sometimes surgeons can feel suturing and dissection during the procedures less challenging with the assistance of the robot. However, even if robotic surgery may confer many benefits over conventional laparoscopy, these advantages should continue to be weighed against the cost of the technology. To date, as long-term outcomes, evidence about robotic sacrocolpopexy for a repair of pelvic organ prolapse are not conclusive, and much more investigations are needed to evaluate subjective and objective outcomes, perioperative and postoperative adverse events, and costs associated with these procedures. It is plausible to think that the main advantage is that robotics may lead to a widespread adoption of minimally invasive techniques in the field of pelvic floor reconstructive surgery. The following review will address the development and current state of robotic assistance in treating pelvic floor reconstruction discussing available data about the techniques of robotic prolapse repair as well as morbidity, costs and clinical outcomes.


Assuntos
Procedimentos Cirúrgicos em Ginecologia/métodos , Prolapso de Órgão Pélvico/cirurgia , Procedimentos Cirúrgicos Robóticos/métodos , Feminino , Procedimentos Cirúrgicos em Ginecologia/economia , Humanos , Laparoscopia/economia , Laparoscopia/métodos , Procedimentos Cirúrgicos Minimamente Invasivos/economia , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Diafragma da Pelve/cirurgia , Procedimentos Cirúrgicos Reconstrutivos/economia , Procedimentos Cirúrgicos Reconstrutivos/métodos , Procedimentos Cirúrgicos Robóticos/economia
6.
Gynecol Oncol ; 151(1): 117-123, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-30100053

RESUMO

OBJECTIVE: Enhanced recovery pathways have been shown to reduce length of stay without increasing readmission or complications in numerous areas of surgery. Uptake of gynecologic oncology ERAS guidelines has been limited. We describe the effect of ERAS guideline implementation in gynecologic oncology on length of stay, patient outcomes, and economic impact for a province-wide single-payer system. METHODS: We compared pre- and post-guideline implementation outcomes in consecutive staging and debulking patients at two centers that provide the majority of surgical gynecologic oncology care in Alberta, Canada between March 2016 and April 2017. Clinical outcomes and compliance were obtained using the ERAS Interactive Audit System. Patients were followed until 30 days after discharge. Negative binomial regression was employed to adjust for patient characteristics. RESULTS: We assessed 152 pre-ERAS and 367 post-ERAS implementation patients. Mean compliance with ERAS care elements increased from 56% to 77.0% after implementation (p < 0.0001). Median length of stay for all surgeries decreased from 4.0 days to 3.0 days post-ERAS (p < 0.0001), which translated to an adjusted LOS decrease of 31.4% (95% CI = [21.7% - 39.9%], p < 0.0001). In medium/high complexity surgery median LOS was reduced by 2.0 days (p = 0.0005). Complications prior to discharge decreased from 53.3% to 36.2% post-ERAS (p = 0.0003). There was no significant difference in readmission (p = 0.6159), complications up to 30 days (p = 0.6274), or mortality (p = 0.3618) between the cohorts. The net cost savings per patient was $956 (95%CI: $162 to $1636). CONCLUSIONS: Systematic implementation of ERAS gynecologic oncology guidelines across a healthcare system improves patient outcomes and saves resources.


Assuntos
Neoplasias dos Genitais Femininos/cirurgia , Fidelidade a Diretrizes/estatística & dados numéricos , Procedimentos Cirúrgicos em Ginecologia/efeitos adversos , Assistência Perioperatória/normas , Complicações Pós-Operatórias/epidemiologia , Idoso , Redução de Custos , Procedimentos Cirúrgicos de Citorredução/efeitos adversos , Procedimentos Cirúrgicos de Citorredução/economia , Procedimentos Cirúrgicos de Citorredução/métodos , Feminino , Neoplasias dos Genitais Femininos/economia , Procedimentos Cirúrgicos em Ginecologia/economia , Procedimentos Cirúrgicos em Ginecologia/métodos , Humanos , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Auditoria Médica , Pessoa de Meia-Idade , Alta do Paciente/estatística & dados numéricos , Readmissão do Paciente/economia , Readmissão do Paciente/estatística & dados numéricos , Assistência Perioperatória/economia , Assistência Perioperatória/métodos , Guias de Prática Clínica como Assunto , Avaliação de Programas e Projetos de Saúde
8.
Int J Urol ; 25(7): 655-659, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29729035

