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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.
Am Surg ; 85(10): 1113-1117, 2019 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-31657305

RESUMO

Although recommendations help guide surgeons' mesh choice in abdominal wall reconstruction (AWR), financial and institutional pressures may play a bigger role. Standardization of an AWR algorithm may help reduce costs and change mesh preferences. We performed a retrospective review of high- and low-risk patients who underwent inpatient AWR between 2014 and 2016. High risk was defined as immunosuppression and/or history of infection/contamination. Patients were stratified by the type of mesh as biologic/biosynthetic or synthetic. These cohorts were analyzed for outcome, complications, and cost. One hundred twelve patients underwent complex AWR. The recurrence rate at two years was not statistically different between high- and low-risk cohorts. No significant difference was found in the recurrence rate between biologic and synthetic meshes when comparing both high- and low-risk cohorts. The average cost of biologic mesh was $9,414.80 versus $524.60 for synthetic. The estimated cost saved when using synthetic mesh for low-risk patients was $295,391.20. In conclusion, recurrence rates for complex AWR seem to be unrelated to mesh selection. There seems to be an excess use of biologic mesh in low-risk patients, adding significant cost. Implementing a critical process to evaluate indications for biologic mesh use could decrease costs without impacting the quality of care, thus improving the overall value of AWR.


Assuntos
Parede Abdominal/cirurgia , Materiais Biocompatíveis/economia , Redução de Custos , Sobremedicalização/economia , Telas Cirúrgicas/economia , Algoritmos , Materiais Biocompatíveis/efeitos adversos , Estudos de Coortes , Humanos , Hospedeiro Imunocomprometido , Sobremedicalização/estatística & dados numéricos , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias , Recidiva , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Telas Cirúrgicas/efeitos adversos , Telas Cirúrgicas/estatística & dados numéricos
3.
J Am Coll Surg ; 228(1): 66-71, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30359837

RESUMO

BACKGROUND: Biologic and biosynthetic meshes typically cost more than synthetic meshes for use in ventral hernia repair (VHR), with unknown comparative effectiveness. STUDY DESIGN: Cost-utility analysis was performed from a limited societal perspective assessing direct medical costs and outcomes for open, elective, retromuscular VHR. Short-term and 5-year major complications and costs were modeled using best available evidence from published studies, Healthcare Cost and Utilization Project data, and Americas Hernia Society Quality Collaborative data. Costs were analyzed in 2017 US dollars, and utilities were assessed using quality adjusted life years (QALYs). Sensitivity analyses were performed to determine threshold probabilities of long-term complications favoring particular mesh types. RESULTS: Synthetic mesh was the preferred strategy, with a cost of $15,620 and QALYs of 18.85, assuming a baseline 5.6% rate of long-term complications for all meshes. One-way sensitivity analysis demonstrated that biosynthetic and biologic mesh became the better choice as long-term complication rates for synthetic mesh increased to 15.5% and 26.2%, respectively. Two-way sensitivity analysis demonstrated that biologic and biosynthetic meshes became favorable as the cost of biologic mesh decreased and long-term synthetic mesh complication rates increased. Biologic and biosynthetic meshes also became more cost-effective when their relative long-term complication rates decreased and long-term synthetic mesh complication rates increased. CONCLUSIONS: Using modeling techniques, synthetic mesh is the best option for retromuscular VHR given currently available evidence. We established long-term complication thresholds, possibly justifying the higher up-front costs for biologic or biosynthetic meshes. This emphasizes the critical need to obtain long-term complication surveillance data to help individualize mesh choice in VHR.


