Cost-Effectiveness Analysis of Transcatheter Arterial Embolization Techniques for the Treatment of Gastrointestinal Bleeding in the United States

OBJECTIVES

Gastrointestinal (GI) bleeding is a common medical emergency associated with significant mortality. Transcatheter arterial embolization first was introduced by Rosch et al as an alternative to surgery for upper GI bleeding. The clinical success in patients with GI bleeding treated with transcatheter arterial embolization previously has been reported. However, there are no cost-effectiveness analyses reported to date. Here we report cost-effectiveness analysis of N-butyl 2-cyanoacrylate glue (NBCA) and ethylene-vinyl alcohol copolymer (Onyx) versus coil (gold standard) for treatment of GI bleeding from a healthcare payer perspective.

METHODS

Fixed-effects modeling with a generalized linear mixed method was used in NBCA and coil intervention arms to determine the pooled probabilities of clinical success and mortality with complications with their confidence intervals, while the Clopper-Pearson model was used for Onyx to determine the same parameters. Models were provided by the "Meta-Analysis with R" software package. A decision tree was built for cost-effectiveness analysis, and Microsoft Excel was used for probabilistic sensitivity analysis. The cost-effective option was determined based on the incremental cost-effectiveness ratio and scatter plots of incremental cost versus incremental quality-adjusted life-years.

RESULTS

Comparing scatter plots and incremental cost-effectiveness ratio results, -$1024 and -$1349 per quality-adjusted life-year for Onyx and N-butyl 2-cyanoacrylate glue, respectively, Onyx was the least expensive and most effective intervention.

CONCLUSION

Onyx was the dominant strategy regardless of threshold values. Our analyses provide a framework for researchers to predict the target clinical effectiveness for early-stage TAE interventions and guide resource allocation decisions.

Clinical Outcomes and Economic Impact of Starting Hemodialysis with a Catheter after Predialysis Arteriovenous Fistula Creation

BACKGROUND

Patients with advanced chronic kidney disease frequently undergo arteriovenous fistula creation prior to reaching end-stage renal disease (ESRD), but some initiate hemodialysis with a central vein catheter, if their fistula is not yet usable. The clinical consequences of the delay in fistula use have not been quantified in such patients. We compared patients with pre-ESRD fistula surgery who initiated dialysis with a catheter versus a fistula in terms of the frequency of post-dialysis vascular access procedures and complications and their economic impact.

METHODS

We identified 205 patients with predialysis fistula creation from 2006 to 2012 at a large dialysis center who started hemodialysis within the ensuing 2 years. Of these, 91 (44%) initiated dialysis with a catheter and 114 (56%) with a fistula. We compared these 2 groups in terms of their annual frequency of percutaneous vascular access procedures, surgical access procedures, total access procedures, hospitalizations due to catheter-related bacteremia, and overall cost of vascular access management.

RESULTS

The 2 groups were similar in demographics, comorbidities, and fistula type. As compared to patients initiating dialysis with a fistula, those initiating with a catheter had a significantly greater annual frequency of percutaneous access procedures (1.29 [1.19-1.40] vs. 0.75 [0.68-0.82]), surgical access procedures (0.69 [0.61-0.76] vs. 0.59 [0.53-0.66]), total access procedures (1.98 [1.86-2.11] vs. 1.34 [1.26-1.44]), and hospitalizations due to catheter-related bacteremia (0.09 [0.07-0.12] vs. 0.02 [0.01-0.03]). Patients initiating dialysis with a catheter incurred a median overall annual cost of access management that was USD 2,669 higher (USD 6,372 [3,121-12,242) vs. USD 3,703 [1,867-6,953], p = 0.0001).

CONCLUSION

Among patients with predialysis fistula creation, those initiating dialysis with a catheter versus a fistula had substantially more frequent percutaneous, surgical, and total vascular access procedures, as well as hospitalizations due to catheter-related bacteremia. The annual cost of access management was substantially higher in those initiating dialysis with a catheter.

Buttonhole versus Stepladder Cannulation for Home Hemodialysis: A Multicenter, Randomized, Pilot Trial

BACKGROUND AND OBJECTIVES

Canadian home hemodialysis guidelines highlight the potential differences in complications associated with arteriovenous fistula (AVF) cannulation technique as a research priority. Our primary objective was to determine the feasibility of randomizing patients with ESKD training for home hemodialysis to buttonhole versus stepladder cannulation of the AVF. Secondary objectives included training time, pain with needling, complications, and cost by cannulation technique.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

All patients training for home hemodialysis at seven Canadian hospitals were assessed for eligibility, and demographic information and access type was collected on everyone. Patients who consented to participate were randomized to buttonhole or stepladder cannulation technique. Time to train for home hemodialysis, pain scores on cannulation, and complications over 12 months was recorded. For eligible but not randomized patients, reasons for not participating in the trial were documented.

RESULTS

Patient recruitment was November 2013 to November 2015. During this time, 158 patients began training for home hemodialysis, and 108 were ineligible for the trial. Diabetes mellitus as a cause of ESKD (31% versus 12%) and central venous catheter use (74% versus 6%) were more common in ineligible patients. Of the 50 eligible patients, 14 patients from four out of seven sites consented to participate in the study (28%). The most common reason for declining to participate was a strong preference for a particular cannulation technique (33%). Patients randomized to buttonhole versus stepladder cannulation required a shorter time to complete home hemodialysis training. We did not observe a reduction in cannulation pain or complications with the buttonhole method. Data linkages for a formal cost analysis were not conducted.

CONCLUSIONS

We were unable to demonstrate the feasibility of conducting a randomized, controlled trial of buttonhole versus stepladder cannulation in Canada with a sufficient number of patients on home hemodialysis to be able to draw meaningful conclusions.

Healthcare Costs Associated with Hemodialysis Catheter–Related Infections: A Single-Center Experience

In patients undergoing hemodialysis, catheter-related bacteremia results in expensive hospitalizations. In our study, the mean cost was $23,451 per hospitalization. When itemized, housing (“bed-related”) costs accounted for 66% of the total; laboratory costs accounted for 4%, radiologic costs accounted for 9%, and procedure-related costs accounted for 21%. Hypoalbuminemia and bacteremia due to methicillin-resistant Staphylococcus aureus (MRSA) are associated with higher healthcare costs; bacteremia due to MRSA is also associated with poor survival rates.

Cost effectiveness of renal denervation therapy for the treatment of resistant hypertension in the UK

BACKGROUND

Patients with resistant hypertension are at a high risk for developing serious cardiovascular events and renal complications. Catheter-based renal denervation (RDN) is a procedure with the potential to normalize systolic blood pressure (SBP).

OBJECTIVE

The overall objective of the study was to estimate the cost effectiveness of RDN in the UK for patients with diagnosed resistant hypertension, expressed as a standard cost per quality-adjusted life-year (QALY) ratio.