RESUMO

OBJECTIVE: To compare nationwide outcomes of tension-free vaginal mesh surgery and laparoscopic sacrocolpopexy for the treatment of pelvic organ prolapse in Japan. METHODS: Using the Diagnosis Procedure Combination database, we collected data on female patients who underwent tension-free vaginal mesh surgery or laparoscopic sacrocolpopexy for pelvic organ prolapse from April 2014 to March 2015. We compared the proportion of perioperative adverse events, duration of anesthesia, total costs and postoperative length of stay between the groups. Univariate and multivariate analyses were carried out for age, comorbidity, mesh volume, additional concomitant surgery and hospital volume. RESULTS: We identified 3023 patients, including 2388 who underwent tension-free vaginal mesh surgery, and 635 who underwent laparoscopic sacrocolpopexy. The median age at the time of surgery was significantly higher in the tension-free vaginal mesh group (71 vs 66 years; P < 0.001). The tension-free vaginal mesh group had a higher proportion of all adverse events (7.1% vs 1.8%; P < 0.001) and a higher proportion of genitourinary complications (5.7% vs 1.1%; P < 0.001). The median duration of anesthesia was shorter in the tension-free vaginal mesh group (150 vs 286 min; P < 0.001). The total cost was significantly lower in the tension-free vaginal mesh group. CONCLUSIONS: Both procedures offer favorable results for surgical treatment of pelvic organ prolapse. Overall, the tension-free vaginal mesh procedure seems to represent a good option for high-risk women, such as elderly patients, whereas laparoscopic sacrocolpopexy is useful for younger patients with a higher level of sexual activity.


Assuntos
Procedimentos Cirúrgicos em Ginecologia/efeitos adversos , Laparoscopia/efeitos adversos , Prolapso de Órgão Pélvico/cirurgia , Complicações Pós-Operatórias/epidemiologia , Telas Cirúrgicas/efeitos adversos , Fatores Etários , Idoso , Feminino , Procedimentos Cirúrgicos em Ginecologia/economia , Procedimentos Cirúrgicos em Ginecologia/instrumentação , Procedimentos Cirúrgicos em Ginecologia/métodos , Humanos , Japão/epidemiologia , Laparoscopia/economia , Laparoscopia/métodos , Tempo de Internação/estatística & dados numéricos , Pessoa de Meia-Idade , Prolapso de Órgão Pélvico/economia , Período Perioperatório , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Fatores de Risco , Telas Cirúrgicas/economia , Resultado do Tratamento
9.
Gynecol Oncol ; 149(2): 232-240, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29544708

RESUMO

Health care in the United States is in the midst of a significant transformation from a "fee for service" to a "fee for value" based model. The Medicare Access and CHIP Reauthorization Act of 2015 has only accelerated this transition. Anticipating these reforms, the Society of Gynecologic Oncology developed the Future of Physician Payment Reform Task Force (PPRTF) in 2015 to develop strategies to ensure fair value based reimbursement policies for gynecologic cancer care. The PPRTF elected as a first task to develop an Alternative Payment Model for thesurgical management of low risk endometrial cancer. The history, rationale, and conceptual framework for the development of an Endometrial Cancer Alternative Payment Model are described in this white paper, as well as directions forfuture efforts.


Assuntos
Neoplasias do Endométrio/economia , Reforma dos Serviços de Saúde/economia , Modelos Econômicos , Mecanismo de Reembolso/economia , Neoplasias do Endométrio/cirurgia , Feminino , Procedimentos Cirúrgicos em Ginecologia/economia , Reforma dos Serviços de Saúde/tendências , Humanos , Médicos/economia , Mecanismo de Reembolso/tendências , Sociedades Médicas , Estados Unidos
10.
Int J Gynecol Cancer ; 28(4): 692-699, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29557825