Assuntos
Produtos Biológicos/economia , Análise Custo-Benefício , Hérnia Ventral/cirurgia , Herniorrafia/métodos , Telas Cirúrgicas/economia , Técnicas de Apoio para a Decisão , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Anos de Vida Ajustados por Qualidade de Vida , Estados Unidos
4.
J Visc Surg ; 155(5): 349-353, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30266341

RESUMO

GOAL: Retrospective analysis of bioprosthetic abdominal wall reconstruction in our center with regard to expenses and reimbursement. PATIENTS AND METHODS: This study included all patients undergoing bioprosthetic abdominal wall reconstruction between 2009 and 2015. All costs were considered in determining the hospital expenditures. Next we compared the incoming revenue for each hospital stay based on disease-related groups (DRG) and additional daily hospital fees. RESULTS: Seventy-six patients underwent abdominal wall reconstruction, 67 of whom had economical data that were exploitable. On the average, our center lost €15,233 for every hospital stay associated with bioprosthetic abdominal wall reconstruction. The existing DRG system is not well adapted to provide adequate reimbursement for costs related to complex abdominal wall repairs, especially when post-operative morbidity leads to prolonged hospital stay and increased expenses. CONCLUSION: Abdominal wall repairs with bioprostheses are expensive and are poorly reimbursed in the French Health care system, mainly because they are often associated with complications that increase the costs considerably. In our opinion, it seems necessary that either reimbursement of this type of prosthesis should be higher than the current DRG allows, or that the DRG classification be redefined, or even, that a specific DRG be created for complex abdominal wall reconstruction.


Assuntos
Parede Abdominal/cirurgia , Bioprótese/economia , Custos Hospitalares , Tempo de Internação/economia , Telas Cirúrgicas/economia , Técnicas de Fechamento de Ferimentos Abdominais/economia , Custos e Análise de Custo , Grupos Diagnósticos Relacionados/economia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Reconstrutivos/economia , Procedimentos Cirúrgicos Reconstrutivos/métodos , Estudos Retrospectivos
5.
J Surg Res ; 230: 137-142, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-30100030

RESUMO

BACKGROUND: Despite the recognition that inguinal hernia (IH) repair is cost-effective, repair rates in low- and middle-income countries remain low. Estimated use of mesh in low- and middle-income countries also remains low despite publications about low-cost, noncommercial mesh. The purpose of our study was to assess the current state of IH repair in the northern and transitional zone of Ghana. MATERIALS AND METHODS: A retrospective review of surgical case logs of IH repairs from 2013 to 2017 in 41 hospitals was performed. Multivariate logistic regression was used to determine predictors of mesh use. RESULTS: Eight thousand eighty male patients underwent IH repair. The range of IH repair in each region was 96 to 295 (overall 123) per 100,000 population. Most cases were performed at district hospitals (84%) and repaired nonurgently (93%) by nonsurgeon physicians (66%). Suture repair was most common (85%) although mesh was used in 15%. The strongest predictor of mesh use was when a surgeon performed surgery (odds ratio [OR] 3.13, P <0.001), followed by surgery being performed in a teaching hospital (OR 2.31, P <0.001). Repair at a regional hospital was a negative predictor of mesh use (OR 0.08, P <0.001) as was the use of general anesthesia (OR 0.40, P = 0.001). CONCLUSIONS: Most IH repairs are performed in district hospitals, by nonsurgeon physicians, and without mesh. Rates of repair and the use of mesh are higher than previous estimates in Ghana and Sub-Saharan Africa but not as high as high-income countries.


Assuntos
Hérnia Inguinal/cirurgia , Herniorrafia/instrumentação , Próteses e Implantes/estatística & dados numéricos , Telas Cirúrgicas/estatística & dados numéricos , Gana , Hérnia Inguinal/economia , Herniorrafia/economia , Herniorrafia/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Próteses e Implantes/economia , Estudos Retrospectivos , Telas Cirúrgicas/economia
6.
Hosp Pract (1995) ; 46(4): 233-237, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30001669