METHODS

A patient lifetime, economic, Markov heath-state model was developed, linking expected changes in SBP to reductions in risks for cardiovascular events and renal complications, using the Framingham, PROCAM, and other published risk equations. The model was developed from the perspective of the healthcare payer in the UK using relevant cost data from 2012. Clinical effectiveness for RDN (a mean reduction of 32 mmHg in SBP) was taken from the phase III Symplicity HTN-2 trial, in patients with a mean baseline SBP of 178 mmHg. HTN-2 was the largest, multicenter randomized controlled trial on the effectiveness of RDN therapy at the time of the model development. A systematic review identified UK-specific sources for utility, mortality, and cost parameter values, and included recently published UK guidelines for the clinical management of hypertension.

RESULTS

RDN therapy resulted in an increase in health benefit over a patient's lifetime compared with anti-hypertensive pharmacological treatment alone (12.77 vs. 12.16 QALYs; discounted). Additional lifetime costs per patient were modeled at £2,961; equivalent to an incremental cost per additional QALY of £4,805. This result was robust to full probabilistic sensitivity and scenario analyses.

CONCLUSION

RDN is an effective clinical procedure that offers patients a meaningful and cost-effective alternative for achieving SBP control, where traditional combination, anti-hypertensive pharmacologic strategies have been proven to be ineffective.

Cost/benefit analysis of chlorhexidine-silver sulfadiazine-impregnated venous catheters for femoral access

Sixty-four patients with chlorhexidine-silver sulfadiazine-impregnated catheters had a lower rate of catheter-related bloodstream infection and lower central venous catheter-related costs per catheter day than 190 patients with a standard catheter.

Chlorhexidine-silver sulfadiazine-impregnated venous catheters save costs

BACKGROUND

Previous cost-effectiveness analyses have found that the use of chlorhexidine-silver sulfadiazine (CHSS)-impregnated catheters is associated with decreased catheter-related bloodstream infections (CRBSI) and central venous catheter (CVC)-related costs. However, in these analyses, the CVC-related cost included the increase of hospital stay.

OBJECTIVE

Our aim was to determine the immediate CVC-related cost (including only the cost of CVC, diagnosis of CRBSI, and antimicrobials for the treatment of CRBSI) of using a CHSS or a standard catheter in internal jugular venous access.

METHODS

We performed a prospective, observational, cohort study of patients admitted to the intensive care unit (ICU), Hospital Universitario de Canarias (Tenerife, Spain), who received 1 or more internal jugular venous catheters.

RESULTS

The study included 245 CHSS-impregnated catheters and 391 standard catheters. Exact logistic regression analysis showed that CHSS-impregnated catheters were associated with a lower incidence of CRBSI, controlling for catheter duration, than standard catheters (0 vs 5.04 CRBSI per 1,000 catheter-days, respectively; odds ratio, 0.80; 95% confidence interval: 0.712-0.898; P < .001). Poisson regression showed that CHSS-impregnated catheters were associated with lower CVC-related cost per day than standard catheters (€3.78 ± €4.45 vs €7.28 ± €16.71, respectively; odds ratio, 0.52; 95% confidence interval: 0.504-0.535; P < .001). Survival analysis showed that CHSS-impregnated catheters were associated with increased CRBSI-free time compared with standard catheters (χ(2) = 14.9; P < .001).

CONCLUSION

The use of CHSS-impregnated catheters reduced the incidence of CRBSI and immediate CVC-related costs in the internal jugular venous access.

PleurX peritoneal catheter drainage system for vacuum-assisted drainage of treatment-resistant, recurrent malignant ascites: a NICE Medical Technology Guidance

The PleurX peritoneal drainage catheter for drainage of malignant ascites in a community setting has been evaluated by the NICE Medical Technologies Evaluation Programme. This article outlines the evidence included in the Sponsor's submission, the independent critique by the External Assessment Centre (EAC) and the recommendations made by the Medical Technologies Advisory Committee (MTAC). In accordance with the scope issued by NICE, the intervention technology was the indwelling PleurX peritoneal catheter drainage system, the comparator was large-volume paracentesis (LVP; inpatient or outpatient) and the population was patients with treatment-resistant, recurrent malignant ascites. Nine studies (ten papers) were identified with a total of 180 PleurX-treated patients; six were case series with more than four patients that, despite being low in the hierarchy of evidence, provided useful safety information. Technical success of the initial PleurX placement procedure was 100% across five studies which reported this outcome. One study reported equal complication rates between patients treated with indwelling PleurX catheters (40 patients and 40 catheters) and those receiving repeated LVPs (67 patients and 392 procedures), 7.5% (3/40; 95% CI 1.6, 20) and 7.5% (5/67; 95% CI 2.2, 15), respectively. All remaining studies were single-arm and reported complication rates of between 0% and 59%; this wide range was largely due to variation in the definition of complications and adverse events. Using validated tools, one case series reported improvements in several ascites-related symptoms after placement of the PleurX catheter; however, an overall quality-of-life improvement at 12 weeks was not demonstrated. Positive patient opinions relating to improved symptom control and convenience were reported in a qualitative study. Cost analysis demonstrated that PleurX offered savings to the NHS when compared with repeated LVPs performed in an inpatient setting. This saving of £679 per patient was driven primarily by reducing hospital bed days (year 2009-2010 values), but would require 23.5 additional community nurse visits. Advice from clinical experts was that additional home visits were overestimated as many patients would receive such visits regardless of whether a PleurX drain had been fitted. The model demonstrated that PleurX would be more expensive than LVP procedures performed in a setting where one or less hospital bed days were used (e.g. day case or outpatient). There was uncertainty surrounding the number of patients for whom insertion of a PleurX drain would be appropriate as well as the point in the care pathway at which such treatment should be administered. MTAC supported the case for adoption and considered that the available evidence showed PleurX was clinically effective, has low complication rates, can improve quality of life and is less costly than inpatient LVP. In Medical Technology Guidance 9 (MTG9), NICE recommended that PleurX peritoneal catheter drainage system be considered for use in patients with treatment-resistant, recurrent malignant ascites.

Cost-effectiveness of balloon kyphoplasty in patients with symptomatic vertebral compression fractures in a UK setting

SUMMARY

Balloon kyphoplasty (BKP) is a procedure used to treat vertebral compression fractures (VCFs). We developed a cost-effectiveness model to evaluate BKP in United Kingsdom patients with hospitalised VCFs and estimated the cost-effectiveness of BKP compared to non-surgical management. The results indicate that BKP provides a cost-effective alternative for treating these patients.

INTRODUCTION

VCFs of osteoporotic patients are associated with chronic pain, a reduction in health-related quality of life (QoL) and high healthcare costs. BKP is a minimally invasive procedure that has resulted in pain relief, vertebral body height-restoration, decreased kyphosis and improved physical functioning in patients with symptomatic VCFs. BKP was shown to improve health-related QoL in a 12-month interim analysis of a randomised phase-III trial.

