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Gadjradj PS, Harhangi BS, Amelink J, van Susante J, Kamper S, van Tulder M, Peul WC, Vleggeert-Lankamp C, Rubinstein SM. Percutaneous Transforaminal Endoscopic Discectomy Versus Open Microdiscectomy for Lumbar Disc Herniation: A Systematic Review and Meta-analysis. Spine (Phila Pa 1976) 2021; 46:538-549. [PMID: 33290374 PMCID: PMC7993912 DOI: 10.1097/brs.0000000000003843] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 09/12/2020] [Accepted: 10/05/2020] [Indexed: 02/06/2023]
Abstract
STUDY DESIGN Systematic review and meta-analysis. OBJECTIVE To give a systematic overview of effectiveness of percutaneous transforaminal endoscopic discectomy (PTED) compared with open microdiscectomy (OM) in the treatment of lumbar disk herniation (LDH). SUMMARY OF BACKGROUND DATA The current standard procedure for the treatment of sciatica caused by LDH, is OM. PTED is an alternative surgical technique which is thought to be less invasive. It is unclear if PTED has comparable outcomes compared with OM. METHODS Multiple online databases were systematically searched up to April 2020 for randomized controlled trials and prospective studies comparing PTED with OM for LDH. Primary outcomes were leg pain and functional status. Pooled effect estimates were calculated for the primary outcomes only and presented as standard mean differences (SMD) with their 95% confidence intervals (CI) at short (1-day postoperative), intermediate (3-6 months), and long-term (12 months). RESULTS We identified 2276 citations, of which eventually 14 studies were included. There was substantial heterogeneity in effects on leg pain at short term. There is moderate quality evidence suggesting no difference in leg pain at intermediate (SMD 0.05, 95% CI -0.10-0.21) and long-term follow-up (SMD 0.11, 95% CI -0.30-0.53). Only one study measured functional status at short-term and reported no differences. There is moderate quality evidence suggesting no difference in functional status at intermediate (SMD -0.09, 95% CI -0.24-0.07) and long-term (SMD -0.11, 95% CI -0.45-0.24). CONCLUSION There is moderate quality evidence suggesting no difference in leg pain or functional status at intermediate and long-term follow-up between PTED and OM in the treatment of LDH. High quality, robust studies reporting on clinical outcomes and cost-effectiveness on the long term are lacking.Level of Evidence: 2.
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Affiliation(s)
- Pravesh S. Gadjradj
- Department of Neurosurgery, Leiden University Medical Center, University Neurosurgical Center Holland (UNCH), Leiden, the Netherlands
| | - Biswadjiet S. Harhangi
- Department of Neurosurgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Jantijn Amelink
- Department of Neurosurgery, Leiden University Medical Center, University Neurosurgical Center Holland (UNCH), Leiden, the Netherlands
| | - Job van Susante
- Department of Orthopedic Surgery, Rijnstate Hospital, Arnhem, the Netherlands
| | - Steven Kamper
- School of Public Health, University of Sydney, Camperdown, Australia
- Centre for Pain, Health and Lifestyle, Australia
| | - Maurits van Tulder
- Faculty Behavioral & Movement Sciences, Amsterdam Movement Sciences Research Institute, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Wilco C. Peul
- Department of Neurosurgery, Leiden University Medical Center, University Neurosurgical Center Holland (UNCH), Leiden, the Netherlands
| | - Carmen Vleggeert-Lankamp
- Department of Neurosurgery, Leiden University Medical Center, University Neurosurgical Center Holland (UNCH), Leiden, the Netherlands
| | - Sidney M. Rubinstein
- Faculty Behavioral & Movement Sciences, Amsterdam Movement Sciences Research Institute, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
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Abstract
BACKGROUND Carpal tunnel syndrome is the most common upper-extremity nerve compression syndrome. Over 500,000 carpal tunnel release (CTR) procedures are performed in the U.S. yearly. We estimated the cost-effectiveness of endoscopic CTR (ECTR) versus open CTR (OCTR) using data from published meta-analyses comparing outcomes for ECTR and OCTR. METHODS We developed a Markov model to examine the cost-effectiveness of OCTR versus ECTR for patients undergoing unilateral CTR in an office setting under local anesthesia and in an operating-room (OR) setting under monitored anesthesia care. The main outcomes were costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). We modeled societal (modeled with a 50-year-old patient) and Medicare payer (modeled with a 65-year-old patient) perspectives, adopting a lifetime time horizon. We performed deterministic and probabilistic sensitivity analyses (PSAs). RESULTS ECTR resulted in 0.00141 additional QALY compared with OCTR. From a societal perspective, assuming 8.21 fewer days of work missed after ECTR than after OCTR, ECTR cost less across all procedure settings. The results are sensitive to the number of days of work missed following surgery. From a payer perspective, ECTR in the OR (ECTROR) cost $1,872 more than OCTR in the office (OCTRoffice), for an ICER of approximately $1,332,000/QALY. The ECTROR cost $654 more than the OCTROR, for an ICER of $464,000/QALY. The ECTRoffice cost $107 more than the OCTRoffice, for an ICER of $76,000/QALY. From a payer perspective, for a willingness-to-pay threshold of $100,000/QALY, OCTRoffice was preferred over ECTROR in 77% of the PSA iterations. From a societal perspective, ECTROR was preferred over OCTRoffice in 61% of the PSA iterations. CONCLUSIONS From a societal perspective, ECTR is associated with lower costs as a result of an earlier return to work and leads to higher QALYs. Additional research on return to work is needed to confirm these findings on the basis of contemporary return-to-work practices. From a payer perspective, ECTR is more expensive and is cost-effective only if performed in an office setting under local anesthesia. LEVEL OF EVIDENCE Economic and Decision Analysis Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- James I Barnes
- VA Palo Alto Health Care System, Palo Alto, California
- Center for Primary Care and Outcomes Research/Center for Health Policy, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Gabrielle Paci
- VOICES Health Policy Research Center, Department of Orthopedic Surgery, Stanford University School of Medicine, Stanford, California
| | - Thompson Zhuang
- VOICES Health Policy Research Center, Department of Orthopedic Surgery, Stanford University School of Medicine, Stanford, California
| | - Laurence C Baker
- Center for Primary Care and Outcomes Research/Center for Health Policy, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Steven M Asch
- VA Center for Innovation to Implementation, Palo Alto, California
- Division of Primary Care and Population Health, Stanford University, Stanford, California
| | - Robin N Kamal
- VOICES Health Policy Research Center, Department of Orthopedic Surgery, Stanford University School of Medicine, Stanford, California
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Kim DJ, Lee HM, Choi SW, Oh SJ, Kong SK, Lee IW. Comparative study of endoscopic and microscopic tympanoplasty performed by a single experienced surgeon. Am J Otolaryngol 2021; 42:102788. [PMID: 33171411 DOI: 10.1016/j.amjoto.2020.102788] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 10/13/2020] [Accepted: 10/17/2020] [Indexed: 01/02/2023]
Abstract
PURPOSE The use of endoscopes in otologic procedures has been increasing worldwide. This study aimed to compare the efficacy of microscopic tympanoplasty (MT) and endoscopic tympanoplasty (ET) for tympanic membrane and middle ear surgery. MATERIALS AND METHODS We retrospectively analyzed 81 patients who underwent MT (n = 44) and ET (n = 37) for chronic otitis media with tympanic membrane perforation performed by a single surgeon between January 2013 and September 2019. The hearing outcomes, graft success rate, complications, operation time and hospital stay, and cost-effectiveness were recorded and compared between groups. Hearing outcomes were determined by pure tone audiometry. Cost-effectiveness was determined by the operation cost and total cost. RESULTS There was no significant difference between the MT and ET groups regarding demographic characteristics, with the exception of the male:female ratio. There was no significant difference in the pre- and postoperative air conduction, bone conduction thresholds, and air-bone gap values between the two groups, but a significant audiologic improvement was observed in both groups (p < 0.05). In terms of recurrence of tympanic membrane perforation, postoperative otorrhea, and discomfort symptoms, there was no significant difference between groups (p > 0.05). The operation time and hospital stay were shorter in the ET group than in the MT group (p < 0.05). There were no significant differences in operation cost between the two groups (p > 0.05), but the total cost was significantly lower in the ET group than the MT group (p < 0.05). CONCLUSION ET is as safe and medically efficacious as conventional MT, shortens the operation time and hospital stay, and is cost-effective.
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Affiliation(s)
- Dong Jo Kim
- Department of Otorhinolaryngology - Head and Neck Surgery, Pusan National University School of Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Hyun Min Lee
- Department of Otorhinolaryngology - Head and Neck Surgery, Pusan National University School of Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Sung-Won Choi
- Department of Otorhinolaryngology - Head and Neck Surgery, Pusan National University School of Medicine, Pusan National University Hospital, Busan, Republic of Korea
| | - Se-Joon Oh
- Department of Otorhinolaryngology - Head and Neck Surgery, Pusan National University School of Medicine, Pusan National University Hospital, Busan, Republic of Korea
| | - Soo-Keun Kong
- Department of Otorhinolaryngology - Head and Neck Surgery, Pusan National University School of Medicine, Pusan National University Hospital, Busan, Republic of Korea
| | - Il-Woo Lee
- Department of Otorhinolaryngology - Head and Neck Surgery, Pusan National University School of Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea.
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Abstract
After the completion of an endoscopic spinal surgery fellowship, the next challenge for the newly minted consultant is to set up a viable and sustainable endoscopic practice. A successful practice of endoscopic spine surgery is dependent on several factors, such as anesthetic support; surgical expertise; support for provision and maintenance of endoscopic equipment; cost of equipment; administrative and nursing support; postoperative care services to optimize patients' outcome and satisfaction; patients' ideas, concerns, and expectations, as well as continuing medical education. In this article, a perspective is given on the early career challenges that a fellowship-trained endoscopic surgeon may encounter in the period leading to first successful endoscopic spinal surgery.
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Affiliation(s)
- Pang Hung Wu
- National University Health System, JurongHealth Campus, Orthopaedic Surgery, Singapore.