RESUMO

OBJECTIVE: This study aimed to compare robotic and open surgery in elderly women diagnosed as having endometrial cancer, in terms of costs, survival, surgical outcome, and operating time. METHODS: Women 70 years or older undergoing open and robotic surgery for endometrial cancers were included consecutively before and after the introduction of robotic surgery at a tertiary center. Costs were calculated using the case-costing system, cost per patient, including the first 30 postoperative days. Relative and overall survival outcomes were obtained from the Swedish National Cancer Registry and analyzed using the Kaplan-Meier method. Surgical outcomes including operating and anesthesia times, estimated blood loss, hospital stay, and intraoperative and postoperative complications were reviewed. RESULTS: In all, 137 and 141 women 70 years or older were identified to have undergone open and robotic surgery, respectively. The groups showed similar body mass index, comorbidities, and tumor characteristics. No statistically significant differences were seen in costs (robotic &OV0556;11,874 vs open &OV0556;11,521, P = 0.463) or 5-year survival outcomes (robotic 94% [95% confidence interval {CI}, 84-105] vs open 87% [95% CI, 78-98], P = 0.529). Robotic surgery was associated with significantly lower estimated blood loss (P < 0.001) and shorter hospital stay (P < 0.001) but longer anesthesia time (186 vs 174 minutes; P < 0.05) and operating theater time (205 vs 190 minutes; P < 0.05). There were no significant differences in intraoperative complications, but robotic surgery resulted in fewer postoperative Clavien-Dindo grade II complications. CONCLUSIONS: Elderly women can safely undergo robotic surgery for endometrial cancer and could be offered this technique to the same extent as younger patients. They may benefit from shorter hospital stay, decreased blood loss, and postoperative complications, without resulting in higher costs to the health care system or jeopardizing their survival.


Assuntos
Neoplasias do Endométrio/cirurgia , Procedimentos Cirúrgicos em Ginecologia/estatística & dados numéricos , Procedimentos Cirúrgicos Robóticos/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Custos e Análise de Custo , Neoplasias do Endométrio/economia , Neoplasias do Endométrio/mortalidade , Feminino , Procedimentos Cirúrgicos em Ginecologia/economia , Humanos , Tempo de Internação , Duração da Cirurgia , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Robóticos/economia , Suécia/epidemiologia
11.
Obstet Gynecol ; 131(3): 484-492, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29420405

RESUMO

OBJECTIVE: To analyze utilization of, and payments for, pelvic organ prolapse procedures after the 2011 U.S. Food and Drug Administration (FDA) communication regarding transvaginal mesh. METHODS: This is a retrospective cohort study examining private claims from three insurance providers for inpatient and outpatient prolapse procedures from 2010 to 2013 in the Health Care Cost Institute. Primary outcomes were the change in utilization of prolapse procedures, with and without mesh, before and after the July 2011 FDA communication. Secondary outcomes were the changes in payments and reimbursements for these procedures. Utilization rates and payments were compared using generalized linear models and interrupted time-series analysis. RESULTS: Utilization of prolapse procedures decreased from 12.3 to 9.7 per 10,000 woman-years (P=.027) with a decrease of 30.7% (3.9 in 2010 to 2.7 in 2013, P=.05) in number of mesh procedures and 16.6% (8.4 in 2010 to 7.0 in 2013, P=.011) for nonmesh procedures. Quarterly utilization of mesh procedures was increasing before the FDA communication and then significantly declined after its release (slope=0.024 vs -0.025, P=.002). Nonmesh procedures, however, were already slightly decreasing before July 2011 and continued to decline at a more rapid pace after that time, although not significantly (slope=-0.004 vs -0.022, P=.47). Inpatient utilization decreased 52.2% (P=.002), whereas outpatient utilization increased 18.5% (P=.132). Payments for individual inpatient procedures, with and without mesh, increased by 12.0% ($8,315 in 2010 to $9,315 in 2013, P=.001) and 15.6% ($7,826 in 2010 to $9,048 in 2013, P=.005), respectively, whereas those for outpatient procedures increased by 41% ($4,961 in 2010 to $6,981 in 2013, P=.006) and 30% ($3,955 in 2010 to $5,149 in 2013, P=.004), respectively. CONCLUSION: Use of prolapse surgery declined during the study period. After the 2011 FDA communication regarding transvaginal mesh, there was a significant decrease in the utilization of procedures with mesh but not for those without mesh. A shift toward outpatient surgeries was observed, and payments for both individual inpatient and outpatient cases increased.