METHODS

The objectives of this study were to develop a Markov cost-effectiveness model to evaluate BKP in patients with painful hospitalised VCFs and to estimate the cost-effectiveness of BKP compared with non-surgical management in a UK setting. It was assumed that QoL-benefits found at 12 months linearly approached zero during another 2 years, and that patients receiving BKP warranted six fewer hospital bed days compared with patients given non-surgical management.

RESULTS

The procedure was associated with quality-adjusted life-years (QALY)-gains of 0.17 and cost/QALY-gains at 8,800 pound sterling. The results were sensitive to assumptions about avoided length of hospital-stay and persistence of kyphoplasty-related QoL-benefits.

CONCLUSION

In conclusion, the results indicate that BKP provides a cost-effective alternative for treating patients with hospitalised VCFs in a UK-setting.

A cost-utility analysis of microwave endometrial ablation versus thermal balloon endometrial ablation

OBJECTIVE

To evaluate the cost-effectiveness of microwave endometrial ablation (MEA) and thermal balloon endometrial ablation (TBALL) for heavy menstrual bleeding.

METHODS

A cost-utility analysis performed alongside a pragmatic RCT in a single hospital within Scotland on women undergoing MEA and TBALL. Resource use data collected from all 314 trial participants were combined with study specific and published unit cost data to estimate a cost per patient. Quality-adjusted life-years (QALYs) were based on EQ-5D responses at baseline, 2 weeks, 6 and 12 months. The incremental cost per QALY of TBALL versus MEA was calculated and bootstrapping was performed to determine the likelihood that a treatment would be cost-effective at different threshold values for society's willingness to pay for a QALY.

RESULTS

The mean cost of TBALL (10 years equipment life, 100 uses annually) of reusable equipment was pound181 (95% confidence interval [CI] pound70-434) greater than MEA. There were no statistically significant differences between the total nonhealth costs and health benefits of the two arms. On average, MEA provided more QALYs after adjusting for baseline EQ-5D score (0.017; 95% CI 0.017-0.051). In terms of mean incremental cost per QALY, MEA was, on average, dominant (less costly and at least as effective) and there was over a 90% chance that MEA would be considered cost-effective at a pound20,000 threshold of a cost per QALY.

CONCLUSIONS

MEA is likely to be more cost-effective than TBALL at 1 year. Further longer-term follow-up is, however, needed.

Buttonhole cannulation in hemodialysis: improved outcomes and increased expense--is it worth it?

BACKGROUND

Access to an adequate blood flow is a requirement for successful hemodialysis (HD). This often means repeated cannulation of an arteriovenous fistula (AVF), which can lead to damage that needs repair and revision. The Buttonhole (BH) method offers a successful cannulation with minimal damage.

DESIGN

A prospective cohort research study was initiated in two HD units in St. John's, Newfoundland and Labrador, to assess the effects of cannulating AVFs using the BH technique from the patient and nurse perspective.

METHODS

Twenty-five nurses and 29 patients completed questionnaires at four times throughout the three-month study period, rating their confidence levels about BH cannulation issues. Patients also provided information on the pain of the cannulation and the frequency of cannulation complications. Nurses documented data on arterial and venous pressures, and hemostasis times. Patient charts were also reviewed for complications requiring extensive interventions such as AVF repair or Central Line Catheter (CVC) placement. The cost of providing the BH cannulation was also examined.

RESULTS

At the end of the study, it was noted that cannulation pain was statistically reduced with both the arterial (p = .002) and venous (p = .010) needles, and vessel pressures and hemostasis times were decreased slightly or stayed the same throughout the study. The frequency of access infections, however, increased, although not significantly. Using a 10-point Likert scale in which a score of > or = 8 indicates a high level of confidence, 77.5% of nurses and 73.9% of patients reported a high level of confidence in the nurses' abilities to use the BH technique effectively. In terms of expense, no significant changes were noted in frequency of procedures required for AVF repair with the BH cannulation, although an increase of approximately $358.80 per patient per year for BH supplies was noted.

CONCLUSION

BH cannulation did provide significant improvements. However, the increase in infection rate was an issue of concern. The additional cost of the BH procedure should be weighed against the positive outcomes realized.

Fecal containment in bedridden patients: economic impact of 2 commercial bowel catheter systems

BACKGROUND

Fecal contamination is a major challenge in patients in acute/critical care settings that is associated with increased cost of care and supplies and with development of pressure ulcers, incontinence dermatitis, skin and soft tissue infections, and urinary tract infections.

OBJECTIVES

To assess the economic impact of fecal containment in bedridden patients using 2 different indwelling bowel catheters and to compare infection rates between groups.

METHODS

A multicenter, observational study was done at 12 US sites (7 that use catheter A, 5 that use catheter B). Patients were followed from insertion of an indwelling bowel catheter system until the patient left the acute/critical care unit or until 29 days after enrollment, whichever came first. Demographic data, frequency of bedding/dressing changes, incidence of infection, and Braden scores (risk of pressure ulcers) were recorded.

RESULTS

The study included 146 bedridden patients (76 with catheter A, 70 with catheter B) who had similar Braden scores at enrollment. The rate of bedding/dressing changes per day differed significantly between groups (1.20 for catheter A vs 1.71 for catheter B; P = .004). According to a formula that accounted for personnel resources and laundry cycle costs, catheter A cost $13.94 less per patient per day to use than did catheter B. Catheter A was less likely than was catheter B to be removed during the observational period (P = .03). Observed infection rates were low.

CONCLUSION

Catheter A may be more cost-effective than catheter B because it requires fewer unscheduled linen changes per patient day.

Case Report: Anaphylaxis Following Cystoscopy With Equipment Sterilized With Cidex® OPA (Ortho-Phthalaldehyde): A Review of Two Cases

BACKGROUND AND PURPOSE

Creation of an optimal retroperitoneal space is of pivotal importance in laparoscopic retroperitoneal surgery. The aim of this study was to examine the balloon dissecting technique developed at our institution, comparing the costs of our device with that of a commercially available balloon retroperitoneal expander.

PATIENTS AND METHODS

Twenty patients scheduled to undergo retroperitoneoscopic surgery were randomly divided in two groups. In group 1, retroperitoneal dilation was performed with the commercially available balloon expander. In group 2, we employed our balloon dilator created with two middle finger of No. 8 powder-free surgical gloves tied to a nondisposable 11-mm trocar and filled with 600 mL of saline employing two 60-mL syringes simultaneously. Subjective evaluation of the created space was performed blindly in both groups. Economic evaluation included the costs of the disposable materials and of the time required for dilation.