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Pickard R, Goulao B, Carnell S, Shen J, MacLennan G, Norrie J, Breckons M, Vale L, Whybrow P, Rapley T, Forbes R, Currer S, Forrest M, Wilkinson J, McColl E, Andrich D, Barclay S, Cook J, Mundy A, N'Dow J, Payne S, Watkin N. Open urethroplasty versus endoscopic urethrotomy for recurrent urethral stricture in men: the OPEN RCT. Health Technol Assess 2020; 24:1-110. [PMID: 33228846 PMCID: PMC7750862 DOI: 10.3310/hta24610] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Men who suffer recurrence of bulbar urethral stricture have to decide between endoscopic urethrotomy and open urethroplasty to manage their urinary symptoms. Evidence of relative clinical effectiveness and cost-effectiveness is lacking. OBJECTIVES To assess benefit, harms and cost-effectiveness of open urethroplasty compared with endoscopic urethrotomy as treatment for recurrent urethral stricture in men. DESIGN Parallel-group, open-label, patient-randomised trial of allocated intervention with 6-monthly follow-ups over 24 months. Target sample size was 210 participants providing outcome data. Participants, clinicians and local research staff could not be blinded to allocation. Central trial staff were blinded when needed. SETTING UK NHS with recruitment from 38 hospital sites. PARTICIPANTS A total of 222 men requiring operative treatment for recurrence of bulbar urethral stricture who had received at least one previous intervention for stricture. INTERVENTIONS A centralised randomisation system using random blocks allocated participants 1 : 1 to open urethroplasty (experimental group) or endoscopic urethrotomy (control group). MAIN OUTCOME MEASURES The primary clinical outcome was control of urinary symptoms. Cost-effectiveness was assessed by cost per quality-adjusted life-year (QALY) gained over 24 months. The main secondary outcome was the need for reintervention for stricture recurrence. RESULTS The mean difference in the area under the curve of repeated measurement of voiding symptoms scored from 0 (no symptoms) to 24 (severe symptoms) between the two groups was -0.36 [95% confidence interval (CI) -1.78 to 1.02; p = 0.6]. Mean voiding symptom scores improved between baseline and 24 months after randomisation from 13.4 [standard deviation (SD) 4.5] to 6 (SD 5.5) for urethroplasty group and from 13.2 (SD 4.7) to 6.4 (SD 5.3) for urethrotomy. Reintervention was less frequent and occurred earlier in the urethroplasty group (hazard ratio 0.52, 95% CI 0.31 to 0.89; p = 0.02). There were two postoperative complications requiring reinterventions in the group that received urethroplasty and five, including one death from pulmonary embolism, in the group that received urethrotomy. Over 24 months, urethroplasty cost on average more than urethrotomy (cost difference £2148, 95% CI £689 to £3606) and resulted in a similar number of QALYs (QALY difference -0.01, 95% CI -0.17 to 0.14). Therefore, based on current evidence, urethrotomy is considered to be cost-effective. LIMITATIONS We were able to include only 69 (63%) of the 109 men allocated to urethroplasty and 90 (80%) of the 113 men allocated to urethrotomy in the primary complete-case intention-to-treat analysis. CONCLUSIONS The similar magnitude of symptom improvement seen for the two procedures over 24 months of follow-up shows that both provide effective symptom control. The lower likelihood of further intervention favours urethroplasty, but this had a higher cost over the 24 months of follow-up and was unlikely to be considered cost-effective. FUTURE WORK Formulate methods to incorporate short-term disutility data into cost-effectiveness analysis. Survey pathways of care for men with urethral stricture, including the use of enhanced recovery after urethroplasty. Establish a pragmatic follow-up schedule to allow national audit of outcomes following urethral surgery with linkage to NHS Hospital Episode Statistics. TRIAL REGISTRATION Current Controlled Trials ISRCTN98009168. FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 61. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Robert Pickard
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Beatriz Goulao
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Sonya Carnell
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Jing Shen
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Graeme MacLennan
- Centre for Healthcare and Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - John Norrie
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Matt Breckons
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Luke Vale
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | | | - Tim Rapley
- Social Work, Education & Community Wellbeing, University of Northumbria, Newcastle upon Tyne, UK
| | - Rebecca Forbes
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Stephanie Currer
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Mark Forrest
- Centre for Healthcare and Randomised Trials, University of Aberdeen, Aberdeen, UK
| | - Jennifer Wilkinson
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Elaine McColl
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Daniela Andrich
- University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Jonathan Cook
- Oxford Clinical Trials Research Unit, Oxford University, Oxford, UK
| | - Anthony Mundy
- University College London Hospitals NHS Foundation Trust, London, UK
| | - James N'Dow
- Academic Urology Unit, University of Aberdeen, Aberdeen, UK
| | - Stephen Payne
- Central Manchester Hospitals NHS Foundation Trust, Manchester, UK
| | - Nick Watkin
- St George's University Hospitals NHS Foundation Trust, London, UK
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Kapoor R, So JBY, Zhu F, Too HP, Yeoh KG, Yoong JSY. Evaluating the Use of microRNA Blood Tests for Gastric Cancer Screening in a Stratified Population-Level Screening Program: An Early Model-Based Cost-Effectiveness Analysis. Value Health 2020; 23:1171-1179. [PMID: 32940235 DOI: 10.1016/j.jval.2020.04.1829] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 04/03/2020] [Accepted: 04/27/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES To evaluate cost-effectiveness of a novel screening strategy using a microRNA (miRNA) blood test as a screen, followed by endoscopy for diagnosis confirmation in a 3-yearly population screening program for gastric cancer. METHODS A Markov cohort model has been developed in Microsoft Excel 2016 for the population identified to be at intermediate risk (Singaporean men, aged 50-75 years with Chinese ethnicity). The interventions compared were (1) initial screening using miRNA test followed by endoscopy for test-positive individuals and a 3-yearly follow-up screening for test-negative individuals (proposed strategy), and (2) no screening with gastric cancer being diagnosed clinically (current practice). The model was evaluated for 25 years with a healthcare perspective and accounted for test characteristics, compliance, disease progression, cancer recurrence, costs, utilities, and mortality. The outcomes measured included incremental cost-effectiveness ratios, cancer stage at diagnosis, and thresholds for significant variables. RESULTS The miRNA-based screening was found to be cost-effective with an incremental cost-effectiveness ratio of $40 971/quality-adjusted life-year. Key drivers included test costs, test accuracy, cancer incidence, and recurrence risk. Threshold analysis highlights the need for high accuracy of miRNA tests (threshold sensitivity: 68%; threshold specificity: 77%). A perfect compliance to screening would double the cancer diagnosis in early stages compared to the current practice. Probabilistic sensitivity analysis reported the miRNA-based screening to be cost-effective in >95% of iterations for a willingness to pay of $70 000/quality-adjusted life-year (approximately equivalent to 1 gross domestic product/capita) CONCLUSIONS: The miRNA-based screening intervention was found to be cost-effective and is expected to contribute immensely in early diagnosis of cancer by improving screening compliance.
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Affiliation(s)
- Ritika Kapoor
- Saw Swee Hock School of Public Health, National University of Singapore, National University Health System, Singapore; Evidera, PPD, Singapore.
| | - Jimmy B Y So
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Surgical Oncology, National University Cancer Institute of Singapore, Singapore; Singapore Gastric Cancer Consortium, Singapore
| | - Feng Zhu
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Heng-Phon Too
- Bioprocessing Technology Institute, A∗STAR, Singapore; Department of Biochemistry, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Khay-Guan Yeoh
- Singapore Gastric Cancer Consortium, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Gastroenterology and Hepatology, National University Health System, Singapore
| | - Joanne Su-Yin Yoong
- Center for Economic and Social Research, University of South California, Los Angeles, CA, USA
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Corral JE, Hoogenboom SA, Kröner PT, Vazquez-Roque MI, Picco MF, Farraye FA, Wallace MB. COVID-19 polymerase chain reaction testing before endoscopy: an economic analysis. Gastrointest Endosc 2020; 92:524-534.e6. [PMID: 32360302 PMCID: PMC7187877 DOI: 10.1016/j.gie.2020.04.049] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 04/21/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The novel coronavirus disease 2019 (COVID-19) pandemic has limited endoscopy utilization, causing significant health and economic losses. We aim to model the impact of polymerase chain reaction (PCR) testing into resuming endoscopy practice. METHODS We performed a retrospective review of endoscopy utilization during the COVID-19 pandemic for a baseline reference. A computer model compared 3 approaches: strategy 1, endoscopy for urgent indications only; strategy 2, testing for semiurgent indications; and strategy 3, testing all patients. Analysis was made under current COVID-19 prevalence and projected prevalence of 5% and 10%. Primary outcomes were number of procedures performed and/or canceled. Secondary outcomes were direct costs, reimbursement, personal protective equipment used, and personnel infected. Disease prevalence, testing accuracy, and costs were obtained from the literature. RESULTS During the COVID-19 pandemic, endoscopy volume was 12.7% of expected. Strategies 2 and 3 were safe and effective interventions to resume endoscopy in semiurgent and elective cases. Investing 22 U.S. dollars (USD) and 105 USD in testing per patient allowed the completion of 19.4% and 95.3% of baseline endoscopies, respectively. False-negative results were seen after testing 4700 patients (or 3 months of applying strategy 2 in our practice). Implementing PCR testing over 1 week in the United States would require 13 and 64 million USD, with a return of 165 and 767 million USD to providers, leaving 65 and 325 healthcare workers infected. CONCLUSIONS PCR testing is an effective strategy to restart endoscopic practice in the United States. PCR screening should be implemented during the second phase of the pandemic, once the healthcare system is able to test and isolate all suspected COVID-19 cases.
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Affiliation(s)
- Juan E Corral
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Sanne A Hoogenboom
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Paul T Kröner
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Maria I Vazquez-Roque
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Michael F Picco
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Francis A Farraye
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Michael B Wallace
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
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Scangas GA, Wu AW, Ting JY, Metson R, Walgama E, Shrime MG, Higgins TS. Cost Utility Analysis of Dupilumab Versus Endoscopic Sinus Surgery for Chronic Rhinosinusitis With Nasal Polyps. Laryngoscope 2020; 131:E26-E33. [PMID: 32243622 DOI: 10.1002/lary.28648] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 02/11/2020] [Accepted: 03/05/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Both endoscopic sinus surgery (ESS) and biologic therapies have shown effectiveness for medically-refractory chronic rhinosinusitis with nasal polyps (CRSwNP) without severe asthma. The objective was to evaluate cost-effectiveness of dupilumab versus ESS for patients with CRSwNP. STUDY DESIGN Cohort-style Markov decision-tree economic model with a 36-year time horizon. METHODS A cohort of 197 CRSwNP patients who underwent ESS were compared with a matched cohort of 293 CRSwNP patients from the SINUS-24 and SINUS-52 Phase 3 studies who underwent treatment with dupilumab 300 mg every 2 weeks. Utility scores were calculated from the SNOT-22 instrument in both cohorts. Decision-tree analysis and a 10-state Markov model utilized published event probabilities and primary data to calculate long-term costs and utility. The primary outcome measure was incremental cost per quality-adjusted life year (QALY), which is expressed as an Incremental Cost Effectiveness Ratio. One-way and probabilistic sensitivity analyses were performed. RESULTS The ESS strategy cost $50,436.99 and produced 9.80 QALYs. The dupilumab treatment strategy cost $536,420.22 and produced 8.95 QALYs. Because dupilumab treatment was more costly and less effective than the ESS strategy, it is dominated by ESS in the base case. One-way sensitivity analyses showed ESS to be cost-effective versus dupilumab regardless of the frequency of revision surgery and at any yearly cost of dupilumab above $855. CONCLUSIONS The ESS treatment strategy is more cost effective than dupilumab for upfront treatment of CRSwNP. More studies are needed to isolate potential phenotypes or endotypes that will benefit most from dupilumab in a cost-effective manner. LEVEL OF EVIDENCE 2C Laryngoscope, 131:E26-E33, 2021.
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Affiliation(s)
- George A Scangas
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, U.S.A
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts, U.S.A
| | - Arthur W Wu
- Department of Otolaryngology, Cedars-Sinai Medical Center, Los Angeles, California, U.S.A
| | - Jonathan Y Ting
- Department of Otolaryngology, Indiana University, Indianapolis, Indiana, U.S.A
| | - Ralph Metson
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, U.S.A
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts, U.S.A
| | - Evan Walgama
- Department of Otolaryngology, Cedars-Sinai Medical Center, Los Angeles, California, U.S.A
| | - Mark G Shrime
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, U.S.A
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts, U.S.A
- Center for Global Surgery Evaluation, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Thomas S Higgins
- Department of Otolaryngology, University of Louisville School of Medicine, Louisville, Kentucky, U.S.A
- Rhinology, Sinus & Skull Base, Kentuckiana Ear, Nose & Throat, Louisville, Kentucky, U.S.A
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Eggerstedt M, Urban MJ, Chi E, Ritz EM, Losavio P. The anesthesia airway evaluation: Correlation with sleep endoscopy findings. Am J Otolaryngol 2020; 41:102362. [PMID: 31810582 DOI: 10.1016/j.amjoto.2019.102362] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 11/19/2019] [Accepted: 11/22/2019] [Indexed: 02/05/2023]
Abstract
PURPOSE Drug-induced sleep endoscopy (DISE) is a cost-effective, safe, and reliable tool to evaluate obstructive sleep apnea (OSA) patients by revealing upper airway sites, patterns, and severity of obstruction. DISE provides valuable data because reliable evaluation of the OSA airway while awake has remained elusive. Few studies (with mixed results) have analyzed the correlation between pre-operation, awake airway assessments routinely performed by anesthesia and DISE results. METHODS Preoperative anesthesia evaluation records and subsequent DISE reports were obtained for 99 adult patients undergoing DISE between 2016 and 2018. All patients carried the diagnosis of OSA, based on polysomnography. Anesthesia-collected variables were compared with DISE findings in an effort to determine if commonly-utilized physical exam findings correlated to patterns of upper airway collapse observed on sleep endoscopy. RESULTS Most anesthesia preoperative evaluation variables were not found to be predictive of any identifiable patterns of collapse on DISE, including Mallampati score, ability to prognath, and overall airway assessment score. Obesity did not correlate with circumferential collapse at the velopharynx, or to multi-level collapse. Thyromental distance <6.5 cm was found to be statistically correlated to total epiglottic collapse (E = 2+). Friedman tongue position scores were found to be correlated to velopharyngeal collapse (p < 0.05). CONCLUSIONS Anesthesia airway assessment algorithms and physical exam findings do not correlate well with findings on sleep endoscopy. DISE remains the gold standard for evaluating levels of collapse and operative planning in the OSA population.
