Procedure, Screening, and Cost of Fecal Microbiota Transplantation

Fecal microbiota transplantation (FMT) is currently considered a potential treatment for various GI-related illnesses, with the goal to replenish natural healthy flora of the GI tract that has been harmed because of antibiotic use or overgrowth of harmful bacteria. Current methods of administering the processed stool include colonoscopy and enema, while an oral capsule is being developed. Each method of administration carries its own set of risks, including adverse reactions to treatment, infection following the invasive administration procedure, and flare-ups of GI-related symptoms. Current oral administration through nasoduodenal tube poses a risk for aspiration which has not been ruled out as the cause of subsequent pneumonia and death in patient trials. The development of an oral capsule could address some of the faults of the current methods, not only making treatment more affordable and accessible but also less of a risk due to its minimally invasive nature. FMT is also a treatment option to attenuate adverse effects associated with antibiotic use, including combatting the emergence of antibiotic resistance, as well as adverse effects related to other medical treatments such as chemotherapy. While FMT is an unexplored treatment option for multiple gastrointestinal disorders and is currently still largely inaccessible for many patients financially, studies have suggested that it could be a more affordable treatment option long-term for patients as aspects of the treatment become more affordable with further research.

Conventional, Speed Sintering and High-Speed Sintering of Zirconia: A Systematic Review of the Current Status of Applications in Dentistry with a Focus on Precision, Mechanical and Optical Parameters

The aim of this systematic review was to provide an overview of the technical and clinical outcomes of conventional, speed sintering and high-speed sintering protocols of zirconia in the dental field. Data on precision, mechanical and optical parameters were evaluated and related to the clinical performance of zirconia ceramic. The PICOS search strategy was applied using MEDLINE to search for in vitro and in vivo studies using MeSH Terms by two reviewers. Of 66 potentially relevant studies, 5 full text articles were selected and 10 were further retrieved through a manual search. All 15 studies included in the systematic review were in vitro studies. Mechanical, precision and optical properties (marginal and internal fit, fracture strength and modulus, wear, translucency and opalescence, aging resistance/hydrothermal aging) were evaluated regarding 3-, 4- and 5-YTZP zirconia material and conventional, high- and high-speed sintering protocols. Mechanical and precision results were similar or better when speed or high-speed sintering methods were used for 3-, 4- and 5-YTZP zirconia. Translucency is usually reduced when 3 Y-TZP is used with speed sintering methods. All types of zirconia using the sintering procedures performed mechanically better compared to lithium disilicate glass ceramics but glass ceramics showed better results regarding translucency.

Diagnosing muscle disease in a cohort of classic dermatomyositis patients seen at a rheumatologic dermatology outpatient clinic

BACKGROUND

Existing criteria to improve the probability of capturing dermatomyositis (DM) include muscle biopsy but little is known about whether less invasive diagnostic procedures may be just as useful.

OBJECTIVE

We aimed to determine whether skin biopsy, electromyography, or magnetic resonance imaging of the involved muscle could be done in lieu of muscle biopsy.

METHODS

Two hundred and seventy-five patients were reviewed to investigate the presence of cutaneous and muscle disease, their timing in relation to diagnosis, and results of skin biopsies, muscle biopsies, magnetic resonance imaging, and electromyography.

RESULTS

Of the cases with findings consistent with DM on muscle biopsy, 65% were in agreement with diagnostic features on electromyography or magnetic resonance imaging. Results of skin and muscle biopsies supported DM in 67% of patients who underwent both procedures.

LIMITATIONS

A limited number of patients had muscle biopsies.

CONCLUSION

In the presence of DM-specific skin findings, less invasive procedures may be sufficient to diagnose DM and guide its management.

Endoscopic ultrasound fine needle biopsy was not more cost-effective than fine-needle aspiration with rapid on-site evaluation in gastrointestinal lesions diagnosis

BACKGROUND AND AIM

Cost-effectiveness comparison between endoscopic ultrasound (EUS)-guided acquisition techniques by fine-needle aspiration (FNA) and fine needle biopsy (FNB) in gastrointestinal lesions is still scarce. EUS-FNB has been shown to be more cost-effective than EUS-FNA, however, when adding rapid on-site evaluation (ROSE) to EUS-FNA, it is unclear whether EUS-FNB remains more cost-effective. Our aim was to assess cost-efficacy of EUS-FNB as compared to EUS-FNA with ROSE in gastrointestinal lesions.