RESUMO

OBJECTIVES: Inguinal hernias of the abdominal wall are common accounting for 75% of all hernia defects. They can be treated with laparoscopic surgery using a transabdominal preperitoneal (TAPP) approach. However, in surgery there is some contention on how to conclude the hernia repair, as there are alternatives of using fibrin sealant (FS) or tack screws for fixation of a mesh implant over the defect in the abdominal wall. In this study, we evaluate the economic consequences of using FS vs. tacks for mesh fixation in TAPP inguinal hernia repair for the UK from a hospital perspective. METHODS: The model was populated with clinical inputs (theater time, hospitalization days, occurrence of seroma, and neuralgia) from a previously conducted study comparing FS and tack screws in patients who had undergone TAPP hernia repair, and cost inputs from official government sources. One-way sensitivity analyses were also conducted to evaluate key drivers of cost analyses. RESULTS: The average cost per case treated with FS 2 mL Tisseel® and tack screws (ProTackTM) was £1,098 and £1,348, respectively, for resource expenses paid by the healthcare system. This would suggest a potential savings achieved of £249 per surgery using FS for mesh fixation. The sensitivity analysis showed that the key drivers for the cost difference were a variation in time to complete the surgery, followed by hospitalization days, and lower adverse outcomes such as seroma and neuralgia in the two cohorts. CONCLUSION: Using FS resulted in cost savings in hospitals based on reduced time to complete surgery, hospitalization time post-op, and lower adverse outcomes. Indirect cost savings were also found in favor of FS when comparing the two alternatives from a societal perspective, as patients were able to return to work more promptly in the FS group versus the tack screws group.


Assuntos
Adesivo Tecidual de Fibrina/economia , Adesivo Tecidual de Fibrina/uso terapêutico , Hérnia Inguinal/economia , Hérnia Inguinal/cirurgia , Laparoscopia/economia , Telas Cirúrgicas/economia , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Recuperação de Função Fisiológica , Resultado do Tratamento , Reino Unido
7.
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
8.
Tech Coloproctol ; 22(4): 265-270, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29732505

RESUMO

BACKGROUND: Previous meta-analyses of randomised controlled trials (RCTs) have suggested a reduction in parastomal hernias (PSH) with prophylactic mesh. However, concerns persist regarding variably supportive evidence and cost. We performed an updated systematic review and meta-analysis to inform a novel cost-effectiveness analysis. METHODS: The PubMed, EMBASE and Cochrane Centre Register of Controlled Trials databases were searched (February 2018). We included RCTs assessing mesh reinforcement during stoma formation. We assessed PSH rates, subsequent repair, complications and operative time. Odds ratios (OR) and numbers needed to treat (NNT) were generated on intention to treat (ITT) and per protocol (PP) bases. These then informed cost analysis using 2017 UK/USA reimbursement rates and stoma care costs. RESULTS: Eleven RCTs were included. Four hundred fifty-three patients were randomised to mesh (PP 412), with 454 controls (PP 413). Six studies used synthetic meshes, three composite and two biological (91.7% colostomies; 3.64% ileostomies, 4.63% not specified). Reductions were seen in the number of hernias detected clinically and on computed tomography scan. For the former, ITT OR was 0.23 (95% confidence interval 0.11-0.51; p = 0.0003; n = 11); NNT 4.17 (2.56-10.0), with fewer subsequent repairs: OR 0.29 (0.13-0.64; p = 0.002; n = 7; NNT16.7 (10.0-33.3). Reductions persisted for synthetic and composite meshes. Operative time was similar, with zero incidence of mesh infection/fistulation, and fewer peristomal complications. Synthetic mesh demonstrated a favourable cost profile, with composite approximately cost neutral, and biological incurring net costs. CONCLUSIONS: Reinforcing elective stomas with mesh (primarily synthetic) reduces subsequent PSH rates, complications, repairs and saves money. We recommend that future RCTs compare mesh subtypes, techniques, and applicability to emergency stomas.


Assuntos
Colostomia/efeitos adversos , Hérnia Abdominal/prevenção & controle , Ileostomia/efeitos adversos , Telas Cirúrgicas , Colostomia/economia , Análise Custo-Benefício , Hérnia Abdominal/etiologia , Humanos , Ileostomia/economia , Análise de Intenção de Tratamento , Números Necessários para Tratar , Ensaios Clínicos Controlados Aleatórios como Assunto , Telas Cirúrgicas/efeitos adversos , Telas Cirúrgicas/economia
10.
J Wound Care ; 27(Sup4): S12-S22, 2018 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-29641342