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Affiliation(s)
- Michael Eggerstedt
- Rush University Medical Center, Department of Otorhinolaryngology - Head & Neck Surgery, Chicago, IL 60612, United States of America.
| | - Matthew J Urban
- Rush University Medical Center, Department of Otorhinolaryngology - Head & Neck Surgery, Chicago, IL 60612, United States of America
| | - Emily Chi
- Rush Medical College at Rush University, Chicago, IL 60612, United States of America
| | - Ethan M Ritz
- Rush University Medical Center, Department of Otorhinolaryngology - Head & Neck Surgery, Chicago, IL 60612, United States of America
| | - Phillip Losavio
- Rush University Medical Center, Department of Otorhinolaryngology - Head & Neck Surgery, Chicago, IL 60612, United States of America
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Kshirsagar RS, Vu PQ, Liang J. Endoscopic versus external dacryocystorhinostomy: temporal and regional trends in the United States Medicare population. Orbit 2019; 38:453-460. [PMID: 30712428 DOI: 10.1080/01676830.2019.1572767] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 01/15/2019] [Indexed: 06/09/2023]
Abstract
Purpose: Endoscopic surgeries, such as dacryocystorhinostomy (DCR), are increasingly performed for orbital and lacrimal conditions. This study describes and compares recent trends in endoscopic DCR with open, or external, DCR in the United States (US). Methods: Medicare-Part-B National Summary data files were analyzed from 2000 to 2015 for temporal and geographic trends in endoscopic and external DCR. Medicare Physician and Other Supplier public use files detailing provider information were collected and analyzed from 2012 to 2015. Results: Between 2000 and 2015, the number of external DCRs remained relatively unchanged (8008 to 7086, -0.7% average annual growth), while the number of endoscopic DCRs steadily increased (881 to 1674, 4.6% average annual growth). The greatest number of endoscopic DCRs were performed in the South Atlantic region, whereas the Mountain region had the greatest number per capita. From 2000 to 2015, the average payment per procedure for external DCR was $526.63, compared with $512.45 for endoscopic DCR. Of endoscopic DCRs performed from 2012 to 2015, 831 (79%) were performed by Ophthalmology, 184 (18%) were performed by Otolaryngology, and the remainder by other subspecialties. Conclusions: The number of endoscopic DCR surgeries increased over the last 15 years while the number of external DCR surgeries remained stable and continued to surpass endoscopic procedures. While ophthalmologists perform the overwhelming majority of endoscopic DCR, otolaryngologists are performing a growing number.
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Affiliation(s)
- Rijul S Kshirsagar
- Department of Head and Neck Surgery, Kaiser Permanente Medical Center Oakland , Oakland , CA , USA
| | - Priscilla Q Vu
- Department of Ophthalmology, Gavin Herbert Eye Institute, University of California, Irvine , Irvine , CA , USA
| | - Jonathan Liang
- Department of Head and Neck Surgery, Kaiser Permanente Medical Center Oakland , Oakland , CA , USA
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11
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Baltin C, Kron F, Urbanski A, Zander T, Kron A, Berlth F, Kleinert R, Hallek M, Hoelscher AH, Chon SH. The economic burden of endoscopic treatment for anastomotic leaks following oncological Ivor Lewis esophagectomy. PLoS One 2019; 14:e0221406. [PMID: 31461487 PMCID: PMC6713440 DOI: 10.1371/journal.pone.0221406] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 08/06/2019] [Indexed: 02/07/2023] Open
Abstract
Background Complications after surgery for esophageal cancer are associated with significant resource utilization. The aim of this study was to analyze the economic burden of two frequently used endoscopic treatments for anastomotic leak management after esophageal surgery: Treatment with a Self-expanding Metal Stent (SEMS) and Endoscopic Vacuum Therapy (EVT). Materials and methods Between January 2012 and December 2016, we identified 60 German-Diagnosis Related Group (G-DRG) cases of patients who received a SEMS and / or EVT for esophageal anastomotic leaks. Direct costs per case were analyzed according to the Institute for Remuneration System in Hospitals (InEK) cost-accounting approach by comparing DRG payments on the case level, including all extra fees per DRG catalogue. Results In total, 60 DRG cases were identified. Of these, 15 patients were excluded because they received a combination of SEMS and EVT. Another 6 cases could not be included due to incomplete DRG data. Finally, N = 39 DRG cases were analyzed from a profit-center perspective. A further analysis of the most frequent DRG code -G03- including InEK cost accounting, revealed almost twice the deficit for the EVT group (N = 13 cases, € - 9.282 per average case) compared to that for the SEMS group (N = 9 cases, € - 5.156 per average case). Conclusion Endoscopic treatments with SEMS and EVT for anastomotic leaks following oncological Ivor Lewis esophagectomies are not cost-efficient for German hospitals. Due to longer hospitalization and insufficient reimbursements, EVT is twice as costly as SEMS treatment. An adequate DRG cost compensation is needed for SEMS and EVT.
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Affiliation(s)
- Christoph Baltin
- Department of Orthopedics and Trauma Surgery, University Hospital of Cologne, Cologne, Germany
| | - Florian Kron
- FOM University of Applied Sciences, Essen, Germany
- Department of Internal Medicine Med I, University Hospital of Cologne, Cologne, Germany
| | - Alexander Urbanski
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Cologne, Germany
| | | | - Anna Kron
- FOM University of Applied Sciences, Essen, Germany
| | - Felix Berlth
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Robert Kleinert
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Cologne, Germany
| | - Michael Hallek
- Department of Internal Medicine Med I, University Hospital of Cologne, Cologne, Germany
| | | | - Seung-Hun Chon
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Cologne, Germany
- * E-mail:
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Devana SK, Jensen AR, Yamaguchi KT, D’Oro A, Buser Z, Wang JC, Petrigliano FA, Dowd C. Trends and Complications in Open Versus Endoscopic Carpal Tunnel Release in Private Payer and Medicare Patient Populations. Hand (N Y) 2019; 14:455-461. [PMID: 29322873 PMCID: PMC6760088 DOI: 10.1177/1558944717751196] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Purpose: The purpose of this study was to report trends, complications, and costs associated with endoscopic carpal tunnel release (ECTR) and open carpal tunnel release (OCTR). Methods: Using Current Procedural Terminology (CPT) and International Classification of Diseases, Ninth Revision (ICD-9) codes, patients who had open versus endoscopic carpal tunnel release (CTR) were identified retrospectively in the PearlDiver database from both the Medicare and Humana (a private payer health insurance) populations from 2005 to 2014. These groups were then evaluated for postoperative complications, including wound infection within 90 days, wound dehiscence within 90 days, and intraoperative median nerve injury. We also used the data output for each group to compare the cost of the 2 procedure types. Data were analyzed via the Student t test. Statistical significance was set at P < .05. Results: A significantly lower percentage of patients in the endoscopic CTR group had a postoperative infection (5.21 vs 7.97 per 1000 patients per year, P < .001; 7.36 vs 11.23 per 1000 patients per year, P < .001) and wound dehiscence (1.58 vs 2.87 per 1000 patients per year, P < .001; 2.14 vs 3.73 per 1000 patients per year, P < .05) than open CTR group in the Medicare and Humana populations, respectively. Median nerve injury occurred 0.59/1000 ECTRs versus 1.69/1000 OCTRs (Medicare) and 1.96/1000 ECTRs versus 3.72/1000 OCTRs (Humana). Endoscopic CTR cost was more than open CTR for both the Medicare population ($1643 vs $1015 per procedure, P < .001) and Humana population ($1928 vs $1191 per procedure, P < .001). Conclusions: In both the Medicare and private insurance patient populations, endoscopic CTR is associated with fewer postoperative complications than open CTR, but is associated with greater expenses.
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Affiliation(s)
| | | | | | | | - Zorica Buser
- University of Southern California, Los
Angeles, USA
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13
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Farias GF, Bernardo WM, De Moura DT, Guedes HG, Brunaldi VO, Visconti TADC, Gonçalves CV, Sakai CM, Matuguma SE, dos Santos ME, Sakai P, De Moura EG. Endoscopic versus surgical treatment for pancreatic pseudocysts: Systematic review and meta-analysis. Medicine (Baltimore) 2019; 98:e14255. [PMID: 30813129 PMCID: PMC6407966 DOI: 10.1097/md.0000000000014255] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE This systematic review and meta-analysis aims to compare surgical and endoscopic treatment for pancreatic pseudocyst (PP). METHODS The researchers did a search in Medline, EMBASE, Scielo/Lilacs, and Cochrane electronic databases for studies comparing surgical and endoscopic drainage of PP s in adult patients. Then, the extracted data were used to perform a meta-analysis. The outcomes were therapeutic success, drainage-related adverse events, general adverse events, recurrence rate, cost, and time of hospitalization. RESULTS There was no significant difference between treatment success rate (risk difference [RD] -0.09; 95% confidence interval [CI] [0.20,0.01]; P = .07), drainage-related adverse events (RD -0.02; 95% CI [-0.04,0.08]; P = .48), general adverse events (RD -0.05; 95% CI [-0.12, 0.02]; P = .13) and recurrence (RD: 0.02; 95% CI [-0.04,0.07]; P = .58) between surgical and endoscopic treatment.Regarding time of hospitalization, the endoscopic group had better results (RD: -4.23; 95% CI [-5.18, -3.29]; P < .00001). When it comes to treatment cost, the endoscopic arm also had better outcomes (RD: -4.68; 95% CI [-5.43,-3.94]; P < .00001). CONCLUSION There is no significant difference between surgical and endoscopic treatment success rates, adverse events and recurrence for PP. However, time of hospitalization and treatment costs were lower in the endoscopic group.
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Affiliation(s)
- Galileu F.A. Farias
- Gastroenterology Department, Gastrointestinal Endoscopy Unit, University of Sao Paulo School of Medicine, Avenida Dr. Enéas de Carvalho Aguiar
| | - Wanderley M. Bernardo
- Thoracic Surgery Department, Instituto do Coração (InCor, Heart Institute), University of Sao Paulo School of Medicine, São Paulo, Brazil
| | - Diogo T.H. De Moura
- Gastroenterology Department, Gastrointestinal Endoscopy Unit, University of Sao Paulo School of Medicine, Avenida Dr. Enéas de Carvalho Aguiar
| | | | - Vitor O. Brunaldi
- Gastroenterology Department, Gastrointestinal Endoscopy Unit, University of Sao Paulo School of Medicine, Avenida Dr. Enéas de Carvalho Aguiar
| | - Thiago A. de C. Visconti
- Gastroenterology Department, Gastrointestinal Endoscopy Unit, University of Sao Paulo School of Medicine, Avenida Dr. Enéas de Carvalho Aguiar
| | - Caio V.T. Gonçalves
- Gastroenterology Department, Gastrointestinal Endoscopy Unit, University of Sao Paulo School of Medicine, Avenida Dr. Enéas de Carvalho Aguiar
| | - Christiano M. Sakai
- Gastroenterology Department, Gastrointestinal Endoscopy Unit, University of Sao Paulo School of Medicine, Avenida Dr. Enéas de Carvalho Aguiar
| | - Sergio E. Matuguma
- Gastroenterology Department, Gastrointestinal Endoscopy Unit, University of Sao Paulo School of Medicine, Avenida Dr. Enéas de Carvalho Aguiar
| | - Marcos E.L. dos Santos
- Gastroenterology Department, Gastrointestinal Endoscopy Unit, University of Sao Paulo School of Medicine, Avenida Dr. Enéas de Carvalho Aguiar
| | - Paulo Sakai
- Gastroenterology Department, Gastrointestinal Endoscopy Unit, University of Sao Paulo School of Medicine, Avenida Dr. Enéas de Carvalho Aguiar
| | - Eduardo G.H. De Moura
- Gastroenterology Department, Gastrointestinal Endoscopy Unit, University of Sao Paulo School of Medicine, Avenida Dr. Enéas de Carvalho Aguiar
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14
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Boughizane S, Briki R, Bannour I, Noomane F, Hireche L. Minimally invasive surgery in the Maghreb: Realities, challenges and perspectives for the future. Tunis Med 2018; 96:844-846. [PMID: 30746677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
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15
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Gould D, Kulber D, Kuschner S, Dellamaggiorra R, Cohen M. Our Surgical Experience: Open Versus Endoscopic Carpal Tunnel Surgery. J Hand Surg Am 2018; 43:853-861. [PMID: 29759797 DOI: 10.1016/j.jhsa.2018.03.029] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 03/18/2018] [Indexed: 02/02/2023]
Abstract
Carpal tunnel release is one of the most common hand operations in the United States and every year approximately 500,000 patients undergo surgical release. In this article, we examine the argument for endoscopic carpal tunnel release versus open carpal tunnel release, as well as some of the literature on anatomical variants in the median nerve at the wrist. We further describe the experience of several surgeons in a large academic practice. The goals of this article are to describe key anatomic findings and to present several cases that have persuaded us to favor offering patients open carpal tunnel release.