METHOD

All patients who underwent EUS-FNA with ROSE or EUS-FNB at Galilee Medical Center were retrospectively reviewed. Cost-effectiveness analysis was based on the additional EUS sessions needed and on the average cost expenditure to achieve one final pathological diagnosis.

RESULTS

Seventy-four cases were included in the final analysis. Of them, 21 patients (28.4%) were in the EUS-FNB group (group A), as compared to 53 patients (71.6%) who underwent EUS-FNA with ROSE (group B). Additional EUS sessions needed to achieve one final pathological diagnosis were needed in 14.3% of group A patients vs 9.4% in group B patients (P = .5). and, the average cost for achieving one final pathological diagnosis was similar in both groups (1226 ± 369$ for group A vs 1158 ± 309.6.7$ for group B, P = .2). Notably, even after analyzing pancreatic and non-pancreatic gastrointestinal lesions separately, there was no cost benefit of EUS-FNB over EUS-FNA with ROSE.

CONCLUSIONS

Cost-effectiveness analysis was not different between EUS-FNB vs EUS-FNA with ROSE. Thus, the preference of one modality over the other should be based on availability and local expertise.

Cost-efficacy and pharmacoeconomics of scalp lesions of psoriatic patients in current Japanese health-care insurance system

Psoriatic scalp lesion is occasionally recalcitrant to topical or systemic treatments including biologic agents. The combined active vitamin D₃ /corticosteroids are more expensive despite their marked efficacy. The aim of the present study is to evaluate total costs as well as costs versus efficacy of topical scalp psoriasis treatments under the current Japanese health-care insurance system. A prospective study was performed from the database of an outpatient clinic. The medical costs of scalp psoriasis patients were evaluated in a prospective manner in each case over a total 12-month duration from July 2017 until August 2019. The total cost of the combined active vitamin D₃ /corticosteroid gel (combined gel) was higher (¥79 350) than that of topical corticosteroid lotion (¥22 970). The cost versus efficacy of the combined gel was lower (¥2026/cost for the reduction of 1 Psoriasis Scalp Severity Index [1PSSI] score) than that of topical corticosteroid lotion (¥2316/1PSSI). The reduction of PSSI score was observed by changing from topical corticosteroid lotion to topical combined gel. The combined gel showed the best cost efficacy in terms of medical economic burden in the current Japanese insurance system.

Point-of-Care Ultrasonography (POCUS) in a Community Emergency Department: An Analysis of Decision Making and Cost Savings Associated With POCUS

OBJECTIVES

Point-of-care ultrasonography (POCUS) is an increasingly integral part of emergency medicine. This study investigated community emergency department physicians' choices regarding ultrasonography as a branch point in clinical decision making.

METHODS

During shifts covering all days of the week and all time-spans over a 3-month period, emergency department physicians were interviewed whenever POCUS was used. Questions focused on the role of POCUS in clinical management and on tests avoided because of ultrasonography use. Cost savings attributable to POCUS were calculated using Center for Medicare and Medicaid Services and FairHealth data. Anonymization of data precluded follow-up testing to account for misdiagnosis.

RESULTS

On average, POCUS use eliminated $1134.31 of additional testing for privately insured patients, $2826.31 for out-of-network or uninsured patients, and $181.63 for Center for Medicare and Medicaid Services patients. Differences were significant when the total cost of eliminated additional testing was compared to a baseline of no savings (p < .001). Aggregate cost savings remained significant when analyses were broadened to include POCUS encounters that did not yield changes in management (p < .001).

CONCLUSIONS

When physicians' clinical expertise suggests that POCUS may be indicated, its use results in significant cost savings, even in encounters in which management is not directly impacted. POCUS, when incorporated earlier and more frequently into community hospital emergency medicine diagnostic protocols, can lower direct and indirect costs associated with diagnostic workups. Community emergency departments, in particular, would benefit from additional investigation informing specific guidelines for the integration of POCUS into clinical management and the role that this has in cost savings.