RESUMO

OBJECTIVE: To compare economic and clinical outcomes between skin staples and 2-octyl cyanoacrylate plus polymer mesh tape, Dermabond Prineo skin closure system, (SCS) among patients undergoing total knee replacement (TKR). METHOD: Retrospective, observational study using the Premier Healthcare Database, which comprises hospital administrative and billing data for over 700 hospitals in the US. Patients selected for study had an elective hospital admission, with discharge occurring between January 2012 and September 2015, carrying primary ICD-9-CM procedure and diagnosis codes for TKR and osteoarthritis. Patients were classified into two mutually-exclusive groups based on billing records during the index admission: those with billing record(s) for the skin closure system (SCS group); and those with billing record(s) for skin staples (staple group). Primary outcomes were index admission's length of stay (LOS), total hospital costs, and discharge status (skilled nursing facility (SNF)/other versus home/home health-care); exploratory outcomes included operating room time (ORT) during index admission and 30, 60, and 90-day readmissions. The SCS and staple groups were propensity score matched (1:1/nearest neighbour/caliper=0.10) on patient, hospital, and provider characteristics. Multivariable regressions accounting for hospital-level clustering after matching were used to compare outcomes between study groups. RESULTS: Each group comprised 971 patients (1942 total patients; mean age: 65.3 years; female: 63.5%). The groups were generally well-balanced on matching covariates: mean standardised difference calculated across 49 covariates=0.049. Compared with the staple group, the SCS group had statistically significant shorter LOS (2.8 days versus 3.2 days, p=0.002), lower rate of discharge to SNF/other versus home/home health-care (26.4% versus 38.5%, p=0.011), and lower rate of 30, 60, and 90-day readmissions (30-day, 1.8% versus 4.4%, p=0.006; 60-day, 3.0% versus 5.4%, p<0.001; 90-day, 5.4% versus 7.4%, p=0.016). Differences between the groups for other outcomes were not statistically significant. CONCLUSION: Among patients undergoing TKR, use of the SCS was associated with shorter LOS, less resource intensive discharge status, and lower rates of all-cause readmission as compared with skin staples.


Assuntos
Artroplastia do Joelho/economia , Telas Cirúrgicas/economia , Suturas/economia , Adolescente , Adulto , Idoso , Cianoacrilatos , Bases de Dados Factuais , Feminino , Custos Hospitalares/estatística & dados numéricos , Humanos , Classificação Internacional de Doenças , Masculino , Pessoa de Meia-Idade , Polímeros , Estudos Retrospectivos , Adesivos Teciduais , Resultado do Tratamento , Estados Unidos , Adulto Jovem
11.
Am Surg ; 84(1): 99-108, 2018 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-29428035

RESUMO

Prophylactic mesh augmentation (PMA) is the implantation of mesh during closure of an index laparotomy to decrease a patient's risk for developing incisional hernia (IH). The current body of evidence lacks refined guidelines for patient selection, mesh placement, and material choice. The purpose of this study is to summarize the literature and identify areas of research needed to foster responsible and appropriate use of PMA as an emerging technique. We conducted a comprehensive review of Scopus, Cochrane, PubMed, and clinicaltrials.gov for articles and trials related to using PMA for IH risk reduction. We further supplemented our review by including select papers on patient-reported outcomes, cost utility, risk modeling, surgical techniques, and available materials highly relevant to PMA. Five-hundred-fifty-one unique articles and 357 trials were reviewed. Multiple studies note a significant decrease in IH incidence with PMA compared with primary suture-only-based closure. No multicenter randomized control trial has been conducted in the United States, and only two such trials are currently active worldwide. Evidence exists supporting the use of PMA, with practical cost utility and models for selecting high-risk patients, but standard PMA guidelines are lacking. Although Europe has progressed with this technique, widespread adoption of PMA requires large-scale pragmatic randomized control trial research, strong evidence-based guidelines, current procedural terminology coding, and resolution of several barriers.