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Affiliation(s)
- Daniel Gould
- Division of Plastic and Reconstructive Surgery, University of Southern California, Los Angeles, CA.
| | - David Kulber
- Division of Plastic and Reconstructive Surgery, University of Southern California, Los Angeles, CA; Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, CA; Division of Plastic Surgery, Cedars Sinai Medical Center, Los Angeles, CA
| | - Stuart Kuschner
- Division of Plastic and Reconstructive Surgery, University of Southern California, Los Angeles, CA; Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, CA
| | - Ryan Dellamaggiorra
- Division of Plastic and Reconstructive Surgery, University of Southern California, Los Angeles, CA; Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, CA
| | - Myles Cohen
- Division of Plastic and Reconstructive Surgery, University of Southern California, Los Angeles, CA; Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, CA; Division of Plastic Surgery, Cedars Sinai Medical Center, Los Angeles, CA
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16
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Krstajić N, Mills B, Murray I, Marshall A, Norberg D, Craven TH, Emanuel P, Choudhary TR, Williams GOS, Scholefield E, Akram AR, Davie A, Hirani N, Bruce A, Moore A, Bradley M, Dhaliwal K. Low-cost high sensitivity pulsed endomicroscopy to visualize tricolor optical signatures. J Biomed Opt 2018; 23:1-12. [PMID: 29992799 DOI: 10.1117/1.jbo.23.7.076005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 05/16/2018] [Indexed: 05/20/2023]
Abstract
A highly sensitive, modular three-color fluorescence endomicroscopy imaging platform spanning the visible to near-infrared (NIR) range is demonstrated. Light-emitting diodes (LEDs) were sequentially pulsed along with the camera acquisition to provide up to 20 frames per second (fps) three-color imaging performance or 60 fps single color imaging. The system was characterized for bacterial and cellular molecular imaging in ex vivo human lung tissue and for bacterial and indocyanine green imaging in ex vivo perfused sheep lungs. A practical method to reduce background tissue autofluorescence is also proposed. The platform was clinically translated into six patients with pulmonary disease to delineate healthy, cancerous, and fibrotic tissue autofluorescent structures. The instrument is the most broadband clinical endomicroscopy system developed to date (covering visible to the NIR, 500 to 900 nm) and demonstrates significant potential for future clinical utility due to its low cost and modular capability to suit a wide variety of molecular imaging applications.
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Affiliation(s)
- Nikola Krstajić
- University of Edinburgh, Queen's Medical Research Institute, EPSRC IRC Hub in Optical Molecular Sens, United Kingdom
- University of Edinburgh, Institute for Integrated Micro and Nano Systems, School of Engineering, Edi, United Kingdom
- University of Dundee, School of Science and Engineering, Dundee, United Kingdom
| | - Bethany Mills
- University of Edinburgh, Queen's Medical Research Institute, EPSRC IRC Hub in Optical Molecular Sens, United Kingdom
| | - Ian Murray
- University of Edinburgh, Queen's Medical Research Institute, EPSRC IRC Hub in Optical Molecular Sens, United Kingdom
| | - Adam Marshall
- University of Edinburgh, Queen's Medical Research Institute, EPSRC IRC Hub in Optical Molecular Sens, United Kingdom
| | - Dominic Norberg
- University of Edinburgh, Queen's Medical Research Institute, EPSRC IRC Hub in Optical Molecular Sens, United Kingdom
| | - Thomas H Craven
- University of Edinburgh, Queen's Medical Research Institute, EPSRC IRC Hub in Optical Molecular Sens, United Kingdom
| | - Philip Emanuel
- University of Edinburgh, Queen's Medical Research Institute, EPSRC IRC Hub in Optical Molecular Sens, United Kingdom
| | - Tushar R Choudhary
- University of Edinburgh, Queen's Medical Research Institute, EPSRC IRC Hub in Optical Molecular Sens, United Kingdom
- Heriot-Watt University, Institute of Biological Chemistry, Biophysics and Bioengineering, Edinburgh, United Kingdom
| | - Gareth O S Williams
- University of Edinburgh, Queen's Medical Research Institute, EPSRC IRC Hub in Optical Molecular Sens, United Kingdom
| | - Emma Scholefield
- University of Edinburgh, Queen's Medical Research Institute, EPSRC IRC Hub in Optical Molecular Sens, United Kingdom
| | - Ahsan R Akram
- University of Edinburgh, Queen's Medical Research Institute, EPSRC IRC Hub in Optical Molecular Sens, United Kingdom
| | - Andrew Davie
- Royal Infirmary of Edinburgh, NHS Lothian, Department of Medical Physics, Edinburgh, United Kingdom
| | - Nik Hirani
- University of Edinburgh, Department of Respiratory Medicine, Edinburgh, United Kingdom
| | - Annya Bruce
- University of Edinburgh, Queen's Medical Research Institute, EPSRC IRC Hub in Optical Molecular Sens, United Kingdom
| | - Anne Moore
- University of Edinburgh, Queen's Medical Research Institute, EPSRC IRC Hub in Optical Molecular Sens, United Kingdom
| | - Mark Bradley
- University of Edinburgh, Queen's Medical Research Institute, EPSRC IRC Hub in Optical Molecular Sens, United Kingdom
- University of Edinburgh, School of Chemistry, EaStChem, Edinburgh, United Kingdom
| | - Kevin Dhaliwal
- University of Edinburgh, Queen's Medical Research Institute, EPSRC IRC Hub in Optical Molecular Sens, United Kingdom
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Abstract
AIMS The objective of this study was to quantify the treatment costs and revision surgery rates in chronic rhinosinusitis (CRS) patients, with and without nasal polyposis (CRSwNP and CRSsNP), who require treatment with endoscopic sinus surgery (ESS). The additive contributions of nasal polyposis (NP) and revision surgery to 1-year costs were a primary focus. MATERIALS AND METHODS Adults (aged 18-64 years) undergoing ESS for CRS in 2012-2015 were identified within the Blue Health Intelligence database and used to estimate revision rates. Patients with ±1 year of enrollment around the index ESS were used to estimate 1-year healthcare expenditures. Revision ESS rates were evaluated via Kaplan-Meier and Cox regression models. Disease-related healthcare and pharmacy expenditures were modeled with generalized linear regression to assess the impact of baseline patient characteristics. RESULTS A total of 86,052 patients underwent ESS for CRS (43.5 ± 12.4 years; 49.3% male), and a sub-set of 23,542 patients were available for 1-year healthcare expenditure analysis (44.0 ± 12.1 years; 50.0% male). Revision ESS rates within 1 year were 3.5% in the CRSwNP cohort and 1.6% in the CRSsNP cohort. NP, deviated septum, gender, and region were statistically significant predictors of revision surgery. Mean 1-year treatment expenditures, including the index ESS, were $8,824 for CRSsNP and $11,166 for CRSwNP patients without revision ESS. CRSwNP doubled the risk of revision surgery in the first year after ESS compared with CRSsNP and cost 24% more in the absence of a second procedure. Revision ESS within the first year increased mean 1-year expenditures by $11,150 and $13,139 for CRSsNP and CRSwNP, respectively. LIMITATIONS The primary limitation was the limited length of follow-up available for estimating revision ESS rates. CONCLUSIONS In a large commercially insured US population, disease-related expenditures for patients having ESS for CRS are substantial, as are the additive impacts of NP and revision surgery.
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Affiliation(s)
- Tina D Hunter
- a CTI Clinical Trial and Consulting Services, Inc., Biostatistics & Health Outcomes Research , Covington , KY , USA
| | - Adam S DeConde
- b University of California-San Diego , San Diego , CA , USA
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18
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Tseng CC, Lai MT, Wu CC, Yuan SP, Ding YF. Cost-effectiveness analysis of endoscopic tympanoplasty versus microscopic tympanoplasty for chronic otitis media in Taiwan. J Chin Med Assoc 2018; 81:284-290. [PMID: 29287705 DOI: 10.1016/j.jcma.2017.06.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Revised: 06/13/2017] [Accepted: 06/20/2017] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Health care systems and physicians need to conform to budgets and streamline resources to provide cost-effective quality care. Although endoscopic tympanoplasty (ET) has been performed for decades, no studies on the cost-effectiveness of ET and microscopic tympanoplasty (MT) for treating chronic otitis media have been published. The present study aimed to compare the cost-effectiveness of ET and MT for treating chronic otitis media. METHODS This study was performed using a Cohort-style Markov decision-tree economic model with a 30-year time horizon. The economic perspective was that of a third-party payer (Taiwan National Health Insurance System). Two treatment strategies were compared, namely ET and MT. The primary outcome was the incremental cost per quality-adjusted life year (QALY). Probabilities were obtained from meta-analyses. Costs were obtained from the published literature and Taiwan National Health Insurance System database. Multiple sensitivity analyses were performed to account for data uncertainty. RESULTS The reference case revealed that the total cost of ET was $NT 20,901 for 17.08 QALY per patient. By contrast, the total cost of MT was $NT 21,171 for 17.15 QALY per patient. The incremental cost effectiveness ratio for ET versus that of MT was $NT 3703 per QALY. The cost-effectiveness acceptability curve indicated that ET was comparable to MT at a willingness-to-pay threshold of larger than $NT 35,000 per QALY. CONCLUSION This cost-effectiveness analysis indicates that ET is comparable to MT for treating chronic otitis media in Taiwan. This result provides the latest information for physicians, the government, and third-party payers to select proper clinical practice.
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Affiliation(s)
- Chih-Chieh Tseng
- Department of Otolaryngology, Wan Fang Medical Center, Taipei Medical University, Taipei, Taiwan, ROC; Department of Otolaryngology, Pojen General Hospital, Taipei, Taiwan, ROC; Department of Otolaryngology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan, ROC.
| | - Ming-Tang Lai
- Department of Otolaryngology, Wan Fang Medical Center, Taipei Medical University, Taipei, Taiwan, ROC
| | - Chia-Che Wu
- Department of Otolaryngology, Wan Fang Medical Center, Taipei Medical University, Taipei, Taiwan, ROC; Department of Otolaryngology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan, ROC
| | - Sheng-Po Yuan
- Department of Otolaryngology, Wan Fang Medical Center, Taipei Medical University, Taipei, Taiwan, ROC
| | - Yi-Fang Ding
- Department of Otolaryngology, Wan Fang Medical Center, Taipei Medical University, Taipei, Taiwan, ROC
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19
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Hampson LA, Lin TK, Wilson L, Allen IE, Gaither TW, Breyer BN. Understanding patients' preferences for surgical management of urethral stricture disease. World J Urol 2017; 35:1799-1805. [PMID: 28664240 PMCID: PMC6452859 DOI: 10.1007/s00345-017-2066-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 06/15/2017] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES To understand how prioritization of treatment attributes and treatment choice varies by patient characteristics, we sought to specifically determine how demographic variables affect patient treatment preference. PATIENTS AND METHODS Male patients with urethral stricture disease participated in a choice-based conjoint (CBC) analysis exercise evaluating six treatment attributes associated with internal urethrotomy and urethroplasty. Demographic and past symptom data were collected. Stratified analysis of demographic variables, including age, education, income, was conducted using a mixed effect logistic regression model to evaluate the coefficient size and confidence intervals between the treatments attribute preferences of each strata. RESULTS 169 patients completed the CBC exercise and were included in our analysis. Overall success of the procedure is the most important treatment attribute to patients and this persists across strata. Older patients (≥65) express preferences for better success rates and fewer future procedures, whereas younger patients prefer a less invasive approach and are more willing to accept additional procedures if needed. Patients with lower levels of education preferred open reconstruction and had a stronger preference against multiple future procedures, whereas those with higher levels of education preferred endoscopic treatment and had a less strong preference against multiple future procedures. Low-income individuals express statistically significant stronger negative preferences against high copay costs compared to high-income individuals. CONCLUSION These results can help to inform physicians' counseling about surgical management of urethral stricture disease to better align patient preferences with treatment selection and encourage shared decision making.