Assuntos
Procedimentos Cirúrgicos em Ginecologia/tendências , Seguro Saúde , Prolapso de Órgão Pélvico/cirurgia , Padrões de Prática Médica/tendências , Utilização de Procedimentos e Técnicas/tendências , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Procedimentos Cirúrgicos em Ginecologia/economia , Procedimentos Cirúrgicos em Ginecologia/instrumentação , Procedimentos Cirúrgicos em Ginecologia/métodos , Humanos , Modelos Lineares , Pessoa de Meia-Idade , Prolapso de Órgão Pélvico/economia , Estudos Retrospectivos , Telas Cirúrgicas , Estados Unidos , United States Food and Drug Administration
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
13.
Surg Endosc ; 32(3): 1593-1599, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-28643058

RESUMO

BACKGROUND: The FloShield Air System® is a new device for laparoscopic surgery that utilizes a continuous dry CO2 gas flow over the scope to defog the lens and protect it from condensation, debris and smoke. We set out to compare the performance and efficiency of the device in terms of operative lens vision quality (OLVQ) with the reference technique (water + povidone-iodine (PVI) solution) during gynecologic laparoscopic surgery. MATERIALS AND METHODS: We conducted a single-center randomized prospective study between March and June 2016 (Trials Database Registration NCT02702531) including 53 patients undergoing gynecologic laparoscopic surgery with water + PVI solution and 51 patients who underwent surgical procedures with the FloShield Air System. The primary outcome measure was the number of laparoscope removals during surgery. Secondary outcome measures were the time to clean, assessment of the quality of vision, the correlation between the laparoscopic surgical complexity and outcomes, and cost effectiveness. RESULTS: Overall, the mean patient age was 43.2 years (range 22-86) and body mass index 24.8 (range 16.8-42.7). The mean number of endoscope removals during surgery was 7.0 (range 0-37) in the water + PVI solution arm and 2.8 (range 0-12) in the FloShield Air System® arm. The number of removals was significantly lower in the FloShield arm (p < 0.001). No difference in time to clean, quality of vision, level of laparoscopic procedure complexity, or cost was observed between the groups. CONSLUSIONS: The FloShield Air System® resulted in fewer laparoscopic lens removals than the water + PVI solution solution, but that there was no difference in quality of vision, cleaning time or cost, especially for the more complex surgery.


Assuntos
Procedimentos Cirúrgicos em Ginecologia/instrumentação , Laparoscópios/normas , Laparoscopia/instrumentação , Lentes/normas , Adulto , Idoso , Idoso de 80 Anos ou mais , Índice de Massa Corporal , Dióxido de Carbono , Custos e Análise de Custo , Feminino , Procedimentos Cirúrgicos em Ginecologia/economia , Procedimentos Cirúrgicos em Ginecologia/métodos , Humanos , Laparoscopia/economia , Laparoscopia/métodos , Pessoa de Meia-Idade , Povidona-Iodo/administração & dosagem , Estudos Prospectivos , Soluções , Água/administração & dosagem , Adulto Jovem
14.
Obstet Gynecol ; 130(6): 1269-1275, 2017 12.
Artigo em Inglês | MEDLINE | ID: mdl-29112648

RESUMO

OBJECTIVE: To examine the cost of care during the first year after a diagnosis of ovarian cancer, estimate the sources of cost, and explore the out-of-pocket costs. METHODS: We performed a retrospective cohort study of women with ovarian cancer diagnosed from 2009 to 2012 who underwent both surgery and adjuvant chemotherapy using the Truven Health MarketScan database. This database is comprised of patients covered by commercial insurance sponsored by more than 100 employers in the United States. Medical expenditures, including physician reimbursement, for a 12-month period beginning on the date of surgery were estimated. All payments were examined, including out-of-pocket costs for patients. Payments were divided into expenditures for inpatient care, outpatient care (including chemotherapy), and outpatient drug costs. The 12-month treatment period was divided into three phases: surgery to 30 days (operative period), 1-6 months (adjuvant therapy), and 6-12 months after surgery. The primary outcome was the overall cost of care within the first year of diagnosis of ovarian cancer; secondary outcomes included assessment of factors associated with cost. RESULTS: A total of 26,548 women with ovarian cancer who underwent surgery were identified. After exclusion of patients with incomplete insurance enrollment or coverage, those who did not undergo chemotherapy, and those with capitated plans, our cohort consisted of 5,031 women. The median total medical expenditures per patient during the first year after the index procedure were $93,632 (interquartile range $62,319-140,140). Inpatient services accounted for $30,708 (interquartile range $20,102-51,107; 37.8%) in expenditures, outpatient services $52,700 (interquartile range $31,210-83,206; 58.3%), and outpatient drug costs $1,814 (interquartile range $603-4,402; 3.8%). The median out-of-pocket expense was $2,988 (interquartile range $1,649-5,088). This included $1,509 (interquartile range $705-2,878) for outpatient services, $589 (interquartile range $3-1,715) for inpatient services, and $351 (interquartile range $149-656) for outpatient drug costs. CONCLUSION: The average cost of care for women with ovarian cancer in the first year after surgery is approximately $100,000. Patients bear approximately 3% of these costs in the form of out-of-pocket expenses.