Assuntos
Hérnia Ventral/cirurgia , Hérnia Incisional/etiologia , Hérnia Incisional/prevenção & controle , Laparotomia , Telas Cirúrgicas , Ensaios Clínicos como Assunto , Medicina Baseada em Evidências , Hérnia Ventral/economia , Humanos , Hérnia Incisional/economia , Laparotomia/métodos , Fatores de Risco , Telas Cirúrgicas/economia , Técnicas de Sutura , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
12.
Am Surg ; 84(1): 118-125, 2018 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-29428038

RESUMO

Incisional hernia (IH) is a challenging, potentially morbid condition. This study evaluates recent trends in hospital encounters associated with IH care in the United States. Using Nationwide Inpatient Sample databases from 2007 to 2011, annual estimates of IH-related hospital discharges, charges, and serious adverse events were identified. Significance in observed trends was tested using regression modeling. From 2007 to 2011, there were 583,054 hospital discharges associated with a diagnosis of IH. 81.1 per cent had a concurrent procedure for IH repair. The average discharge included a female patient (63.2%), 59.8 years of age, with either Medicare (45.3%) or Private insurance (38.3%) as the anticipated primary payer. Comparing 2007 to 2011, significant increases in IH discharges (12%; 2007 = 109,702 vs 2011 = 123,034, P = 0.009) and IH repairs (10%; 2007 = 90,588 vs 2011 = 99,622, P < 0.001) were observed. This was accompanied by a 37 per cent increase in hospital charges (2007 = $44,587 vs 2011 = $60,968, P < 0.001), resulting in a total healthcare bill of $7.3 billion in 2011. Significant trends toward greater patient age (2007 = 59.7 years vs 2011 = 60.2 years, P < 0.001), higher comorbidity index (2007 = 3.0 vs 2011 = 3.5, P < 0.001), and increased frequency of serious adverse events (2007 = 13.5% vs 2011 = 17.7%, P < 0.001) were noted. Further work is needed to identify interventions to mitigate the risk of IH development.


Assuntos
Herniorrafia/economia , Preços Hospitalares , Hérnia Incisional/economia , Pacientes Internados , Laparoscopia/economia , Tempo de Internação/economia , Telas Cirúrgicas/economia , Custos e Análise de Custo , Feminino , Preços Hospitalares/tendências , Hospitais , Humanos , Hérnia Incisional/diagnóstico , Hérnia Incisional/etiologia , Hérnia Incisional/cirurgia , Masculino , Medicare , Pessoa de Meia-Idade , Alta do Paciente/economia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Estados Unidos
13.
J Med Econ ; 21(3): 294-300, 2018 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-29171319

RESUMO

AIMS: Infection is a major complication of cardiovascular implantable electronic device (CIED) therapy that usually requires device extraction and is associated with increased morbidity and mortality. The TYRX Antibacterial Envelope is a polypropylene mesh that stabilizes the CIED and elutes minocycline and rifampin to reduce the risk of post-operative infection. METHODS: A decision tree was developed to assess the cost-effectiveness of TYRX vs standard of care (SOC) following implantation of four CIED device types. The model was parameterized for a UK National Health Service perspective. Probabilities were derived from the literature. Resource use included drug acquisition and administration, hospitalization, adverse events, device extraction, and replacement. Incremental cost-effectiveness ratios (ICERs) were calculated from costs and quality-adjusted life-years (QALYs). RESULTS: Over a 12-month time horizon, TYRX was less costly and more effective than SOC when utilized in patients with an ICD or CRT-D. TYRX was associated with ICERs of £46,548 and £21,768 per QALY gained in patients with an IPG or CRT-P, respectively. TYRX was cost-effective at a £30,000 threshold at baseline probabilities of infection exceeding 1.65% (CRT-D), 1.95% (CRT-P), 1.87% (IPG), and 1.38% (ICD). LIMITATIONS AND CONCLUSIONS: Device-specific infection rates for high-risk patients were not available in the literature and not used in this analysis, potentially under-estimating the impact of TYRX in certain devices. Nevertheless, TYRX is associated with a reduction in post-operative infection risk relative to SOC, resulting in reduced healthcare resource utilization at an initial cost. The ICERs are below the accepted willingness-to-pay thresholds used by UK decision-makers. TYRX, therefore, represents a cost-effective prevention option for CIED patients at high-risk of post-operative infection.