RESULTS

In all cases, the dilation was considered good. In group 1, the median time required to dilate the retroperitoneal space was 3.15 minutes, whereas in group 2, the median time required was 1.16 minutes, and the time required to dissect the retroperitoneal space was 4.41 minutes (total 5.57 minutes). Considering the costs of the disposable material, the overall costs of creating the retroperitoneal space was 141.95 euro in group 1 and 60.27 euro in group 2 (P < 0.005).

CONCLUSION

The original dissecting balloon employed at our institution is easy and fast and offers a valid option for the proper dissection of the retroperitoneal space. Moreover, it was revealed to be cost-effective compared with the commercially available device.

A novel catheter system for percutaneous intracoronary artery cardiomyoplasty

BACKGROUND

Current medical and invasive treatment strategies are often found to be inadequate to treat patients with acute myocardial infarction. Cell and tissue therapies are a promising treatment alternative for patients with severe ischemic heart disease.

OBJECTIVES

The objective of this study was to evaluate the efficacy of a new means of direct myocardial access using the percutaneous coronary intervention (PCI) technique.

METHODS

We used a system consisting of an injection needle catheter that implants cells and the injection guide catheter that delivers the injection needle catheter into the target lesion. We harvested skeletal myoblasts from Yorkshire swine (n = 8; 50-60 kg), expanded them in culture and labeled them with a fluorescent cell-linker kit. The myoblasts (106 cells), along with green dye, were injected into the normal heart of swine using this novel system. Histological analysis was performed on Days 0 (n = 4) and 14 (n = 4) after injection.

RESULTS

Working along the coronary artery, the catheter was easily delivered to the left anterior descending (LAD) coronary artery with the conventional PCI technique. No events of death, cardiac tamponade or other procedural complication occurred. Electrocardiography did not detect cardiac arrhythmia during the 14 days following the injection. On gross inspection, the heart was observed through its outer surface, and the myoblasts and green dye were well localized in the LAD area.

CONCLUSIONS

The present study demonstrates the feasibility of a new means of a direct myocardial injection system without any adverse outcomes.

Total extraperitoneal (TEP) mesh repair of inguinal hernia in the developing world: comparison of low-cost indigenous balloon dissection versus direct telescopic dissection: a prospective randomized controlled study

BACKGROUND

Creation of extraperitoneal space during TEP repair requires an expensive commercially available balloon.

PATIENTS AND METHODS

Fifty-six patients suffering from uncomplicated primary unilateral or bilateral groin hernia were randomized into two groups; group 1--indigenous balloon dissection and group 2--direct telescopic dissection.

RESULTS

There were 55 males and 1 female, with an average age of 49 years; 50% of the inguinal hernias were bilateral. Creation of extraperitoneal space was considered as satisfactory in majority of patients (94.6%) with satisfactory anatomical delineation. Peritoneal breach was noticed during dissection in 36 (64.3%) patients. There was one (3.8%) conversion of TEP to TAPP in group 2. Distance between pubic symphysis to umbilicus was an important factor, which affected the easiness of dissection. In patients with this distance <or=14 cm lateral placement of ports was considered for easy use of graspers. The incidence of scrotal edema was significantly higher in group 2 as compared with group 1 (p < 0.01). Patients with indirect inguinal hernias in group 2 presented with a greater number of scrotal edema. Pain score on VAS at 6 h after surgery was significantly higher in group 2 (p < 0.021). Patients with age <65 years, bilateral hernias, and indirect hernias had a correlation with higher pain score at 6 h. Of the patients, 17.9% developed seroma in group 1 versus 64.3% in group 2 (p < 0.001).

CONCLUSION

Anatomical delineation of inguinal area and dissection in the extraperitoneal space in TEP repair was equally satisfactory with both low-cost indigenous balloon (group 1) and telescopic dissection (group 2). Balloon dissection was associated with significantly reduced postoperative pain at 6 h, scrotal edema, and seroma formation. However at 3 months follow-up balloon dissection did not offer significant advantage over direct telescopic dissection in the overall long-term outcome of TEP repairs. If balloon dissection is considered useful for the beginner, low-cost indigenous balloon may be used to avoid higher cost of commercially available balloon dissector with added early advantages.

Device occlusion of Fontan fenestration--an economical alternative

Fenestrating the Fontan circuit during total cavopulmonary anastomosis is commonly performed to reduce postoperative mortality and morbidity. The resulting systemic desaturation may progressively increase leading to symptoms. We report the case of a symptomatic eight year old, whose Fontan circuit fenestration was closed using a patent ductus arteriosus occluder. The marked improvement in the patient's clinical status immediately and after 3 months confirms this device to be a safe, and economically better alternative to the atrial septal defect occluder.

Health economic evaluation of therapeutic strategies in patients with idiopathic achalasia: results of a randomized trial comparing pneumatic dilatation with laparoscopic cardiomyotomy

BACKGROUND

We have prospectively collected information concerning the costs incurred during the management of patients allocated to either forceful dilatation or to an immediate laparoscopic operation because of newly diagnosed achalasia.

METHODS

Fifty-one patients with newly diagnosed achalasia were randomized to either pneumatic dilatation to a diameter of 30-40 mm or to a laparoscopic myotomy to which was added a posterior partial fundoplication. Follow-ups were scheduled at 1, 3, 6, and 12 months after inclusion. At each follow-up visit a study nurse interviewed the patients regarding symptoms and their quality of life (QoL) and a health economic questionnaire was completed. In the latter questionnaire, patients were asked to report the presence and character of contacts with the healthcare system since the last visit.

RESULTS

In the dilatation group six patients (23%), including the patient who was operated on because of perforation, were classified as failures during the first 12 months of follow-up compared to one (4%) in the myotomy group (p = 0.047). Five of those classified as failures in the dilatation group subsequently had a surgical myotomy and the sixth patient was treated with repeated dilatations. The patient classified as failure in the myotomy group was treated with endoscopic dilatation. The initial treatment cost and the total costs were significantly higher for laparoscopic myotomy compared to a pneumatic dilatation-based strategy (p = 0.0002 and p = 0.0019, respectively). When the total costs were subdivided into the different resources used, we found that the single largest cost item for pneumatic dilatation was that for hospital stay and that for laparoscopic myotomy was the actual operative treatment (operating room time). The cost-effectiveness analysis, relating to the actual treatment failures, revealed that the cost to avoid one treatment failure (incremental cost-effectiveness ratio) amounted to 9239 euros.

CONCLUSION

The current prospective, controlled clinical trial shows that despite a higher level of clinical efficacy of laparoscopic myotomy to prevent treatment failure in newly diagnosed achalasia, the cost effectiveness of pneumatic dilatation is superior, at least when a reasonable time horizon is applied.

The cost of laparoscopic myotomy versus pneumatic dilatation for esophageal achalasia

BACKGROUND

The two main treatment options for esophageal achalasia are laparoscopic distal esophageal myotomy (LM) and pneumatic dilatation (PD). Our objective was to compare the costs of these management strategies.