Cost-Effective Management of Stenosing Tenosynovitis

PURPOSE

Stenosing tenosynovitis (STS) is a common condition treated by hand surgeons. Limited evidence exists to support the nonsurgical management of STS. The purpose of this study was to prospectively evaluate a cohort of patients with STS, and to determine the strategy for treating patients with this condition that is most cost effective in terms of dollars reimbursed by payers.

METHODS

Prospective data were collected on patients diagnosed with STS between March 2014 and September 2014. All patients were initially treated with a corticosteroid injection. Patients with persistent symptoms were given the option of injection or surgery. A maximum of 3 injections were offered. All patients were evaluated every 6 months through office appointments or phone calls. A cost analysis was performed in our cohort using actual reimbursement rates for injections, initial and established patient visits, and facility and physician fees for surgery, using the reimbursement rates from the 6 payers covering this patient cohort. Cost savings were calculated based on offering 1, 2, and 3 injections.

RESULTS

Eighty-eight digits in 82 patients were followed for an average of 21.9 months (range, 18.7-22.7 mo) after an initial corticosteroid injection. Thirty-five digits went on to surgical release, whereas 53 digits were treated nonsurgically. Had all patients initially undergone surgery, the cost would have totaled $169,088.98 ($1,921 per digit). Offering up to 3 injections yielded a potential savings of $72,730 ($826 per digit) or 43% of the total cost. For the 33 patients who underwent more than 1 injection, offering a second injection yielded potential savings of $15,956 ($484 per digit, 22.7%), and for the 7 patients presenting a third time, a third injection saved $1,986 ($283 per digit, 14.5%).

CONCLUSIONS

Based on the data from our cohort, the efficient way to treat STS in terms of health care dollars spent is to offer up to 3 injections before surgical release. The first injection had the highest component of cost savings, at $826 per digit.

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic/Decision Analysis III.

Cost per care of the first year of direct antiviral agents in the Liguria Region: a multicenter analysis

Aims

Despite the remarkable efficacy shown in clinical practice, concerns have been raised about the costs associated with direct antiviral agent (DAA) therapy. This article presents the real-life costs for DAA treatment sustained by the Italian National Health Service in the Liguria Region (Northern Italy).

Methods

A retrospective analysis of the cost per care sustained for DAA treatment, relating to the period from January 1 to December 31, 2015 in five centers in Liguria was performed. All patients undergoing DAA-based treatments for hepatitis C virus (HCV) infection were enrolled. On-treatment costs included: HCV treatment, laboratory test, outpatient services, attended visits, drugs used for the management of adverse events (erythropoietin, albumin or red blood cell packs) and inpatient service admissions.

Results

In total, 327 patients were enrolled. No difference in terms of sustained virologic response (SVR) rate among different treatments was reported. The majority (85.0%) of patients did not report any side effects and only 15 (4.6%) required hospital admission. Forty-two patients (12.8%) required high-cost drugs for the management of adverse events. The overall cost sustained was €14,744,433. DAA±ribavirin (RBV) accounted for the wide majority of this cost (98.9%; €14,585,123). Genotype (GT) 1, the most commonly treated GT, was associated with an average cost of €43,445 per patient. Detailed analysis of the costs for GT 1 showed the treatment based on ritonavir boosted paritaprevir/ombitasvir + dasabuvir±RBV with an average cost of €24,978 (RBV+) and €25,448 (RBV−) per patient was the most cost-effective. The average cost per SVR was €48,184. Once again, the ritonavir boosted paritaprevir/ombitasvir + dasabuvir regimen was associated with the lowest cost/SVR (€25,448/SVR [GT 1b] and similar results for other GTs).

Conclusion

Antiviral regimen is the major contributor to costs in the treatment of HCV infection. Appropriate regimen selection could result in a major cost saving, which can be reinvested to allow more patients to be treated.