Assuntos
Antibacterianos/administração & dosagem , Antibacterianos/economia , Insuficiência Cardíaca/cirurgia , Controle de Infecções/métodos , Próteses e Implantes/microbiologia , Telas Cirúrgicas/economia , Análise Custo-Benefício , Humanos , Mortalidade/tendências , Qualidade de Vida , Reino Unido
14.
Ann Surg ; 267(2): 370-374, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-27906759

RESUMO

OBJECTIVE: The aim of this study was to assess the impact of developing a hernia program on mesh utilization. BACKGROUND: With the ongoing changes in healthcare, the value of all interventions will see increased scrutiny. Hernia mesh can be one of the most costly components of hernia repairs. A disease-based institutional hernia program that defines roles for mesh utilization and measures outcomes has the potential to add significant value to hospital systems. METHODS: In August 2014, a disease-based hernia program was initiated across a hospital system. In collaboration with hospital administration, surgical operations, and all surgeons involved in the care of hernia patients, general guidelines for mesh utilization based on CDC wound class were created. All hernia repairs performed between January 2013 and November 2015 were reviewed. RESULTS: Approximately, 13,937 hernias were repaired during the study period. Biologic mesh was used in 0.4% of clean, 7.1% of clean-contaminated, 38.5% of contaminated, and 58.8% of dirty cases. After initiation of the hernia program there was a reduction in biologic mesh utilization across the system (clean: 66% reduction; clean-contaminated: 63% reduction; contaminated: 55% reduction; dirty: 47% reduction). Surgeons who participated in the hernia program used significantly less biologic mesh in clean (P < 0.01), clean-contaminated (P = 0.01) and contaminated (P < 0.01) hernia repairs. CONCLUSIONS: The development of a system-wide hernia program based on collaboration with the hospital administration, operating room purchasing and clinicians resulted in a significant reduction in costly mesh utilization. This collaborative effort from all stakeholders involved in the care of a specific disease process could provide a reproducible model to improve the value equation through cost reduction strategies in today's healthcare environment.


Assuntos
Utilização de Equipamentos e Suprimentos/tendências , Fidelidade a Diretrizes/tendências , Herniorrafia/economia , Custos Hospitalares/tendências , Padrões de Prática Médica/tendências , Desenvolvimento de Programas/métodos , Telas Cirúrgicas/economia , Utilização de Equipamentos e Suprimentos/economia , Fidelidade a Diretrizes/economia , Herniorrafia/instrumentação , Herniorrafia/métodos , Herniorrafia/normas , Humanos , Ohio , Guias de Prática Clínica como Assunto , Padrões de Prática Médica/economia , Avaliação de Programas e Projetos de Saúde , Estudos Retrospectivos
15.
J Plast Reconstr Aesthet Surg ; 71(3): 353-365, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29196176

RESUMO

INTRODUCTION: Breast reconstruction is one of the most common procedures performed by plastic surgeons and is achieved through various choices in both technology and method. Cost-effectiveness analyses are increasingly important in assessing differences in value between treatment options, which is relevant in a world of confined resources. A thorough evaluation of the cost-effectiveness literature can assist surgeons and health systems evaluate high-value care models. METHODS: A systematic review of PubMed, Web of Science, and the Cost-Effectiveness Analysis Registry was conducted. Two reviewers independently evaluated all publications up until August 17, 2017. RESULTS: After removal of duplicates, 1996 records were screened, from which 53 studies underwent full text review. All the 13 studies included for final analysis mention an incremental cost-effectiveness ratio. Five studies evaluated the cost-effectiveness of technologies including acellular dermal matrix (ADM) in staged prosthetic reconstruction, ADM in direct-to-implant (DTI) reconstruction, preoperative computed tomography angiography in autologous reconstruction, indocyanine green dye angiography in evaluating anastomotic patency, and abdominal mesh reinforcement in abdominal tissue transfer. The remaining eight studies evaluated the cost-effectiveness of different reconstruction methods. Cost-effective strategies included free vs. pedicled abdominal tissue transfer, DTI vs. staged prosthetic reconstruction, and fascia-sparing variants of free abdominal tissue transfer. CONCLUSIONS: Current evidence demonstrates multiple cost-effective technologies and methods in accomplishing successful breast reconstruction. Plastic surgeons should be well informed of such economic models when engaging payers and policymakers in discussions regarding high-value breast reconstruction.