METHODS

We constructed a decision analytic model consisting of two treatment strategies for patients diagnosed with achalasia. Probabilities of events were systematically derived from a literature review, supplemented by expert opinion when necessary. Costs were estimated from the perspective of a third-party payer and society, including both direct and indirect costs. Future costs were discounted at a rate of 5.5% over a time horizon of 5 and 10 years. Uncertainty in the probability estimates was incorporated using probabilistic sensitivity analyses. We tested uncertainty in the model by modifying key assumptions and repeating the analysis.

RESULTS

From the societal perspective, the expected cost per patient was $10,789 (LM) compared with $5,315 (PD) five years following diagnosis, and $11,804 (LM) compared with $7,717 (PD) after 10 years. The 95% confidence interval of the incremental cost per patient treated with LM was ($5,280, $5,668) after five years, and ($3,863, $4,311) after 10 years. The incremental cost of LM was similar from the third-party payer perspective and in the secondary model analyzed.

CONCLUSIONS

Initial LM is a more costly management strategy under all clinically plausible scenarios tested in this model. Further research is needed to determine patients' preferences for the two treatment modalities, and society's willingness to bear the incremental cost of LM for those who choose it.

Direct primary or secondary percutaneous ureteral stenting: what is the most compliant option in patients with malignant ureteral obstructions?

The objective of this study was to analyze three ureteral stenting techniques in patients with malignant ureteral obstructions, considering the indications, techniques, procedural costs, and complications. In the period between June 2003 and June 2006, 45 patients with bilateral malignant ureteral obstructions were evaluated (24 males, 21 females; average age, 68.3; range, 42-87). All of the patients were treated with ureteral stenting: 30 (mild strictures) with direct stenting (insertion of the stent without predilation), 30 (moderate/severe strictures) with primary stenting (insertion of the stent after predilation in a one-stage procedure), and 30 (mild/moderate/severe strictures with infection) with secondary stenting (insertion of the stent after predilation and 2-3 days after nephrostomy). The incidence of complications and procedural costs were compared by a statistical analysis. The primary technical success rate was 98.89%. We did not observe any major complications. The minor complication rate was 11.1%. The incidence of complications for the various techniques was not statistically significantly. The statistical analysis of costs demonstrated that the average cost of secondary stenting (637 euros; SD, 115 euros) was significantly higher than that of procedures which involved direct or primary stenting (560 euros; SD, 108 euros). We conclude that one-step stenting (direct or primary) is a valid option to secondary stenting in correctly selected patients, owing to the fact that when the procedure is performed by expert interventional radiologists there are high technical success rates, low complication rates, and a reduction in costs.

Electronic Reminders Improve Procedure Documentation Compliance and Professional Fee Reimbursement

BACKGROUND

Medicolegal, clinical, and reimbursement needs warrant complete and accurate documentation. We sought to identify and improve our compliance rate for the documentation of arterial catheterization in the perioperative setting.

METHODS

We first reviewed 12 mo of electronic anesthesia records to establish a baseline compliance rate for arterial catheter documentation. Residents and Certified Registered Nurse Anesthetists were randomly assigned to a control group and experimental group. When surgical incision and anesthesia end were documented in the electronic record keeper, a reminder routine checked for an invasive arterial blood pressure tracing. If a case used an arterial catheter, but no procedure note was observed, the resident or Certified Registered Nurse Anesthetist assigned to the case was sent an automated alphanumeric pager and e-mail reminder. Providers in the control group received no pager or e-mail message. After 2 mo, all staff received the reminders.

RESULTS

A baseline compliance rate of 80% was observed (1963 of 2459 catheters documented). During the 2-mo study period, providers in the control group documented 152 of 202 (75%) arterial catheters, and the experimental group documented 177 of 201 (88%) arterial lines (P < 0.001). After all staff began receiving reminders, 309 of 314 arterial lines were documented in a subsequent 2 mo period (98%). Extrapolating this compliance rate to 12 mo of expected arterial catheter placement would result in an annual incremental $40,500 of professional fee reimbursement.

CONCLUSIONS

The complexity of the tertiary care process results in documentation deficiencies. Inexpensive automated reminders can drastically improve compliance without the need for complicated negative or positive feedback.

Economics of flexible vs. rigid catheters for intrauterine insemination

A decision tree model was created to investigate pregnancy rates, as well as cost factors associated with rigid vs. flexible catheters. Although the flexible catheter costs more than the rigid catheter, it is associated with a higher pregnancy rate, which decreases costs of IUI treatment because fewer cycles are needed.

Current disparities in the prices of medical materials between Japan and the United States: further investigation of cardiovascular medical devices

OBJECTIVES

Prices of medical devices in Japan were previously reported to be 2 to 4 times higher than those in the United States in 1996 and 1997. However, such data are out of date. We previously compared the market prices in early 2005 between Japan and the US for 16 items in 10 categories of medical materials, and showed that price differences still existed for all these items. However, the number of items investigated was small for each category, and generalization of the results might have been limited. The present study conducted a further investigation into price information for multiple items for each category, focusing on 5 cardiovascular devices.

METHODS

The US market price information was obtained from interviews of a healthcare provider network and 2 different group-purchasing organizations. We could obtain price information on 19 items in 5 categories. We substituted the Japanese reimbursement prices for the Japanese market prices.

RESULTS

The price ratio (Japanese reimbursement price / US market price)was 2.0-3.5 for coronary stents, 5.9-6.8 for percutaneous transluminal coronary angioplasty catheters, 2.2-3.5 for pacemakers, 1.6-2.5 for mechanical valves, and 3.4-4.7 for oxygenators.

CONCLUSIONS

The price disparities for cardiovascular devices between Japan and the US were reconfirmed. Japan's healthcare system should establish group-purchasing organizations, promote centers of clinical excellence, and abolish regulation of parallel imports and protectionism under the Japanese Pharmaceutical Affairs Law.

Modified Central Line for Pneumothorax

Pneumothoraxes, whether spontaneous or iatrogenic, frequently require drainage. Although the recent trend has been toward a catheter-based approach, many thoracic surgeons continue to use chest tubes. Tube thoracostomy is associated with significant pain at the time of insertion and during continued drainage. Pneumothorax catheters are less painful but more expensive, and some have been associated with significant failure. After disappointing experience with pneumothorax catheters, we have modified a central line to use in lieu of a pneumothorax kit. We have found this technique to be effective, safe, reliable, and inexpensive.

Termination of second and early third trimester pregnancy: comparison of 3 methods

The efficacy and safety of 3 methods used in legal termination of pregnancy in the second and early third trimester was assessed in 258 women in Jordan randomly assigned to receive Foley catheter (with and without traction) or prostaglandin E2 vaginal tablets. The failure rate of termination and the total insertion-to-termination time was higher with Foley catheter without traction (16.5%, 16.5 hours) than with traction (10.0%, 14.2 hours) or prostaglandin (8.0%, 11.5 hours). However, Foley catheter as a method of termination of pregnancy in second and early third trimester is safe and inexpensive, and its efficacy can be enhanced with the use of traction to give similar results to prostaglandin E2.