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Affiliation(s)
- Lindsay A Hampson
- Department of Urology, UCSF School of Medicine, 400 Parnassus Ave, A638, Box 0738, San Francisco, CA, 94143, USA.
| | - Tracy K Lin
- Department of Clinical Pharmacy, UCSF School of Pharmacy, San Francisco, USA
| | - Leslie Wilson
- Department of Clinical Pharmacy, UCSF School of Pharmacy, San Francisco, USA
| | - Isabel E Allen
- Department of Epidemiology and Biostatistics, UCSF School of Medicine, San Francisco, USA
| | | | - Benjamin N Breyer
- Department of Urology, UCSF School of Medicine, 400 Parnassus Ave, A638, Box 0738, San Francisco, CA, 94143, USA
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Tang Y, Carns J, Richards-Kortum RR. Line-scanning confocal microendoscope for nuclear morphometry imaging. J Biomed Opt 2017; 22:1-6. [PMID: 29129041 PMCID: PMC5681860 DOI: 10.1117/1.jbo.22.11.116005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 10/31/2017] [Indexed: 05/04/2023]
Abstract
Fiber-optic endomicroscopy is a minimally invasive method to image cellular morphology in vivo. Using a coherent fiber bundle as an image relay, it allows additional imaging optics to be placed at the distal end of the fiber outside the body. In this research, we use this approach to demonstrate a compact, low-cost line-scanning confocal fluorescence microendoscope that can be constructed for <$5000. Confocal imaging is enabled without the need for mechanical scanning by synchronizing a digital light projector with the rolling shutter of a CMOS camera. Its axial performance is characterized in comparison with a nonscanned high-resolution microendoscope. We validate the optical sectioning capability of the microendoscope by imaging a two-dimensional phantom and ex vivo mouse esophageal and colon tissues. Results show that optical sectioning using this approach improves visualization of nuclear morphometry and suggest that this low-cost line-scanning microendoscope can be used to evaluate various pathological conditions.
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Affiliation(s)
- Yubo Tang
- Rice University, Department of Bioengineering, Houston, Texas, United States
| | - Jennifer Carns
- Rice University, Department of Bioengineering, Houston, Texas, United States
| | - Rebecca R. Richards-Kortum
- Rice University, Department of Bioengineering, Houston, Texas, United States
- Address all correspondence to: Rebecca R. Richards-Kortum, E-mail:
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McKinnon BJ. If only it were that simple [Editorial]. Ear Nose Throat J 2017; 96:354-360. [PMID: 28931185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023] Open
Affiliation(s)
- Brian J McKinnon
- Department of Otolaryngology-Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, PA, USA
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Jones K, Case JB, Evans B, Monnet E. Evaluation of the economic and clinical feasibility of introducing rigid endoscopy and laparoscopy to a small animal general practice. J Am Vet Med Assoc 2017; 250:795-800. [PMID: 28306484 DOI: 10.2460/javma.250.7.795] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To evaluate the economic and clinical feasibility of introducing rigid endoscopy and laparoscopy to a small animal general practice. DESIGN Prospective study. SAMPLE A single 2-veterinarian small animal practice in southern California. PROCEDURES In early 2012, endoscopic equipment was purchased, and both veterinarians in the practice undertook training in rigid endoscopic and laparoscopic procedures. Subsequently, information for client-owned animals that underwent endoscopic and laparoscopic procedures during a 12-month period (2012 to 2013) was collected. Cost of equipment and training, revenue generated, specific procedures performed, surgery time, complications, and client satisfaction were evaluated. RESULTS 78 endoscopic procedures were performed in 73 patients, including 71 dogs, 1 cat, and 1 rabbit. Cost of endoscopic and laparoscopic equipment and training in the first year was $14,809.71; most equipment was financed through a 5-year lease at a total cost of $57,507.70 ($ 10,675.20/y). Total revenue generated in the first year was $50,423.63. The most common procedures performed were ovariectomy (OVE; n = 49), prophylactic gastropexy (6), and video otoscopy (12). Mean ± SD surgery times for OVE (n = 44) and for OVE with gastropexy (5) were 63.7 ± 19.7 minutes and 73.0 ± 33.5 minutes; respectively. Twelve of 54 patients undergoing laparoscopic procedures experienced minor intraoperative complications. Conversion to laparotomy was not required in any patient. There were no major complications. All 49 clients available for follow-up were satisfied. CONCLUSIONS AND CLINICAL RELEVANCE With appropriate training and equipment, incorporation of basic rigid endoscopy and laparoscopy may be feasible in small animal general practice. However, results of the present study are not applicable to all veterinarians and practice settings, and patient safety considerations should always be paramount.
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Lourijsen ES, de Borgie CAJM, Vleming M, Fokkens WJ. Endoscopic sinus surgery in adult patients with chronic rhinosinusitis with nasal polyps (PolypESS): study protocol for a randomised controlled trial. Trials 2017; 18:39. [PMID: 28114954 PMCID: PMC5259992 DOI: 10.1186/s13063-016-1728-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 11/23/2016] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Chronic rhinosinusitis with nasal polyps is a chronic disease frequently seen in otorhinolaryngological practice. Along with its chronic disease burden it creates high societal costs. Therapy consists of long-term use of medication and, if insufficient, endoscopic sinus surgery. No consensus exists on the right timing and extent of disease that warrants surgery. Furthermore, there is lack of clinical knowledge about the benefit of surgery over medication only. The current trial evaluates the clinical effectiveness and cost-effectiveness of endoscopic sinus surgery in addition to drug treatment versus medication exclusively in the adult patient group with nasal polyps. METHODS A prospective, multicentre, superiority, randomised controlled (PolypESS) trial in 238 patients aged 18 years or older selected for primary or revision endoscopic sinus surgery by the otorhinolaryngologist was designed. Patients will be randomised to either endoscopic sinus surgery in addition to medication or medical therapy only. Relevant data will be collected prior to randomisation, at baseline and 3, 6, 12, 18 and 24 months after start of treatment. Complete follow-up will be 24 months. Primary outcome is disease-specific Health-related Quality of Life quantified by the SNOT-22 after 12-month follow-up. Secondary outcomes are generic Health-related Quality of Life, cost-effectiveness, objective signs of disease and adverse effects of treatment. Subgroup analyses will be performed to verify whether treatment effects differ among patient phenotypes. DISCUSSION The PolypESS trial will investigate tailored care in adult patients with chronic rhinosinusitis with nasal polyps and will result in improved clinical pathways to help to determine in which circumstances to perform surgery. TRIAL REGISTRATION Dutch Trial Register, NTR4978 . Registered on 27 November 2014.
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Affiliation(s)
- Evelijn S. Lourijsen
- Department of Otorhinolaryngology, Academic Medical Centre, Meibergdreef 9, 1105 SZ Amsterdam, The Netherlands
| | | | - Marleen Vleming
- Department of Otorhinolaryngology, Flevo Hospital, Hospitaalweg 1, 1315 RA Almere, The Netherlands
| | - Wytske J. Fokkens
- Department of Otorhinolaryngology, Academic Medical Centre, Meibergdreef 9, 1105 SZ Amsterdam, The Netherlands
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Abstract
OBJECTIVE: To undertake cost-utility analysis for endoscopic sinus surgery (ESS) in order to analyze the cost-effectiveness of different chronic sinusitis severity groups. METHODS: One hundred ninety-two patients with chronic sinusitis were evaluated with a Chronic Sinusitis Survey (CSS) before and 1-year after ESS. Direct health care cost data during the first year after operation were retrieved. The utility gain is defined as change in the CSS total score. The cost-utility ratio was defined as cost per utility gain. Patients are stratified by disease severity using the Harvard Staging System. RESULTS: The average total direct cost attributable to ESS is NT $40,829 in the first postoperative year and the average cost-utility ratio is NT $2194.42. The high cost-utility ratio of NT $3246.45 for pansinusitis cases is due to the higher cost and limited utility gain. CONCLUSIONS: Treating mild and moderate chronic sinusitis are most cost-effective because of their favorable utility gain and relatively reasonable cost. However, there is no proportional linear relationship between disease severity and cost-utility ratio.
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Affiliation(s)
- Pa-Chun Wang
- Department of Otolaryngology, Cathay General Hospital, Taichung, Taiwan, Republic of China
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Solon C, Klausnitzer R, Blissett D, Ihara Z. Economic value of narrow band imaging versus white light endoscopy for the characterization of diminutive polyps in the colon: systematic literature review and cost-consequence model. J Med Econ 2016; 19:1040-1048. [PMID: 27207009 DOI: 10.1080/13696998.2016.1192550] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIMS To demonstrate the economic implication of adopting narrow-band imaging (NBI) for the characterization of diminutive polyps in the colon from an English payer perspective. MATERIALS AND METHODS A decision-tree model was undertaken to perform a cost-consequence and budget impact analysis from the NHS England perspective in the UK, over a 7-year time horizon. Clinical inputs came from the published literature (both randomized controlled trials and meta-analyses) identified through a systematic literature review, and cost inputs came from national list prices and unpublished internal market data. Deterministic sensitivity analysis (DSA) was conducted on the budget impact results to assess their robustness. RESULTS Optical diagnosis with NBI offered cost savings vs white light endoscopy (WLE) over 7 years due to reductions in histological exams, resections, and associated adverse events, while having minimal impact on health outcomes. Budget impact analysis demonstrated annual cost savings of £141 192 057 over 7 years, with histological exams being the biggest cost driver. DSA showed these results to be robust, but most sensitive to the cost of tariff with and without biopsy, and the cost of histological exam. Break-even analysis to explore how changing the unit cost and number of biopsies per patient would change the budget impact found NBI consistently offered net savings, even if the cost of biopsy was £0. LIMITATIONS Although every effort was made to ensure robustness of results, as with any model, there were some limitations including a lack of published data for certain clinical inputs and potential variation between model inputs and real-life cost and market share values. CONCLUSIONS Optical diagnosis with NBI was found to be equally effective compared with the standard of care (WLE), while potentially enabling cost savings from the NHS England perspective.
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Abstract
BACKGROUND Remote-access techniques have been described over the recent years as a method of removing the thyroid gland without an incision in the neck. However, there is confusion related to the number of techniques available and the ideal patient selection criteria for a given technique. The aims of this review were to develop a simple classification of these approaches, describe the optimal patient selection criteria, evaluate the outcomes objectively, and define the barriers to adoption. METHODS A review of the literature was performed to identify the described techniques. A simple classification was developed. Technical details, outcomes, and the learning curve were described. Expert opinion consensus was formulated regarding recommendations for patient selection and performance of remote-access thyroid surgery. RESULTS Remote-access thyroid procedures can be categorized into endoscopic or robotic breast, bilateral axillo-breast, axillary, and facelift approaches. The experience in the United States involves the latter two techniques. The limited data in the literature suggest long operative times, a steep learning curve, and higher costs with remote-access thyroid surgery compared with conventional thyroidectomy. Nevertheless, a consensus was reached that, in appropriate hands, it can be a viable option for patients with unilateral small nodules who wish to avoid a neck incision. CONCLUSIONS Remote-access thyroidectomy has a role in a small group of patients who fit strict selection criteria. These approaches require an additional level of expertise, and therefore should be done by surgeons performing a high volume of thyroid and robotic surgery.