Assuntos
Análise Custo-Benefício , Mamoplastia/economia , Mamoplastia/métodos , Derme Acelular/economia , Implante Mamário/economia , Implantes de Mama/economia , Angiografia por Tomografia Computadorizada/economia , Feminino , Humanos , Retalhos Cirúrgicos/economia , Telas Cirúrgicas/economia , Dispositivos para Expansão de Tecidos/economia
16.
Ghana Med J ; 51(2): 78-82, 2017 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-28955103

RESUMO

OBJECTIVES: To describe our experience and success in the use of low cost mesh for the repair of inguinal hernias in consenting adult patients. METHODS: A prospective study was carried out from August 2010 to December 2013 in ten district hospitals across Northern Ghana. The patients were divided into four groups according to Kingsnorth's classification of hernias. Low cost mesh was used to repair uncomplicated groin hernia. Those hernias associated with complications were excluded. We assessed the patients for wound infection, long term incisional pain and recurrence of hernia. The data collected was entered, cleaned, validated and analyzed. RESULTS: One hundred and eighty-four patients had tension-free repair of their inguinal hernias using non-insecticide impregnated mosquito net mesh. The median age of the patients was 51 years. The male to female ratio was 7:1. Using Kingsnorth's classification, H3 hernias were (62, 33.7%), followed by the H1 group (56, 30.4%). Local anaesthesia was used in 70% and less than 5% had general anaesthesia. The cost of low cost mesh to each patient was calculated to be $ 1.8(GH¢7.2) vs $ 45(GH¢ 180) for commercial mesh of same size. The benefit to the patient and the facility was enormous. Wound hematoma was noticed in 7% while superficial surgical site infection was 3%. No patient reported of long term wound pain. There was no recurrence of hernia. CONCLUSION: Low cost mesh such as sterilized mosquito net mesh for use in hernioplasty in resource-limited settings is reasonable, acceptable and cost-effective, it should be widely propagated. FUNDING: None declared.


Assuntos
Hérnia Inguinal/cirurgia , Herniorrafia/economia , Telas Cirúrgicas/economia , Adulto , Idoso , Anestesia Local , Feminino , Gana , Hematoma/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Mosquiteiros/economia , Complicações Pós-Operatórias/epidemiologia , Estudos Prospectivos , Recidiva , Infecção da Ferida Cirúrgica/epidemiologia , Resultado do Tratamento
18.
Ann Surg ; 266(1): 185-188, 2017 07.
Artigo em Inglês | MEDLINE | ID: mdl-28594679

RESUMO

OBJECTIVE: To evaluate the use of the new absorbable polymer scaffold poly-4-hydroxybutyrate (P4HB) in complex abdominal wall reconstruction. BACKGROUND: Complex abdominal wall reconstruction has witnessed tremendous success in the last decade after the introduction of cadaveric biologic scaffolds. However, the use of cadaveric biologic mesh has been expensive and plagued by complications such as seroma, infection, and recurrent hernia. Despite widespread application of cadaveric biologic mesh, little data exist on the superiority of these materials in the setting of high-risk wounds in patients. P4HB, an absorbable polymer scaffold, may present a new alternative to these cadaveric biologic grafts. METHODS: A retrospective analysis of our initial experience with the absorbable polymer scaffold P4HB compared with a consecutive contiguous group treated with porcine cadaveric mesh for complex abdominal wall reconstructions. Our analysis was performed using SAS 9.3 and Stata 12. RESULTS: The P4HB group (n = 31) experienced shorter drain time (10.0 vs 14.3 d; P < 0.002), fewer complications (22.6% vs 40.5%; P < 0.046), and reherniation (6.5% vs 23.8%; P < 0.049) than the porcine cadaveric mesh group (n = 42). Multivariate analysis for infection identified: porcine cadaveric mesh odds ratio 2.82, length of stay odds ratio 1.11; complications: drinker odds ratio 6.52, porcine cadaveric mesh odds ratio 4.03, African American odds ratio 3.08, length of stay odds ratio 1.11; and hernia recurrence: porcine cadaveric mesh odds ratio 5.18, drinker odds ratio 3.62, African American odds ratio 0.24. Cost analysis identified that P4HB had a $7328.91 financial advantage in initial hospitalization and $2241.17 in the 90-day postdischarge global period resulting in $9570.07 per case advantage over porcine cadaveric mesh. CONCLUSIONS: In our early clinical experience with the absorbable polymer matrix scaffold P4HB, it seemed to provide superior clinical performance and value-based benefit compared with porcine cadaveric biologic mesh.