Cost-effectiveness analysis of levonorgestrel intrauterine system and thermal balloon ablation for heavy menstrual bleeding

OBJECTIVE

To compare the cost-effectiveness of levonorgestrel intrauterine system (LNG-IUS) (Mirena; Schering Co., Turku, Finland) and thermal balloon ablation (Thermachoicetrade mark; Gynecare Inc., Menlo Park, CA, USA) for the treatment of heavy menstrual bleeding.

DESIGN

An open, pragmatic, prospective randomised trial.

SETTING

A menstrual disorders clinic at National Women's Hospital, Auckland, New Zealand.

POPULATION

Seventy-nine women with self-defined heavy menstrual bleeding randomised to the LNG-IUS (40 women) or the thermal balloon ablation (39 women).

METHODS

Decision tree modelling using primary source data was used to identify the incremental cost-effectiveness of the two treatments.

MAIN OUTCOME MEASURES

Direct and indirect costs of medical treatment, including treatment costs, subsequent medical procedures, lost income and medical treatment for failed procedures. The change in quality of life as assessed by the Short Form-36 (SF-36) measured between time of treatment and 24 months was the primary outcome measure. Economic modelling examined the expected cost and outcome for a woman entering each treatment. Sensitivity analysis explored the robustness of the results.

RESULTS

The expected cost of treatment was $NZ1241 ($US869) for the LNG-IUS and $NZ2418 ($US1693) for the thermal balloon ablation. The LNG-IUS was associated with an increase of 15 points on the SF-36 scale, compared with 12 points for the thermal balloon ablation. Sensitivity analysis indicates that the results are robust to a 25% decrease in the price of the primary cost drivers and to variations in the rates of failed treatment between the conditions.

CONCLUSION

The LNG-IUS would appear to be cost-effective when compared with the thermal balloon ablation for treatment of heavy menstrual bleeding.

Use of human nasal cannulas during bronchoscopy procedures as a simple method for maintaining adequate oxygen saturation in pigtailed macaques (Macaca nemestrina)

Rising concerns over respiratory illnesses caused by agents such as avian influenza viruses and SARS coronavirus have prompted intensive research efforts and the resurgence of nonhuman primates as models for these human diseases. In the context of studying influenza infection and vaccine development, serial bronchoscopic procedures, including bronchial brush biopsies and bronchoalveolar lavage, were performed in pigtailed macaques (Macaca nemestrina). The possible need for oxygen supplementation during these procedures was anticipated because of the size of the animals relative to the 5-mm bronchoscope. We therefore monitored oxyhemoglobin saturation, a measure of arterial blood oxygen content, before and after insertion of the bronchoscope, during bronchoalveolar lavage, and after initiation of oxygen supplementation. Although more data are required to draw definitive conclusions, our findings suggested the need for oxygen supplementation during such procedures in nonhuman primates, despite the fact that human patients undergoing bronchoscopy and lavage do not routinely get oxygen unless they are already compromised. Our data also suggested that the need for supplementation could not be predicted from simple parameters such as size of the animal, presence of respiratory clinical signs, or experimental treatment. Finally, we show a simple and cost-effective method of using human nasal cannulas for delivering oxygen to pigtailed macaques during bronchoscopic procedures, and we believe that, after further testing, this method could be used safely and effectively in other nonhuman primate species.

Cost savings of an adult hospital nutrition support team

OBJECTIVES

A hospital-based nutrition support team (NST) may need to demonstrate cost savings and quality benefits. The primary aim of this study was to determine whether an NST could show tangible cost savings (equipment, investigations, and medication costs) from managing patients considered for parenteral nutrition (PN). Secondary aims related to the quality issues of placement of PN catheters, catheter-related sepsis (CRS), duration of parenteral nutrition, and mortality.

METHODS

An NST was formed in 1999 and worked in all adult areas of a university hospital (Leicester Royal Infirmary). Comparative data about all patients given PN were collected for 2 consecutive years (a retrospective pre-NST year and a prospective NST year).

RESULTS

In the pre-NST year there were 82 PN episodes (54 patients), 665 PN days, and a CRS rate of 71% (seven infections/100 PN days). In the NST year, there were 133 referrals for PN but only 78 PN episodes (75 patients, 59% of referrals), 752 PN days, and a decreased overall CRS rate of 29% (three infections/100 PN days, P < 0.05) but a rate of 7% (0.6 infection/100 PN days) in the final 3 mo of the NST year. Tangible cost savings for the NST year were derived from 55 avoided PN episodes (42741 pounds sterlings) and 35 avoided CRS episodes (7974 pounds sterlings). Thirty-nine percent of PN catheters were inserted by the NST with no insertion-related complications. Competency-based training of ward nursing staff decreased the CRS rate. Mean duration of PN increased from 8 to 10 d (P not significant). In-hospital mortality for patients who had PN was 23 of 54 (43%) in the pre-NST year compared with 18 of 75 (24%) in the NST year (P < 0.05).

CONCLUSIONS

Although the number of PN days increased with an NST, tangible cost savings of 50715 pounds sterlings were demonstrated within the NST year by avoided PN episodes and a decreased incidence of CRS. These savings justify the salaries of a nutrition nurse specialist and a senior dietitian.

Establishment and maintenance of vascular access in incident hemodialysis patients: a prospective cost analysis

Despite the importance of hemodialysis vascular access, the cost of vascular access care has not been studied in detail. A prospective cost analysis was performed among incident hemodialysis patients to determine the cost of vascular access care overall and on the basis of access type. Detailed clinical and demographic information, as well as data on access type, was collected for all local incident hemodialysis patients between July 1, 1999, and November 1, 2001. A comprehensive measure of total vascular access costs, including surgery, radiology, hospitalization for access complications, physician costs, costs for management of outpatient bacteremia, and vascular access monitoring costs, was obtained. Costs are reported in 2002 Canadian dollars (1 CAN dollar = 0.69 US dollar). A total of 239 consecutive incident hemodialysis patients were identified, 49, 157, and 33 of whom were dialyzed exclusively with a catheter or had a native arteriovenous fistula or synthetic graft attempted, respectively. In year 1, 18.4% of all hospital admissions were for vascular access-related complications. The mean cost of all vascular access care in year 1 was 6890 CAN dollars(median 4020 dollars; interquartile range [IQR] 2440 dollars to 7540 dollars). The mean cost of access care per patient-year at risk for maintaining a catheter exclusively, attempting an arteriovenous fistula, or attempting a graft was 9180 dollars (median 3812 dollars; IQR 2250 dollars to 7762 dollars), 7989 dollars (median 4641 dollars ; IQR 3035 dollars to 8832 dollars), and 11,685 dollars (median 8152 dollars; IQR 3395 dollars to 12,908 dollars), respectively (P = 0.01). Vascular access care is responsible for a significant proportion of health care costs in the first year of hemodialysis. These results support clinical practice guidelines that recommend preferential placement of a native fistula.