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Affiliation(s)
- Eren Berber
- Department of Endocrine Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Victor Bernet
- Division of Endocrinology, Mayo Clinic, Jacksonville, Florida
| | - Thomas J. Fahey
- Department of Endocrine Surgery, Weill Cornell Medical College/New York Presbyterian Hospital, New York, New York
| | - Electron Kebebew
- Endocrine Oncology Branch, National Cancer Institutes of Health, Bethesda, Maryland
| | - Ashok Shaha
- Department of Head and Neck Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Brendan C. Stack
- Department of Otolaryngology—Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Michael Stang
- Division of Endocrine Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - David L. Steward
- Department of Otolaryngology—Head and Neck Surgery, University Hospital, Cincinnati, Ohio
| | - David J. Terris
- Department of Otolaryngology, Augusta University, Augusta, Georgia
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Dittler I, Dornfeld W, Schöb R, Cocke J, Rojahn J, Kraume M, Eibl D. A Cost-effective and Reliable Method to Predict Mechanical Stress in Single-use and Standard Pumps. J Vis Exp 2015:e53052. [PMID: 26274765 PMCID: PMC4545201 DOI: 10.3791/53052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Pumps are mainly used when transferring sterile culture broths in biopharmaceutical and biotechnological production processes. However, during the pumping process shear forces occur which can lead to qualitative and/or quantitative product loss. To calculate the mechanical stress with limited experimental expense, an oil-water emulsion system was used, whose suitability was demonstrated for drop size detections in bioreactors(1). As drop breakup of the oil-water emulsion system is a function of mechanical stress, drop sizes need to be counted over the experimental time of shear stress investigations. In previous studies, the inline endoscopy has been shown to be an accurate and reliable measurement technique for drop size detections in liquid/liquid dispersions. The aim of this protocol is to show the suitability of the inline endoscopy technique for drop size measurements in pumping processes. In order to express the drop size, the Sauter mean diameter d32 was used as the representative diameter of drops in the oil-water emulsion. The results showed low variation in the Sauter mean diameters, which were quantified by standard deviations of below 15%, indicating the reliability of the measurement technique.
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Affiliation(s)
- Ina Dittler
- Institute of Biotechnology, School of Life Sciences and Facility Management, Zurich University of Applied Sciences;
| | | | | | | | | | - Matthias Kraume
- Institute of Chemical and Process Engineering, Technische Universität Berlin
| | - Dieter Eibl
- Institute of Biotechnology, School of Life Sciences and Facility Management, Zurich University of Applied Sciences
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Campbell HE, Stokes EA, Bargo D, Logan RF, Mora A, Hodge R, Gray A, James MW, Stanley AJ, Everett SM, Bailey AA, Dallal H, Greenaway J, Dyer C, Llewelyn C, Walsh TS, Travis SPL, Murphy MF, Jairath V. Costs and quality of life associated with acute upper gastrointestinal bleeding in the UK: cohort analysis of patients in a cluster randomised trial. BMJ Open 2015; 5:e007230. [PMID: 25926146 PMCID: PMC4420945 DOI: 10.1136/bmjopen-2014-007230] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVES Data on costs associated with acute upper gastrointestinal bleeding (AUGIB) are scarce. We provide estimates of UK healthcare costs, indirect costs and health-related quality of life (HRQoL) for patients presenting to hospital with AUGIB. SETTING Six UK university hospitals with >20 AUGIB admissions per month, >400 adult beds, 24 h endoscopy, and on-site access to intensive care and surgery. PARTICIPANTS 936 patients aged ≥18 years, admitted with AUGIB, and enrolled between August 2012 and March 2013 in the TRIGGER trial of AUGIB comparing restrictive versus liberal red blood cell (RBC) transfusion thresholds. PRIMARY AND SECONDARY OUTCOME MEASURES Healthcare resource use during hospitalisation and postdischarge up to 28 days, unpaid informal care, time away from paid employment and HRQoL using the EuroQol EQ-5D at 28 days were measured prospectively. National unit costs were used to value resource use. Initial in-hospital treatment costs were upscaled to a UK level. RESULTS Mean initial in-hospital costs were £2458 (SE=£216) per patient. Inpatient bed days, endoscopy and RBC transfusions were key cost drivers. Postdischarge healthcare costs were £391 (£44) per patient. One-third of patients received unpaid informal care and the quarter in paid employment required time away from work. Mean HRQoL for survivors was 0.74. Annual initial inhospital treatment cost for all AUGIB cases in the UK was estimated to be £155.5 million, with exploratory analyses of the incremental costs of treating hospitalised patients developing AUGIB generating figures of between £143 million and £168 million. CONCLUSIONS AUGIB is a large burden for UK hospitals with inpatient stay, endoscopy and RBC transfusions as the main cost drivers. It is anticipated that this work will enable quantification of the impact of cost reduction strategies in AUGIB and will inform economic analyses of novel or existing interventions for AUGIB. TRIAL REGISTRATION NUMBER ISRCTN85757829 and NCT02105532.
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Affiliation(s)
- H E Campbell
- Nuffield Department of Population Health, Health Economics Research Centre, University of Oxford, Oxford, UK
| | - E A Stokes
- Nuffield Department of Population Health, Health Economics Research Centre, University of Oxford, Oxford, UK
| | - D Bargo
- Nuffield Department of Population Health, Health Economics Research Centre, University of Oxford, Oxford, UK
| | - R F Logan
- Nottingham Digestive Diseases NIHR Biomedical Research Unit, University of Nottingham, Nottingham, UK
| | - A Mora
- Clinical Trials Unit, NHS Blood and Transplant, Cambridge, UK
| | - R Hodge
- Clinical Trials Unit, NHS Blood and Transplant, Cambridge, UK
| | - A Gray
- Department of Emergency Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - M W James
- Nottingham Digestive Diseases NIHR Biomedical Research Unit, University of Nottingham, Nottingham, UK
| | - A J Stanley
- Gastrointestinal Unit, Glasgow Royal Infirmary, Glasgow, UK
| | - S M Everett
- Department of Gastroenterology, St James's University Hospital, Leeds, UK
| | - A A Bailey
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - H Dallal
- Department of Gastroenterology, James Cook University Hospital, Middlesbrough, UK
| | - J Greenaway
- Department of Gastroenterology, James Cook University Hospital, Middlesbrough, UK
| | - C Dyer
- Clinical Trials Unit, NHS Blood and Transplant, Oxford, UK
| | - C Llewelyn
- Clinical Trials Unit, NHS Blood and Transplant, Cambridge, UK
| | - T S Walsh
- Centre for Inflammation Research, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - S P L Travis
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - M F Murphy
- Clinical Trials Unit, NHS Blood and Transplant, Oxford, UK National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, Oxford University Hospitals and University of Oxford, Oxford, UK
| | - V Jairath
- Translational Gastroenterology Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK Clinical Trials Unit, NHS Blood and Transplant, Oxford, UK
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Rudmik L, Soler ZM, Mace JC, Schlosser RJ, Smith TL. Economic evaluation of endoscopic sinus surgery versus continued medical therapy for refractory chronic rhinosinusitis. Laryngoscope 2015; 125:25-32. [PMID: 25186499 PMCID: PMC4280303 DOI: 10.1002/lary.24916] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 07/18/2014] [Accepted: 08/06/2014] [Indexed: 01/08/2023]
Abstract
OBJECTIVES/HYPOTHESIS To evaluate the long-term cost-effectiveness of endoscopic sinus surgery (ESS) compared to continued medical therapy for patients with refractory chronic rhinosinusitis (CRS). STUDY DESIGN Cohort-style Markov decision-tree economic evaluation. METHODS The economic perspective was the U.S. third-party payer with a 30-year time horizon. The two comparative treatment strategies were: 1) ESS, followed by appropriate postoperative medical therapy; and 2) continued medical therapy alone. Primary outcome was the incremental cost per quality-adjusted life year (QALY). Costs were discounted at a rate of 3.5% in the reference case. Multiple sensitivity analyses were performed, including differing time-horizons, discounting scenarios, and a probabilistic sensitivity analysis (PSA). RESULTS The reference case demonstrated that the ESS strategy cost a total of $48,838.38 and produced a total of 20.50 QALYs. The medical therapy alone strategy cost a total of $28,948.98 and produced a total of 17.13 QALYs. The incremental cost effectiveness ratio for ESS versus medical therapy alone is $5,901.90 per QALY. The cost-effectiveness acceptability curve from the PSA demonstrated that there is a 74% certainty that the ESS strategy is the most cost-effective decision for any willingness to pay a threshold greater than $25,000. The time-horizon analysis suggests that ESS becomes the cost-effective intervention within the third year after surgery. CONCLUSION Results from this study suggest that employing an ESS treatment strategy is the most cost-effective intervention compared to continued medical therapy alone for the long-term management of patients with refractory CRS.
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Affiliation(s)
- Luke Rudmik
- Division of Otolaryngology - Head and Neck Surgery, Department of Surgery; University of Calgary, Calgary, Alberta
| | - Zachary M. Soler
- Division of Rhinology and Sinus Surgery, Department of Otolaryngology - Head and Neck Surgery; Medical University of South Carolina; Charleston, South Carolina, USA
| | - Jess C. Mace
- Division of Rhinology and Sinus Surgery, Oregon Sinus Center, Department of Otolaryngology-Head and Neck Surgery; Oregon Health and Science University, Portland, Oregon, USA
| | - Rodney J. Schlosser
- Division of Rhinology and Sinus Surgery, Department of Otolaryngology - Head and Neck Surgery; Medical University of South Carolina; Charleston, South Carolina, USA
| | - Timothy L. Smith
- Division of Rhinology and Sinus Surgery, Oregon Sinus Center, Department of Otolaryngology-Head and Neck Surgery; Oregon Health and Science University, Portland, Oregon, USA
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Jacobs J. Editorial: allergy and immunology. Int Forum Allergy Rhinol 2014; 3:689-90. [PMID: 24078290 DOI: 10.1002/alr.21225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Sangchan A, Chaiyakunapruk N, Supakankunti S, Pugkhem A, Mairiang P. Cost utility analysis of endoscopic biliary stent in unresectable hilar cholangiocarcinoma: decision analytic modeling approach. Hepatogastroenterology 2014; 61:1175-1181. [PMID: 25436278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND/AIMS Endoscopic biliary drainage using metal and plastic stent in unresectable hilar cholangiocarcinoma (HCA) is widely used but little is known about their cost-effectiveness. This study evaluated the cost-utility of endoscopic metal and plastic stent drainage in unresectable complex, Bismuth type II-IV, HCA patients. METHODOLOGY Decision analytic model, Markov model, was used to evaluate cost and quality-adjusted life year (QALY) of endoscopic biliary drainage in unresectable HCA. Costs of treatment and utilities of each Markov state were retrieved from hospital charges and unresectable HCA patients from tertiary care hospital in Thailand, respectively. Transition probabilities were derived from international literature. Base case analyses and sensitivity analyses were performed. RESULTS Under the base-case analysis, metal stent is more effective but more expensive than plastic stent. An incremental cost per additional QALY gained is 192,650 baht (US$ 6,318). From probabilistic sensitivity analysis, at the willingness to pay threshold of one and three times GDP per capita or 158,000 baht (US$ 5,182) and 474,000 baht (US$ 15,546), the probability of metal stent being cost-effective is 26.4% and 99.8%, respectively. CONCLUSIONS Based on the WHO recommendation regarding the cost-effectiveness threshold criteria, endoscopic metal stent drainage is cost-effective compared to plastic stent in unresectable complex HCA.
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Zhou HJ, Dan YY, Naidoo N, Li SC, Yeoh KG. A cost-effectiveness analysis evaluating endoscopic surveillance for gastric cancer for populations with low to intermediate risk. PLoS One 2013; 8:e83959. [PMID: 24386314 PMCID: PMC3873968 DOI: 10.1371/journal.pone.0083959] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Accepted: 11/10/2013] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Gastric cancer (GC) surveillance based on oesophagogastroduodenoscopy (OGD) appears to be a promising strategy for GC prevention. By evaluating the cost-effectiveness of endoscopic surveillance in Singaporean Chinese, this study aimed to inform the implementation of such a program in a population with a low to intermediate GC risk. METHODS USING A REFERENCE STRATEGY OF NO OGD INTERVENTION, WE EVALUATED FOUR STRATEGIES: 2-yearly OGD surveillance, annual OGD surveillance, 2-yearly OGD screening and 2-yearly screening plus annual surveillance in Singaporean Chinese aged 50-69 years. From a perspective of the healthcare system, Markov models were built to simulate the life experience of the target population. The models projected discounted lifetime costs ($), quality adjusted life year (QALY), and incremental cost-effectiveness ratio (ICER) indicating the cost-effectiveness of each strategy against a Singapore willingness-to-pay of $46,200/QALY. Deterministic and probabilistic sensitivity analyses were used to identify the influential variables and their associated thresholds, and to quantify the influence of parameter uncertainties respectively. RESULTS With an ICER of $44,098/QALY, the annual OGD surveillance was the optimal strategy while the 2-yearly surveillance was the most cost-effective strategy (ICER = $25,949/QALY). The screening-based strategies were either extendedly dominated or cost-ineffective. The cost-effectiveness heterogeneity of the four strategies was observed across age-gender subgroups. Eight influential parameters were identified each with their specific thresholds to define the choice of optimal strategy. Accounting for the model uncertainties, the probability that the annual surveillance is the optimal strategy in Singapore was 44.5%. CONCLUSION Endoscopic surveillance is potentially cost-effective in the prevention of GC for populations at low to intermediate risk. Regarding program implementation, a detailed analysis of influential factors and their associated thresholds is necessary. Multiple strategies should be considered in order to recommend the right strategy for the right population.