Assuntos
Quimioterapia Adjuvante/economia , Procedimentos Cirúrgicos em Ginecologia/economia , Custos de Cuidados de Saúde/estatística & dados numéricos , Gastos em Saúde/estatística & dados numéricos , Neoplasias Ovarianas , Administração dos Cuidados ao Paciente , Adulto , Idoso , Quimioterapia Adjuvante/métodos , Estudos de Coortes , Alocação de Custos/estatística & dados numéricos , Feminino , Procedimentos Cirúrgicos em Ginecologia/métodos , Humanos , Pessoa de Meia-Idade , Neoplasias Ovarianas/diagnóstico , Neoplasias Ovarianas/terapia , Administração dos Cuidados ao Paciente/economia , Administração dos Cuidados ao Paciente/métodos , Estudos Retrospectivos , Estados Unidos
15.
BMJ Open ; 7(9): e015571, 2017 Sep 03.
Artigo em Inglês | MEDLINE | ID: mdl-28871011

RESUMO

OBJECTIVE: To assess the budget impact of using ulipristal acetate (UPA) 5 mg to treat women with uterine fibroids (UF) causing moderate to severe symptoms. DESIGN: We modelled trends in the number of surgical procedures for symptomatic UF, with and without the use of UPA for preoperative or intermittent treatment and assessed the budget impact of UPA use from the French national healthcare insurance system perspective. SETTING: A French national hospital database (PMSI) that records admissions and relative procedures to public and private hospitals. PARTICIPANTS: Women eligible for surgical procedures for uterine fibroids. MAIN OUTCOME MEASURES: Economic impact of UPA treatment. RESULTS: This study based on observational retrospective data shows that the current use of UPA in its preoperative indication was associated with 5645 fewer surgeries from 2013 to 2015. Extrapolation suggests 17 885 fewer surgeries from 2016 to 2019. Overall, preoperative use of UPA results in substantial cost savings for the French national healthcare insurance system, with a cumulated budget impact estimated at €-5 million from 2013 to 2015 and €-13.5 million from 2016 to 2019. In addition, treating women nearing the menopause (≥48 years old) with intermittent treatment from 2017 to 2019 could produce an incremental cost saving of €19 million. CONCLUSIONS: This study shows that the use of UPA in women eligible for surgical procedures for UF is associated with considerable savings for the French national healthcare insurance system in both preoperative and intermittent indications by decreasing the need to perform surgeries.


Assuntos
Redução de Custos/estatística & dados numéricos , Procedimentos Cirúrgicos em Ginecologia/economia , Leiomioma/terapia , Norpregnadienos/economia , Neoplasias Uterinas/terapia , Adolescente , Adulto , Distribuição por Idade , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Feminino , França , Humanos , Modelos Lineares , Pessoa de Meia-Idade , Norpregnadienos/uso terapêutico , Estudos Retrospectivos , Adulto Jovem
16.
Aust N Z J Obstet Gynaecol ; 57(5): 493-498, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-28857135

RESUMO

There has been a significant increase in minimally invasive surgery in gynaecology over the last 15 years, with approximately only one-third of hysterectomies for benign disease now performed via laparotomy. While robotic surgery offers considerable technical advantages over conventional laparoscopy and is associated with only a modest learning curve, the improvement in clinical outcomes is marginal and there are several disadvantages. There are increased set-up and operating times, the need to accommodate and maintain large sophisticated equipment, and the requirement for additional training. The preeminent issue regarding the place of robotic gynaecological surgery is cost. How this is addressed and contained will ultimately determine uptake in Australia. From the published literature to date, robotic surgery compared with conventional laparoscopic surgery is associated with marginal improvements in clinical outcomes for benign hysterectomy and endometrial cancer surgery, but little improvement for other benign gynaecological surgery or for cervical cancer surgery. Robotic surgery probably does improve clinical outcomes in obese and morbidly obese patients and is associated with improved ergonomics for the surgeon. It is likely that there will be continued substantial improvements in robotic surgical platforms into the foreseeable future and that robotic surgery will play an increasingly important role in gynaecological surgery in Australia.