Economic burden of psoriatic patients in Japan: Analysis from a single outpatient clinic

Topical and systemic agents have dramatically improved the treatment efficacy of psoriasis. Few reports, however, exist describing the economic burden in Japanese psoriatic patients. The aim of the study was to evaluate the total costs as well as cost versus efficacy of topical and systemic treatments of psoriatic patients under the Japanese health insurance system. The retrospective study was performed from the database of our clinic, which is located in Hokkaido Prefecture. Cost and effectiveness of psoriatic patients were evaluated during the 12-month period from April 2015 to March 2016. Data were collected and calculated for the total cost per year, treatment efficacy and cost versus efficacy. The mean total cost of topical corticosteroid treatment was ¥18 184/year and was lowest among the treatments. The systemic treatment with biologics was most expensive and the costs were over ¥400 000/year. Among the topical treatments, calcipotriol/betamethasone dipropionate was most expensive (¥34 693/year). However, cost versus efficacy was not significantly different from that of topical corticosteroid treatments. The cost of secukinumab was highest among all the treatments (¥631 600/year). However, treatment day per cost was lowest of all the psoriasis treatments. Biologics showed the highest cost than topical or systemic treatments. However, they showed most marked efficacy in terms of improving the psoriatic skin lesions.

How to Pitch an Antibiotic Stewardship Program to the Hospital C-Suite

Hospitals will soon require antibiotic stewardship programs. Infectious diseases specialists must craft business plans to engage hospital leadership to fund such programs. In this article, we review key cost and revenue elements that should be covered in such plans.

Society is placing increasing emphasis on the importance of antimicrobial stewardship programs (ASPs). New regulatory standards require hospitals to implement ASPs. Infectious Diseases (ID) specialists will need to help design and implement such programs at hospitals. A critical component of establishing such programs is submitting a business plan to hospital leadership justifying the cost and structure of the ASP and explaining what benefits the hospital will gain in return. In this article, we explore typical elements of such business plans and describe how hospital leadership may evaluate and determine the value of such plans. Understanding hospital costs and revenue models is critical to creating a viable and realistic business plan to support ASPs.

Once-weekly hypofractionated breast irradiation: fool's gold or diamond in the rough?

Daily conventionally fractionated breast irradiation over 5-7 weeks is costly and inconvenient. Its use is associated with disparities in both the delivery of quality care and outcomes for vulnerable populations. Alternatively, daily hypofractionated breast irradiation delivered over 3 weeks exhibits equal efficacy and toxicity profiles. Today, a new generation of accelerated radiotherapy for breast cancer has emerged. Once-weekly hypofractionated breast irradiation has been tested in pilot and large randomized studies and the initial data appear promising. As the data mature, this new approach has implications for cost-efficacy and provision of radiotherapy services. The purpose of this review is to explore the evolution of once-weekly hypofractionated breast irradiation including our ongoing institutional clinical trial at the University of Louisville.

Hidden costs of antiretroviral treatment: the public health efficiency of drug packaging

While the overall percentage of unused antiretroviral medicines returned to the hospital pharmacy is low, their cost is quite high. Adverse events, treatment failure, pharmacokinetic interactions, pregnancy, or treatment simplification are common reasons for unplanned treatment changes. Socially inefficient antiretroviral packages prevent the reuse of drugs returned to the hospital pharmacy. We defined antiretroviral package categories based on the excellence of drug packaging and analyzed the number of pills and costs of drugs returned during a period of 1 year in a hospital-based HIV unit attending to 2,413 treated individuals. A total of 6,090 pills (34% of all returned antiretrovirals) – with a cost of 47,139.91€ – would be totally lost, mainly due to being packed up in the lowest efficiency packages. Newer treatments are packaged in low-excellence categories of packages, thus favoring the maintenance of these hidden costs in the near future. Therefore, costs of this low-efficiency drug packaging, where medication packages are started but not completed, in high-cost medications are substantial and should be properly addressed. Any improvement in the packaging by the manufacturer, and favoring the choice of drugs supplied through efficient packages (when efficacy, toxicity, and convenience are similar), should minimize the treatment expenditures paid by national health budgets.