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Affiliation(s)
- Hui Jun Zhou
- School of Public Health, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yock Young Dan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Nasheen Naidoo
- School of Public Health, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Shu Chuen Li
- Discipline of Pharmacy & Experimental Pharmacology, School of Biomedical Sciences & Pharmacy, University of Newcastle, Callaghan, Australia
| | - Khay Guan Yeoh
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- * E-mail:
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Abstract
AIM To investigate the level of percutaneous endoscopic gastrostomy (PEG) feeding in elderly people with diabetes resident in Nursing homes in one area of the U.K., to describe their degree of disability, co-morbidities and to estimate medication costs of these residents. METHODS The data was collected from a retrospective case notes review of the 75 people with known diabetes who were resident in the 11 Nursing homes in the Coventry Teaching PCT in early 2010. RESULTS 14 residents (19% of the total sample) had PEG feeds in situ and one (1.3%) had a nasogastric feeding tube in situ. The 14 residents were taking a total of 80 daily medications, a mean of 5.7 daily medications per resident (range 3-10). The total medication costs for the regular medications for these 14 residents was 2410 euros per month giving a mean of 172 euros/month (range 14-935 euros per month). All of the 14 were recorded as being bedbound, having no speech and being doubly incontinent. CONCLUSION All 14 residents being PEG fed have severe levels of disability. Cerebro vascular accident and dementia are the main recorded co-morbidities. The most expensive monthly medication costs were for special order liquid medications, many for cardio vascular disease prevention, which may be considered as inappropriate in such severely disabled residents.
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Affiliation(s)
- R Gadsby
- Warwick Medical School, University of Warwick CV4 7AL.
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Hanna BMN, Kilty SJ. Middle turbinate suture technique: a cost-saving and effective method for middle meatal preservation after endoscopic sinus surgery. J Otolaryngol Head Neck Surg 2012; 41:407-412. [PMID: 23700586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND Lateralization of the middle turbinate following endoscopic sinus surgery (ESS) can lead to increased patient morbidity. Numerous techniques have been proposed to avoid this complication, including middle turbinectomy, stents, controlled synechiae formation, and metal clips. OBJECTIVES To determine if a suture technique is an effective middle turbinate stabilization procedure and to determine the cost savings of this technique compared to commercially available middle meatal stents. MATERIAL AND METHODS Retrospective review of 60 cases, all performed by the senior author using a middle turbinate suture technique, and the 3-month postoperative results. The efficacy of the technique was determined, as well as its cost compared to other materials for middle meatal preservation. RESULTS A total of 110 turbinates were treated with the suture technique in 60 patients. The success rate was 98.2% (108 of 110). Commercial stent use cost ranged from 8 to 83 times the price of the suture depending on the stent. CONCLUSION The middle turbinate suture technique is effective in preventing turbinate lateralization and has a significantly lower cost than commercially available middle meatal spacer materials.
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Affiliation(s)
- Bassem M N Hanna
- Department of Otolaryngology-Head and Neck Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON
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Abstract
BACKGROUND We have developed a framework for translating existing sources of synthesized and quality-assessed evidence, primarily systematic reviews, into actionable messages in the form of short accessible briefings. The service aims to address real-life problems in response to requests from decision-makers.Development of the framework was based on a scoping review of existing resources and our initial experience with two briefing topics, including models of service provision for young people with eating disorders. We also drew on previous experience in dissemination research and practice. Where appropriate, we made use of the SUPporting POlicy relevant Reviews and Trials (SUPPORT) tools for evidence-informed policymaking. FINDINGS To produce a product that it is fit for this purpose it has been necessary to go beyond a traditional summary of the available evidence relating to effectiveness. Briefings have, therefore, included consideration of cost effectiveness, local applicability, implications relating to local service delivery, budgets, implementation and equity. Our first evidence briefings produced under this framework cover diagnostic endoscopy by specialist nurses and integrated care pathways in mental healthcare settings. CONCLUSIONS The framework will enable researchers to present and contextualize evidence from systematic reviews and other sources of synthesized and quality-assessed evidence. The approach is designed to address the wide range of questions of interest to decision-makers, especially those commissioning services or managing service delivery and organization in primary or secondary care. Evaluation of the use and usefulness of the evidence briefings we produce is an integral part of the framework and will help to fill a gap in the literature.
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Affiliation(s)
- Duncan Chambers
- Centre for Reviews and Dissemination, University of York, Heslington, York, YO10 5DD, UK
| | - Paul Wilson
- Centre for Reviews and Dissemination, University of York, Heslington, York, YO10 5DD, UK
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Pini G, Porpiglia F, Micali S, Rassweiler J. Minilaparoscopy, needlescopy and microlaparoscopy: decreasing invasiveness, maintaining the standard laparoscopic approach. ARCH ESP UROL 2012; 65:366-383. [PMID: 22495278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVES To review the development of miniaturized laparoscopic instruments with particular attention to the urological field and focusing on nomenclature, history and outcomes. METHODS A comprehensive literature search was conducted in order to find articles related to Minilaparoscopy, Needlescopy, Microlaparoscopy. The most relevant papers over the last 30 years were selected in base to the experience from the panel of experts, journal, authorship and /or content. RESULTS 258 manuscripts were found, 14 of them review, 126 about general surgery, 86 gynecology, 55 urology, 31 thoracic surgery. Minilaparoscopy is the main topic in 169 papers, Needlescopy in 58 and Microlaparoscopy in 32. No clinical randomized trials are available in urology. Most significant articles are 4 prospective non-randomized match-case control. CONCLUSIONS We are facing a Minilaparoscopy of second-generation with superior performance granted by new endoscopes and most effective instruments. Up to date, Minilaparoscopy has demonstrated in almost all urologic indication to be feasible, safe and able to improve cosmetic and postoperative pain control. Anyway, clinical randomized trials are still lacking and only studies from other discipline can corroborate this trend.
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Affiliation(s)
- Giovannalberto Pini
- Department of Urology, SLK Kliniken Heilbronn, University of Heidelberg, Germany
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Abstract
CONTEXT The frequency with which anesthesiologists or nurse anesthetists provide sedation for gastrointestinal endoscopies, especially for low-risk patients, is poorly understood and controversial. OBJECTIVE To quantify temporal comparisons and regional variation in the use of and payment for gastroenterology anesthesia services. DESIGN, SETTING, AND PATIENTS A retrospective analysis of claims data for a 5% representative sample of Medicare fee-for-service patients (1.1 million adults) and a sample of 5.5 million commercially insured patients between 2003 and 2009. MAIN OUTCOME MEASURES Total number of upper gastrointestinal endoscopies and colonoscopies, proportion of gastroenterology procedures with associated anesthesia claims, payments for gastroenterology anesthesia services, and proportion of services and spending for gastroenterology anesthesia delivered to low-risk patients (American Society of Anesthesiologists physical status class 1 or 2). RESULTS The number of gastroenterology procedures per million enrollees remained largely unchanged in Medicare patients (mean, 136,718 procedures), but increased more than 50% in commercially insured patients (from 33,599 in 2003 to 50,816 in 2009). In both populations, the proportion of procedures using anesthesia services increased from approximately 14% in 2003 to more than 30% in 2009, and more than two-thirds of anesthesia services were delivered to low-risk patients. There was substantial regional variation in the proportion of procedures using anesthesia services in both populations (ranging from 13% in the West to 59% in the Northeast). Payments for gastroenterology anesthesia services doubled in Medicare patients and quadrupled in commercially insured patients. CONCLUSIONS Between 2003 and 2009, utilization of anesthesia services during gastroenterology procedures increased substantially. Anesthesia services are predominantly used in low-risk patients and show considerable regional variation.
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Mulaik MW. Fluoroscopy: to bill or not to bill. MGMA Connex 2010; 10:11-12. [PMID: 21049809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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Abstract
Routine upper and/or lower endoscopy and percutaneous liver biopsy in the same patient are rarely performed on the same day. The aim of this study was to determine the safety, cost savings, and patient satisfaction of these same day procedures. A retrospective cohort study of patients undergoing same day endoscopy and percutaneous liver biopsy between February 2003 and July 2006 at Brooke Army Medical Center was performed. Eighty-nine patients were identified as having same day endoscopy and percutaneous liver biopsy during the study period. No study endpoint complications were identified. A cost savings of $333 per patient for a same day diagnostic upper endoscopy, colonoscopy, and percutaneous liver biopsy was found. More patients in both groups preferred same day procedures (P < 0.001). In conclusion, endoscopy and percutaneous liver biopsy can safely be performed in the same patient on the same day, which simultaneously increases patient satisfaction and is cost-effective.
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Affiliation(s)
- J Aaron Cook
- Brooke Army Medical Center, 3841 Roger Brooke Drive, Ft. Sam Houston, TX 78234, USA
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Kikuchi K. Comment on national survey of endoscopic thymectomy: survey report from the Japanese Association for Research on the Thymus. Gen Thorac Cardiovasc Surg 2009; 57:1-2. [PMID: 19160004 DOI: 10.1007/s11748-008-0373-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2008] [Indexed: 11/28/2022]
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Brill J. What is an endoscopist worth? Gastrointest Endosc 2008; 68:647-8. [PMID: 18926176 DOI: 10.1016/j.gie.2008.04.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2008] [Accepted: 04/28/2008] [Indexed: 12/10/2022]
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Pezzilli R. Endoscopic or surgical approach to cure pancreatitis and its complications: the history continues. JOP 2008; 9:577-578. [PMID: 18648153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
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Fitzgerald TN, Duffy AJ, Bell RL, Berman L, Longo WE, Roberts KE. Computer-based endoscopy simulation: emerging roles in teaching and professional skills assessment. J Surg Educ 2008; 65:229-235. [PMID: 18571138 DOI: 10.1016/j.jsurg.2008.02.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2007] [Revised: 01/23/2008] [Accepted: 02/28/2008] [Indexed: 05/26/2023]
Abstract
Advances in endoscopy simulation are reviewed with emphasis on applications in teaching and skills assessment. Endoscopy simulation has only been realized recently in a computer-based fashion because of advances in technology, but several studies have been performed both to validate computer-based endoscopy simulators and to assess their potential role in training. Multiple studies have shown that simulators can distinguish between clinicians at different skill levels and also have shown improvement in clinician skill, particularly at the early stages of training. This article summarizes those studies. The cost versus benefit of endoscopic simulators is also discussed, as well as the upcoming role of simulators in judging competence and as a tool in the credentialing process.
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Affiliation(s)
- Tamara N Fitzgerald
- Department of Surgery, Yale University School of Medicine, New Haven, CT 06510, USA
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Gondim JA, Ferraz T, Mota I, Studart D, Almeida JPC, Gomes E, Schops M. Outcome of surgical intrasellar growth hormone tumor performed by a pituitary specialist surgeon in a developing country. ACTA ACUST UNITED AC 2008; 72:15-9; discussion 19. [PMID: 18440607 DOI: 10.1016/j.surneu.2008.02.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2007] [Accepted: 02/04/2008] [Indexed: 10/22/2022]
Abstract
BACKGROUND Acromegaly is an excessive GH secretion, which in most cases, is caused by a pituitary GH-secreting adenoma. Traditional treatment of acromegaly consists of surgery, drug therapy, and eventually radiotherapy. The aim of this retrospective study is to evaluate the results of transsphenoidal endoscopic surgery in a group of patients with intrasellar GH adenoma who were operated by a pituitary specialist surgeon. We shall then argue about the economical advantages, for the NHS of a developing country, between surgical and medical treatment. METHODS We have analyzed data from 33 patients with intrasellar GH tumor who had been referred to the neuroendocrine department of the HGF, Brazil. The patients underwent a transsphenoidal endoscopic adenomectomy for acromegaly between 2000 and 2005. Their ages were between 20 and 67 years (mean, 44 years) at the moment of surgery. No cavernous sinus invasion was present. Follow-up was a median of 2 years (range, 12 months-6 years). RESULTS All 33 patients had intrasellar adenoma, 84.84% of patients achieved remission by surgery. One patient was operated twice and reached hormonal normalization. Five patients still had the disease and refused a second surgery. A treatment with octreotide was started for these 5 patients and resulted in an adequate control of GH and IGF-1 levels. No patients had radiotherapy. CONCLUSION Our patients, with intrasellar GH tumor, operated by a pituitary specialist neurosurgeon had remission rates approaching those obtained by most specialized neurosurgical centers worldwide. For equal results, our study shows that the surgical treatment is the best issue for the patient and for the NHS.