Assuntos
Parede Abdominal/cirurgia , Implantes Absorvíveis , Poliésteres , Tecidos Suporte , Implantes Absorvíveis/economia , Animais , Cadáver , Redução de Custos , Feminino , Hérnia Abdominal/cirurgia , Custos Hospitalares , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Recidiva , Telas Cirúrgicas/economia , Suínos , Tecidos Suporte/economia
19.
Minerva Chir ; 72(5): 365-367, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-28425686

RESUMO

BACKGROUND: In endoscopic hernia repair totally extraperitoneal approach (TEP) and transabdominal preperitoneal approach (TAPP) are seen as equivalent surgical techniques in quality, but not in procedure-time. METHODS: We compared the two most common procedures in endoscopic hernia surgery. Focusing on the duration of the surgical procedure, we analyzed 7176 endoscopic hernia operations in 25 hospitals retrospectively and compared it to the literature. RESULTS: In our study TEP (N.=2799) took on average 59 minutes, TAPP (N.=4377) took 67.5 minutes, thus with a significant difference (P=0.043). In high volume centres this difference was even bigger. As there are few consistent advantages of one of the procedures in general, the procedure' s duration becomes more important. CONCLUSIONS: If time is the main reason, the TEP procedure takes on average 8.5 minutes less time, so it can be more cost-effective.


Assuntos
Hérnia Abdominal/cirurgia , Herniorrafia/métodos , Laparoscopia , Telas Cirúrgicas , Adulto , Idoso , Hérnia Abdominal/economia , Herniorrafia/economia , Hospitais , Humanos , Itália , Laparoscopia/economia , Laparoscopia/métodos , Estudos Retrospectivos , Telas Cirúrgicas/economia , Resultado do Tratamento
20.
Updates Surg ; 69(3): 375-381, 2017 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-28444543

RESUMO

Repair of an incisional hernia (IH) generates costs on several levels and domains of society. The aim of this study was to make a complete cost analysis of incisional hernia repair (IHR) with synthetic and biological mesh and to compare it with financial reimbursement. Patients were grouped into three levels to determine the complexity of their care, and hence, the costs involved. Group 1 included patients without comorbidities, who underwent a "standard" incisional hernia repair (SIHR), with synthetic mesh. Group 2 included patients with comorbidities, who underwent the same surgical procedure. Group 3 included all patients who underwent a "complex" IHR (CIHR) with biological mesh. Total costs were divided into direct (including preoperative and operative phases) and indirect costs (medications and working days loss). Reimbursement was calculated according to Diagnosis-Related Group (DRG). From 2012 to 2014, 76 patients underwent prosthetic IHR: group 1 (35 pts); group 2 (30 pts); and group 3 (11 pts). The direct costs of preoperative and operative phases for groups 1 and 2 were €5544.25 and €5020.65, respectively, and €16,397.17 in group 3. The total reimbursement in the three groups was €68,292.37 for group 1, €80,014.14 for group 2, and €72,173.79 for group 3, with a total loss of €124,658.43, €69,675.36, and €100,620.04, respectively. All DRGs underestimate the costs related to IHR and CIHR, thus resulting in an important economic loss for the hospital. The cost analysis shows that patient-related risk factors do not alter the overall costs. To provide a correct "cost-based" reimbursement, different DRGs should be created for different types of hernias and prostheses.


Assuntos
Custos de Cuidados de Saúde/estatística & dados numéricos , Herniorrafia/economia , Herniorrafia/instrumentação , Hérnia Incisional/cirurgia , Telas Cirúrgicas/economia , Adulto , Idoso , Feminino , Herniorrafia/métodos , Humanos , Hérnia Incisional/economia , Reembolso de Seguro de Saúde/estatística & dados numéricos , Itália , Masculino , Pessoa de Meia-Idade
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