Smoking cessation in Asians: focus on varenicline

Smoking is a modifiable risk factor for morbidity and mortality caused by cancer, cardiovascular diseases, respiratory diseases, and many other diseases. Given the large population size and high prevalence of smoking in Asia, successful smoking cessation could potentially prevent the large number of premature deaths in Asians. However, most dependent smokers cannot successfully quit smoking due to nicotine addiction, and they need professional help and smoking cessation therapies. Varenicline is a highly selective partial agonist for the nicotinic acetylcholine receptor α4β2 subtype, which is believed to be responsible for mediating the reinforcing properties of nicotine. This article is a narrative review, which summarizes the smoking cessation efficacy, side effects, and cost utilities of varenicline in Asians. From this review, we conclude that varenicline is an effective medication that could assist smoking cessation in the Asian populations. The adverse events of varenicline are tolerable, and the most common events were nausea and abnormal dreams. Both the efficacy and tolerance of varenicline in Asians are similar to that in Western populations. Considering the cost utilities, varenicline should be recommended for use in smoking cessation and be covered by medical insurance in most Asian countries.

Regional variation in anesthesia assistance during outpatient colonoscopy is not associated with differences in polyp detection or complication rates

BACKGROUND & AIMS

We investigated the rate and predictors of anesthesia assistance during outpatient colonoscopy and whether anesthesia assistance is associated with colonoscopy interventions and outcomes.

METHODS

We performed a retrospective cohort study using a 20% sample of Medicare administrative claims submitted during the 2003 calendar year. We analyzed data from 328,177 adults, 66 years old or older, who underwent outpatient colonoscopy examinations.

RESULTS

Overall, 8.7% of outpatient colonoscopies were performed with anesthesia assistance. In multivariate analysis, independent predictors of anesthesia assistance included black race, female sex, and a nonscreening indication; anesthesia assistance increased with median income and comorbidities. General and colorectal surgeons, fewer years in their practice, and nonhospital site of service were also significantly associated with anesthesia assistance. The strongest predictor of anesthesia assistance was the Medicare carrier, with odds ratios ranging from 0.22 (95% confidence interval: 0.12-0.43) for the Arkansas carrier (crude rate 0.9%) to 9.90 (95% confidence interval: 7.92-12.39) for the Empire carrier in New York area (crude rate 35.3%) compared with the Wisconsin carrier (crude rate 4.3%). There was also considerable variation among endoscopists; 75% of providers had no colonoscopies with anesthesia assistance recorded in their dataset, and 4.5% of providers had anesthesia assistance in at least three quarters of their examinations. Anesthesia assistance was not associated with the diagnosis of polyps, the performance of biopsy or polypectomy, or complications in multivariate analyses.

CONCLUSIONS

There are significant variations among regions and sites of service in anesthesia assistance during outpatient colonoscopies of Medicare beneficiaries. Although this variation has considerable economic implications, it was not associated with measures of patient risk or outcomes, such as polyp detection or procedure-related complications.

Many patients who undergo surgery for colorectal cancer receive surveillance colonoscopies earlier than recommended by guidelines

BACKGROUND & AIMS

Patients treated with surgery for colorectal cancer (CRC) should undergo colonoscopy examinations 1, 4, and 9 years later, to check for cancer recurrence. We investigated the use patterns of surveillance colonoscopies among Medicare patients.

METHODS

We used the Surveillance, Epidemiology and End Results (SEER)-Medicare linked database to identify patients who underwent curative surgery for colorectal cancer from 1992 to 2005 and analyzed the timing of the first 3 colonoscopies after surgery. Early surveillance colonoscopy was defined as a colonoscopy, for no reason other than surveillance, within 3 months to 2 years after a colonoscopy examination with normal results.

RESULTS

Approximately 32.1% and 27.3% of patients with normal results from their first and second colonoscopies, respectively, underwent subsequent surveillance colonoscopies within 2 years (earlier than recommended). Of patients who were older than 80 years at their first colonoscopy, 23.6% underwent a repeat procedure within 2 years for no clear indication. In multivariable analysis, early surveillance colonoscopy was not associated with sex, race, or patients' level of education. There was significant regional variation in early surveillance colonoscopies among the Surveillance, Epidemiology, and End Results regions. There was a significant trend toward reduced occurrence of second early surveillance colonoscopies.

CONCLUSIONS

Many Medicare enrollees who have undergone curative resection for colorectal cancer undergo surveillance colonoscopy more frequently than recommended by the guidelines. Reducing overuse could free limited resources for appropriate colonoscopy examinations of inadequately screened populations.