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Affiliation(s)
- Jackson A Gondim
- Neurosurgical Department, General Hospital of Fortaleza, Brazil.
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Chand M, Nash GF. NOTES: because we can or because we should? J R Soc Med 2008; 101:160-2. [PMID: 18387902 DOI: 10.1258/jrsm.2007.070450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Garside R, Pitt M, Somerville M, Stein K, Price A, Gilbert N. Surveillance of Barrett's oesophagus: exploring the uncertainty through systematic review, expert workshop and economic modelling. Health Technol Assess 2008; 10:1-142, iii-iv. [PMID: 16545207 DOI: 10.3310/hta10080] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES To assess what is known about the effectiveness, safety, affordability, cost-effectiveness and organisational impact of endoscopic surveillance in preventing morbidity and mortality from adenocarcinoma in patients with Barrett's oesophagus. In addition, to identify important areas of uncertainty in current knowledge for these programmes and to identify areas for further research. DATA SOURCES Electronic databases up to March 2004. Experts in Barrett's oesophagus from the UK. REVIEW METHODS A systematic review of the effectiveness of endoscopic surveillance of Barrett's oesophagus was carried out following methodological guidelines. Experts in Barrett's oesophagus from the UK were invited to contribute to a workshop held in London in May 2004 on surveillance of Barrett's oesophagus. Small group discussion, using a modified nominal group technique, identified key areas of uncertainty and ranked them for importance. A Markov model was developed to assess the cost-effectiveness of a surveillance programme for patients with Barrett's oesophagus compared with no surveillance and to quantify important areas of uncertainty. The model estimates incremental cost--utility and expected value of perfect information for an endoscopic surveillance programme compared with no surveillance. A cohort of 1000 55-year-old men with a diagnosis of Barrett's oesophagus was modelled for 20 years. The base case used costs in 2004 and took the perspective of the UK NHS. Estimates of expected value of information were included. RESULTS No randomised controlled trials (RCTs) or well-designed non-randomised controlled studies were identified, although two comparative studies and numerous case series were found. Reaching clear conclusions from these studies was impossible owing to lack of RCT evidence. In addition, there was incomplete reporting of data particularly about cause of death, and changes in surveillance practice over time were mentioned but not explained in several studies. Three cost--utility analyses of surveillance of Barrett's oesophagus were identified, of which one was a further development of a previous study by the same group. Both sets of authors used Markov modelling and confined their analysis to 50- or 55-year-old white men with gastro-oesophageal reflux disease (GORD) symptoms. The models were run either for 30 years or to age 75 years. As these models are American, there are almost certainly differences in practice from the UK and possible underlying differences in the epidemiology and natural history of the disease. The costs of the procedures involved are also likely to be very different. The expert workshop identified the following key areas of uncertainty that needed to be addressed: the contribution of risk factors for the progression of Barrett's oesophagus to the development of high-grade dysplasia (HGD) and adenocarcinoma of the oesophagus; possible techniques for use in the general population to identify patients with high risk of adenocarcinoma; effectiveness of treatments for Barrett's oesophagus in altering cancer incidence; how best to identify those at risk in order to target treatment; whether surveillance programmes should take place at all; and whether there are clinical subgroups at higher risk of adenocarcinoma. Our Markov model suggests that the base case scenario of endoscopic surveillance of Barrett's oesophagus at 3-yearly intervals, with low-grade dysplasia surveyed yearly and HGD 3-monthly, does more harm than good when compared with no surveillance. Surveillance produces fewer quality-adjusted life-years (QALYs) for higher cost than no surveillance, therefore it is dominated by no surveillance. The cost per cancer identified approaches pound 45,000 in the surveillance arm and there is no apparent survival advantage owing to high recurrence rates and increased mortality due to more oesophagectomies in this arm. Non-surveillance continues to cost less and result in better quality of life whatever the surveillance intervals for Barrett's oesophagus and dysplastic states and whatever the costs (including none) attached to endoscopy and biopsy as the surveillance test. The probabilistic analyses assess the overall uncertainty in the model. According to this, it is very unlikely that surveillance will be cost-effective even at relatively high levels of willingness to pay. The simulation showed that, in the majority of model runs, non-surveillance continued to cost less and result in better quality of life than surveillance. At the population level (i.e. people with Barrett's oesophagus in England and Wales), a value of pound 6.5 million is placed on acquiring perfect information about surveillance for Barrett's oesophagus using expected value of perfect information (EVPI) analyses, if the surveillance is assumed to be relevant over 10 years. As with the one-way sensitivity analyses, the partial EVPI highlighted recurrence of adenocarcinoma of the oesophagus (ACO) after surgery and time taken for ACO to become symptomatic as particularly important parameters in the model. CONCLUSIONS The systematic review concludes that there is insufficient evidence available to assess the clinical effectiveness of surveillance programmes of Barrett's oesophagus. There are numerous gaps in the evidence, of which the lack of RCT data is the major one. The expert workshop reflected these gaps in the range of topics raised as important in answering the question of the effectiveness of surveillance. Previous models of cost-effectiveness have most recently shown that surveillance programmes either do more harm than good compared with no surveillance or are unlikely to be cost-effective at usual levels of willingness to pay. Our cost--utility model has shown that, across a range of values for the various parameters that have been chosen to reflect uncertainty in the inputs, it is likely that surveillance programmes do more harm than good -- costing more and conferring lower quality of life than no surveillance. Probabilistic analysis shows that, in most cases, surveillance does more harm and costs more than no surveillance. It is unlikely, but still possible, that surveillance may prove to be cost-effective. The cost-effectiveness acceptability curve, however, shows that surveillance is unlikely to be cost-effective at either the 'usual' level of willingness to pay ( pound 20,000-30,000 per QALY) or at much higher levels. The expected value of perfect information at the population level is pound 6.5 million. Future research should target both the overall effectiveness of surveillance and the individual elements that contribute to a surveillance programme, particularly the performance of the test and the effectiveness of treatment for both Barrett's oesophagus and ACO. In addition, of particular importance is the clarification of the natural history of Barrett's oesophagus.
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Affiliation(s)
- R Garside
- Peninsula Technology Assessment Group, Peninsula Medical School, Universities of Exeter and Plymouth, Exeter, UK
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Abstract
In Natural Orifice Transluminal Endoscopic Surgery (NOTES) a flexible endoscope is passed through a natural orifice of the body and intra-abdominal procedures can be performed through a transvisceral (transgastric, -colonic, -vaginal or -vesical) incision. Principally, this state-of-the-art technology decreases invasiveness and postoperative pain, prevents postoperative hernia formation and improves cosmetic results. However, numerous questions regarding the technique are unanswered yet. Further research is necessary to extend the armamentarium of minimally invasive surgery. This article reviews the current state of experimental results and clinical approaches of NOTES.
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Affiliation(s)
- György Wéber
- Pécsi Tudományegyetem, Altalános Orvostudományi Kar, Sebészeti Oktató és Kutató Intézet, 7624 Pécs.
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Abstract
BACKGROUND Erythromycin is a potent stimulator of gastrointestinal motility. Recent studies have examined the use of intravenous erythromycin to clear the stomach of blood before oesophago-gastroduodenoscopy (EGD) for acute upper gastrointestinal haemorrhage (UGIH). These studies have shown clinical effectiveness. AIM To evaluate the cost-effectiveness of this intervention. METHODS We sought to determine the cost-effectiveness of erythromycin before EGD from the payer's perspective. We found three relevant studies of erythromycin and used these data for the analysis. We obtained costs for intravenous erythromycin and charges for peptic ulcer hospitalization, EGD, surgery, and angiographic embolization. Complication rates were also incorporated from the literature. We implemented a model of health-related quality of life to measure the impact of the intervention. We created a decision-analysis tree and performed a probabilistic sensitivity analysis. RESULTS A strategy of erythromycin prior to EGD resulted in a cost-effective outcome in a majority of trials using willingness-to-pay figures of USD 0, USD 50,000 and USD 100,000 per quality-adjusted life-year (QALY). CONCLUSION Because of the implications for cost saving and increase in QALY, we would recommend giving erythromycin prior to EGD for UGIH.
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Affiliation(s)
- N S Winstead
- Gastroenterology and Hepatology, University of Alabama-Birmingham, Birmingham, AL, USA.
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Epstein DM, Sculpher MJ, Manca A, Michaels J, Thompson SG, Brown LC, Powell JT, Buxton MJ, Greenhalgh RM. Modelling the long-term cost-effectiveness of endovascular or open repair for abdominal aortic aneurysm. Br J Surg 2007; 95:183-90. [PMID: 17876749 DOI: 10.1002/bjs.5911] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Abstract
Background
Recent randomized trials have shown that endovascular abdominal aortic aneurysm repair (EVAR) has a 3 per cent aneurysm-related survival benefit in patients fit for open surgery, but it also has uncertain long-term outcomes and higher costs. This study assessed the cost-effectiveness of EVAR.
Methods
A decision model was constructed to estimate the lifetime costs and quality-adjusted life years (QALYs) with EVAR and open repair in men aged 74 years. The model includes the risks of death from aneurysm, other cardiovascular and non-cardiovascular causes, secondary reinterventions and non-fatal cardiovascular events. Data were taken largely from the EVAR trial 1 and supplemented from other sources.
Results
Under the base-case (primary) assumptions, EVAR cost £3800 (95 per cent confidence interval (c.i.) £2400 to £5200) more per patient than open repair but produced fewer lifetime QALYs (mean − 0·020 (95 per cent c.i. − 0·189 to 0·165)). These results were sensitive to alternative model assumptions.
Conclusion
EVAR is unlikely to be cost-effective on the basis of existing devices, costs and evidence, but there remains considerable uncertainty.
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Affiliation(s)
- D M Epstein
- Centre for Health Economics, University of York, York, UK.
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50
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Abstract
AbstractBackground:In most centres in the United Kingdom, endoscopic dacryocystorhinostomy is currently undertaken as a joint operation between ophthalmologists and otolaryngologists. The addition of an extra surgeon, the use of endoscopic equipment and the relatively lower success rate of this procedure made us compare endoscopic dacryocystorhinostomy and external dacryocystorhinostomy with regards to costs and income for our hospital.Methods:All 38 primary endoscopic dacryocystorhinostomy cases performed in our centre in 2001–2003 were retrospectively compared with the 49 external dacryocystorhinostomy cases performed in 1993–2000. Cost–income calculations were made based on: rate of local anaesthesia, success rate, rate of day case admission, hospital reference cost for dacryocystorhinostomy, and the income per case extracted from national tariffs (based on the Health Resources Group). Also, the average number of cases per session was used to calculate the income gained per session for each method.Results:The following rates between the endoscopic and the external dacryocystorhinostomy were found: local anaesthesia, 29 vs 6 per cent, respectively; day-case operation, 95 vs 12 per cent, respectively; and success rate, 87 vs 94 per cent, respectively. The average number of endoscopic dacryocystorhinostomy cases conducted in a single theatre session was twice that of external dacryocystorhinostomy cases. Endoscopic dacryocystorhinostomy generated approximately twice the income of external dacryocystorhinostomy (£6585 vs £3292, respectively).Conclusion:Endoscopic dacryocystorhinostomy is more cost-effective than external dacryocystorhinostomy, despite having a lower success rate and greater usage of resources, as the endoscopic procedure generates more income. This is mainly due to the higher number of cases per session and the higher rates of local anaesthesia and day case operations possible.
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Affiliation(s)
- S Anari
- Department of Otolaryngology/Head and Neck Surgery, Carlisle, UK.
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