Assuntos
Neoplasias dos Genitais Femininos/cirurgia , Procedimentos Cirúrgicos em Ginecologia/tendências , Laparoscopia/tendências , Procedimentos Cirúrgicos Robóticos/tendências , Austrália , Feminino , Previsões , Procedimentos Cirúrgicos em Ginecologia/economia , Procedimentos Cirúrgicos em Ginecologia/métodos , Humanos , Histerectomia/métodos , Histerectomia/tendências , Obesidade/cirurgia , Procedimentos Cirúrgicos Robóticos/economia
17.
Int J Gynecol Cancer ; 27(8): 1788-1793, 2017 10.
Artigo em Inglês | MEDLINE | ID: mdl-28937446

RESUMO

OBJECTIVES: The purpose of this study was to compare the costs of traditional laparoscopy and robotic-assisted laparoscopy in the treatment of endometrial cancer. METHODS AND MATERIALS: A total of 101 patients with endometrial cancer were randomized to the study and operated on starting from 2010 until 2013, at the Department of Obstetrics and Gynecology of Tampere University Hospital, Tampere, Finland. Costs were calculated based on internal accounting, hospital database, and purchase prices and were compared using intention-to-treat analysis. Main outcome measures were item costs and total costs related to the operation, including a 6-month postoperative follow-up. RESULTS: The total costs including late complications were 2160 &OV0556; higher in the robotic group (median for traditional 5823 &OV0556;, vs robot median 7983 &OV0556;, P < 0.001). The difference was due to higher costs for instruments and equipment as well as to more expensive operating room and postanesthesia care unit time. Traditional laparoscopy involved higher costs for operation personnel, general costs, medication used in the operation, and surgeon, although these costs were not substantial. There was no significant difference in in-patient stay, laboratory, radiology, blood products, or costs related to complications. CONCLUSIONS: According to this study, robotic-assisted laparoscopy is 37% more expensive than traditional laparoscopy in the treatment of endometrial cancer. The cost difference is mainly explained by amortization of the robot and its instrumentation.


Assuntos
Neoplasias do Endométrio/economia , Neoplasias do Endométrio/cirurgia , Procedimentos Cirúrgicos em Ginecologia/economia , Laparoscopia/economia , União Europeia , Feminino , Finlândia , Procedimentos Cirúrgicos em Ginecologia/métodos , Custos de Cuidados de Saúde , Humanos , Laparoscopia/métodos
18.
Surg Endosc ; 31(12): 5418-5426, 2017 12.
Artigo em Inglês | MEDLINE | ID: mdl-28634629

RESUMO

BACKGROUND: The success of newly introduced surgical techniques is generally primarily assessed by surgical outcome measures. However, data on medical liability should concomitantly be used to evaluate provided care as they give a unique insight into substandard care from patient's point of view. The aim of this study was to analyze the number and type of medical claims after laparoscopic gynecologic procedures since the introduction of advanced laparoscopy two decades ago. Secondly, our objective was to identify trends and/or risk factors associated with these claims. METHODS: To identify the claims, we searched the databases of the two largest medical liability mutual insurance companies in The Netherlands (MediRisk and Centramed), covering together 96% of the Dutch hospitals. All claims related to laparoscopic gynecologic surgery and filed between 1993 and 2015 were included. RESULTS: A total of 133 claims met our inclusion criteria, of which 54 were accepted claims (41%) and 79 rejected (59%). The number of claims remained relatively constant over time. The majority of claims were filed for visceral and/or vascular injuries (82%), specifically to the bowel (40%) and ureters (20%). More than one-third of the injuries were entry related (38%) and 77% of the claims were filed after non-advanced procedures. A delay in diagnosing injuries was the primary reason for financial compensation (33%). The median sum paid to patients was €12,000 (500-848,689). In 90 claims, an attorney was defending the patient (83% for the accepted claims; 57% for the rejected claims). CONCLUSION: The number of claims remained relatively constant during the study period. Most claims were provoked by bowel and ureter injuries. Delay in recognizing injuries was the most encountered reason for granting financial compensation. Entering the abdominal cavity during laparoscopy continues to be a potential dangerous step. As a result, gynecologists are recommended to thoroughly counsel patients undergoing any laparoscopic procedure, even regarding the risk of entry-related injuries.