A cost-utility analysis of microwave and thermal balloon endometrial ablation techniques for the treatment of heavy menstrual bleeding

OBJECTIVE

To assess the cost effectiveness of the second-generation surgical treatments for heavy menstrual bleeding (microwave and thermal balloon endometrial ablation) compared with existing endometrial ablation techniques (transcervical resection and rollerball, alone or in combination) and hysterectomy.

DESIGN

A state transition (Markov) cost-utility economic model.

POPULATION

Women with heavy menstrual bleeding.

METHODS

A Markov model was developed using spreadsheet software. Transition probabilities, costs and quality of life data were obtained from a systematic review of effectiveness undertaken by the authors, from published sources, and expert opinion. Cost data were obtained from the literature and from a NHS trust hospital. Indirect comparison of thermal balloon endometrial ablation versus microwave endometrial ablation or either second-generation endometrial ablation method versus hysterectomy, and comparison of second-generation versus first-generation techniques were carried out from the perspective of health service payers. The effects of uncertainty were explored through extensive one-way sensitivity analyses and Monte Carlo simulation.

MAIN OUTCOME MEASURES

Incremental cost effectiveness ratios based on cost per quality adjusted life year (QALY) gained, and cost effectiveness acceptability curves.

RESULTS

Compared with first-generation techniques, both microwave and thermal balloon endometrial ablation cost less and accrued more QALYs. Hysterectomy was more expensive, but accrued more QALYs than all endometrial ablation methods. Baseline results showed that differences between microwave endometrial ablation and thermal balloon endometrial ablation were slight. Sensitivity analyses showed that small changes in values may have a marked effect on cost effectiveness. Probabilistic simulation highlighted the uncertainty in comparisons between different endometrial ablation options, particularly between second-generation techniques.

CONCLUSIONS

Despite limitations in available data, the analysis suggests that second-generation techniques are likely to be more cost effective than first-generation techniques in most cases. Hysterectomy, where a woman finds this option acceptable, continues to be a very cost effective procedure compared with all endometrial ablation methods.

Which cannulae fit the Ipas manual vacuum aspiration syringe?

BACKGROUND

The Ipas double-valve manual vacuum aspiration (MVA) syringe is an alternative to electrical vacuum aspiration.

METHODS

This study determines which US cannulae (flexible, rigid-straight and rigid-curved) work with the Ipas MVA syringe. Cannulae from Ipas, MedGyn, Berkeley and Milex, in sizes 6-12 mm, were randomized and affixed to the MVA syringe. A pressure gauge was attached to the cannula with rubber tubing. Pressure readings were recorded initially and over 30 s.

RESULTS

Milex cannulae were not compatible. For the remaining brands, initial vacuum pressures ranged from 55 to 65 mmHg. Flexible cannulae from Ipas, Berkeley and MedGyn maintained initial pressures without leaks, as did the 6-12-mm straight- and curved-rigid cannulae by Berkeley. Eight of the 13 tested MedGyn rigid cannulae lost >10% pressure over 30 s.

CONCLUSION

Several US manufacturers produce cannulae that fit on the Ipas MVA syringe without a leak, including Ipas flexible cannula; Berkeley flexible, rigid-straight and rigid-curve cannulae and MedGyn flexible cannula, but not their rigid cannulae.

Clinical and economic evaluation of the trellis thrombectomy device for arterial occlusions: preliminary analysis

OBJECTIVES

This preliminary study examined the technical efficacy, safety, and cost of treating arterial occlusions with a single device that combines pharmacologic and mechanical thrombolysis.

METHODS

The technical success, bleeding complications, and costs for the first 26 consecutive patients in whom lower extremity ischemia was treated with the Trellis infusion catheter (TIC) were analyzed. Procedure time, thrombolytic infusion time, technical success, bleeding complications (major and intracranial hemorrhage), interventional suite time, and 30-day amputation-free survival were evaluated.

RESULTS

15 of 26 patients (58%) who received treatment with the TIC had acute arterial occlusions, and 11 of 26 patients (42%) had nonacute arterial occlusions. Nineteen of 26 patients (73.1%) received treatment of an infrainguinal occlusion, and 7 of 26 patients (26.9%) received treatment of a suprainguinal occlusion. Lower extremity native arteries were treated in 18 of 26 patients (69%), and lower extremity bypass grafts in 8 of 26 patients (31%). The technical success rate with TIC treatment was 92%, and the 30-day amputation-free survival rate was 96%. There was no difference in technical success or amputation-free survival rate between acute versus nonacute arterial occlusions, native artery versus bypass grafts, and suprainguinal versus infrainguinal arterial occlusions. Procedure time was 2.1 +/- 0.9 hours, and infusion time was 0.3 +/- 0.2 hours. There were no bleeding complications; however, 3 of 26 patients (11.5%) required further intervention to treat distal embolization. The overall mean cost for patients with TIC treatment was $3216 +/- $1740.

CONCLUSIONS

Early results of TIC treatment in patients with arterial occlusions suggest that it is as effective as traditional catheter-directed thrombolysis. Furthermore, there were no bleeding complications, likely the result of TIC requiring shorter procedure and infusion times.

A Novel, Inexpensive, Double Lumen Suprapubic Catheter for Urodynamics

PURPOSE

We describe a novel, double lumen, intravesical, suprapubic catheter designed to meet the requirements of pediatric urodynamics that is easy to use and has minimal complications.

MATERIALS AND METHODS

A commercially available 10Fr pediatric suprapubic pigtail catheter forms the outer lumen for instilling filling media. A 16 gauge epidural catheter is inserted through the outer catheter providing an inner lumen for measuring intravesical pressures. The resultant double-lumen catheter is inserted suprapubically using a peel away needle supplied with the 10Fr catheter, with the patient under general anesthetic.

RESULTS

The catheter has been used for 15 years in more than 700 patients with good reliability and few complications. The concentric construction of the double lumens and the rigidity of the inner intravesical pressure channel ensure there is no transmission of pressure from the filling channel to the inner lumen. The catheter has a circular cross section and a pigtail distal end which help to retain it within the bladder. There is low resistance to filling that allows adequate filling rates to be achieved by gravity rather than necessitating a pump. The catheter is easily made from readily available components and is less expensive than other double-lumen catheters suitable for suprapubic use.

CONCLUSIONS

A reliable, double lumen catheter that fulfills criteria not found in commercially available alternatives can be inexpensively made for urodynamics.