Assuntos
Procedimentos Cirúrgicos em Ginecologia/efeitos adversos , Complicações Intraoperatórias/economia , Laparoscopia/efeitos adversos , Imperícia , Erros Médicos , Adolescente , Adulto , Idoso , Compensação e Reparação , Bases de Dados Factuais , Feminino , Procedimentos Cirúrgicos em Ginecologia/economia , Procedimentos Cirúrgicos em Ginecologia/estatística & dados numéricos , Humanos , Seguro de Responsabilidade Civil , Complicações Intraoperatórias/epidemiologia , Laparoscopia/economia , Laparoscopia/estatística & dados numéricos , Responsabilidade Legal , Imperícia/economia , Imperícia/legislação & jurisprudência , Erros Médicos/economia , Erros Médicos/legislação & jurisprudência , Pessoa de Meia-Idade , Países Baixos/epidemiologia , Fatores de Risco , Adulto Jovem
19.
Artigo em Inglês | MEDLINE | ID: mdl-28526229

RESUMO

Robotic approach is a rather new technique that can be used to optimise the management of patients with gynaecological cancer. However, concerns have been raised regarding the cost of such an approach compared to laparoscopic or open techniques. The aim of our chapter is to review the data of papers published so far that analyse the cost of robotic gynaecological oncology. A systematic review of the current literature was performed trying to assess the cost of the robotic technique including parameters that affect it and ways to minimise it in favour of the patients and health care systems.


Assuntos
Análise Custo-Benefício , Neoplasias dos Genitais Femininos/cirurgia , Procedimentos Cirúrgicos em Ginecologia/economia , Laparoscopia/economia , Procedimentos Cirúrgicos Robóticos/economia , Feminino , Neoplasias dos Genitais Femininos/economia , Procedimentos Cirúrgicos em Ginecologia/métodos , Humanos , Laparoscopia/métodos , Procedimentos Cirúrgicos Robóticos/métodos
20.
Int J Qual Health Care ; 29(2): 222-227, 2017 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-28407094

RESUMO

Objective: In Korea, the Value Incentive Program (VIP) was first applied to selected clinical conditions in 2007 to evaluate the performance of medical institutes. We examined whether the condition-specific performance of the VIP resulted in measurable improvement in quality of care and in reduced medical costs. Design: Population-based retrospective observational study. Setting: We used two data set including the results of quality assessment and hospitalization data from National Health Claim data from 2011 to 2014. Participants: Participants who were admitted to the hospital for obstetrics and gynecology were included. A total of 535 289 hospitalizations were included in our analysis. Methods: We used a generalized estimating equation (GEE) model to identify associations between the quality assessment and length of stay (LOS). A GEE model based on a gamma distribution was used to evaluate medical cost. The Poisson regression analysis was used to evaluate readmission. Main Outcome Measures: The outcome variables included LOS, medical costs and readmission within 30 days. Results: Higher condition-specific performance by VIP participants was associated with shorter LOSs, decreases in medical cost, and lower within 30-day readmission rates for target and non-target surgeries. LOS and readmission within 30 days were different by change in quality assessment at each medical institute. Conclusions: Our findings contribute to the body of evidence used by policy-makers for expansion and development of the VIP. The study revealed the positive effects of quality assessment on quality of care. To reduce the between-institute quality gap, alternative strategies are needed for medical institutes that had low performance.


Assuntos
Procedimentos Cirúrgicos em Ginecologia/economia , Procedimentos Cirúrgicos Obstétricos/economia , Qualidade da Assistência à Saúde/economia , Reembolso de Incentivo/economia , Reembolso de Incentivo/estatística & dados numéricos , Adulto , Feminino , Procedimentos Cirúrgicos em Ginecologia/estatística & dados numéricos , Hospitalização , Humanos , Tempo de Internação/estatística & dados numéricos , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Obstétricos/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , República da Coreia , Estudos Retrospectivos
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