The effectiveness and cost-effectiveness of microwave and thermal balloon endometrial ablation for heavy menstrual bleeding: a systematic review and economic modelling

OBJECTIVES

To estimate the clinical effectiveness and cost-effectiveness of microwave endometrial ablation (MEA) and thermal balloon endometrial ablation (TBEA) for heavy menstrual bleeding (HMB), compared with the existing (first-generation) endometrial ablation (EA) techniques of transcervical resection (TCRE) and rollerball (RB) ablation, and hysterectomy.

DATA SOURCES

Electronic databases, bibliographies of articles, and also experts in the field and relevant industry bodies were asked to provide information.

REVIEW METHODS

A detailed search strategy was carried out to identify systematic reviews and controlled trials of MEA and TBEA versus first-generation techniques for EA. In addition to electronic database searching, reference lists were hand-searched and information sought from manufacturers of EA devices and by experts in the field. A deterministic Markov model was developed to assess cost-effectiveness. Data for the model were taken from a range of sources.

RESULTS

The systematic review of first-generation EA techniques versus hysterectomy found that EA offered an alternative to hysterectomy for HMB, with fewer complications and a shorter recovery period. Satisfaction and effectiveness were high for both MEA and TBEA. Costs were lower with EA although the difference narrows over time. Second-generation EA techniques are an alternative treatment to first-generation techniques for HMB, and first-generation techniques are known to offer an alternative to hysterectomy. Although no trials of second-generation techniques and hysterectomy have been undertaken, it seems reasonable to assume that second-generation techniques also offer an alternative surgical treatment. Using the model to assess cost-effectiveness, costs were very slightly higher for MEA when compared to TBEA, and differences in quality-adjusted life-years (QALYs) were negligible. For MEA compared with transcervical resection of the endometrium (TCRE) and RB ablation, costs were slightly lower with MEA and MEA accrued very slightly more QALYs. Compared with hysterectomy, MEA costs less and accrues slightly fewer QALYs. For TBEA compared with TCRE and RB ablation, costs were lower with TBEA and TBEA accrued slightly more QALYs. Compared with hysterectomy, TBEA costs moderately less and accrues moderately fewer QALYs.

CONCLUSIONS

Overall, there were few significant differences between the outcomes of first- and second-generation techniques including bleeding, satisfaction and QoL measures and repeat surgery rates. Second-generation techniques had significantly shorter operating and theatre times and there appear to be fewer serious perioperative adverse effects with second-generation techniques and postoperative effects are similar. Compared with hysterectomy, TCRE and RB are quicker to perform and result in shorter hospitalisation and faster return to work. Hysterectomy results in more adverse effects and is more expensive, although the need for retreatment leads this difference to decrease over time. Satisfaction with hysterectomy is initially higher, but there is no significant difference after 2 years. The economic model suggests that second-generation techniques are more cost-effective than first-generation techniques of EA for HMB. Both TBEA and MEA appear to be less costly than hysterectomy, although the latter results in more QALYs. Further research is suggested to make direct comparisons of the cost-effectiveness of second-generation EA techniques, to carry out longer term follow-up for all methods of EA in RCTs, and to develop more sophisticated modelling studies. Further research is also recommended into HMB to establish health-state utility values, its surgical treatment, convalescence, complications of treatment, symptoms and patient satisfaction.

Cost-assessment of alternative management strategies for achalasia

Achalasia is a primary oesophageal motor disorder characterised by the abnormal relaxation of the lower oesophageal sphincter (LES) and absent oesophageal peristalsis. It is a rare disease, with an estimated incidence of approximately 1/100,000 and a prevalence close to 10/100,000 [1]. Its exact aetiology remains unknown. Autoimmune, infectious, degenerative and hereditary processes have all been proposed as factors that lead to a chronic inflammatory response in the myenteric plexus, thus resulting in selective loss of inhibitory neurons [2] and failure of the LES to relax and aperistalsis in the body of the oesophagus. The most common symptoms of achalasia are dysphagia for solids and liquids, regurgitation, chest pain, weight loss and heartburn in > 90 approximately 75, 40 - 50, approximately 60, approximately 40%, respectively [3,4]. The diagnosis is based on symptoms, barium swallow and manometry. A barium oesophagram typically shows a dilated oesophagus that tapers into a 'bird-beak' at the gastro-oesophageal junction with lack of normal peristalsis on fluoroscopic evaluation. The characteristic manometric features of achalasia are abnormal LES relaxation and aperistalsis; additionally, the LES pressure is frequently high, but can also be normal. Current practice of medicine is faced with rising healthcare costs and limited budgets [5]. We are therefore confronted with an increasing demand to justify the value of our therapeutic interventions, not only from the risk/benefit standpoint but also from the cost perspective [6,7].

Effectiveness and infectious morbidity of outpatient cervical ripening with a Foley catheter

OBJECTIVE

To assess the effectiveness and infectious morbidity of outpatient cervical ripening with a Foley catheter.

STUDY DESIGN

Labor inductions utilizing a Foley catheter for cervical ripening from January 1994 to October 1999 were retrospectively reviewed. The inductions were divided into inpatient and outpatient groups. Vaginal delivery rates and infectious morbidity were compared between the 2 groups.

RESULTS

There were 315 inpatient and 300 outpatient cases. The observed differences in vaginal delivery rates and infectious morbidity were not clinically or statistically significant. However, there was insufficient power to exclude a type II error. The cost savings was $165,000, and there is the potential to save $750 per patient with this method.

CONCLUSION

Outpatient cervical ripening with a Foley catheter is clinically effective, does not result in excess infectious morbidity and is more cost effective as compared to inpatient cervical ripening.

[Simple and cost effective cannula for sialography: Technical note]

We developed a simple and cost-effective modified cannula for sialography. The cannulae were made from nineteen, twenty-one and twenty-three gauge winged infusion set which are generally used for injection of contrast material in radiological imaging. In this article, we intend to introduce this cannula and discuss its utility.

Improving vascular access outcomes: a systems approach to eliminating structural barriers

Maximizing AV fistula creation, regular access monitoring, prompt outpatient interventions and minimizing catheter use are well-accepted approaches for vascular access management. Systemic barriers impede the application of these strategies. A misaligned reimbursement system coupled with educational deficits and a lack of accountability has contributed to the institutionalization of substandard vascular access care. The hallmark of performance management is to create systems in which incentives are aligned to produce desired behaviors. Realigning reimbursement through a combination of pre-ESRD funding, enhancements to the composite rate to reward outcomes and cover vascular access monitoring and updated reimbursement for outpatient vascular access procedures would improve care and decrease unnecessary hospitalizations. This should be coupled with clearly defined outcome standards and accountability incorporated into hospital accreditation and credentialing. Capitation may provide alternative solutions. A two-phased approach including reimbursement reform while exploring capitation represents a prudent course with the best likelihood of success.