Radiation protection in CT-guided interventions: does real-time dose visualisation lead to a reduction in radiation dose to participating radiologists? A single-centre evaluation

AIM

To evaluate if real-time dose visualisation during computed tomography (CT)-guided interventions leads to a reduction in radiation dose to participating radiologists.

MATERIALS AND METHODS

The individual radiation dose radiologists are exposed to during CT interventions was measured using dedicated dosimeters (RaySafe i2-system, Unfors RaySafe GmbH, Billdal, Sweden) worn over the usual radiation protective apron. Initially, only the total radiation dose was measured, without visualisation (control group). In the following study period, the radiation dose was shown to participants on a live screen in real-time (experimental group). In both groups, the dose was recorded in 1-second intervals. The results collected were evaluated by comparison using descriptive statistics and mixed-effect models. In particular, the variables experience, gender, role, and position during the intervention were analysed.

RESULTS

In total, 517 measurements of 304 interventions (n=249 with and n=268 without live screen) performed by 29 radiologists acting as interventionalists or assistants were analysed. All CT-guided interventions were performed percutaneously, the majority of which (n=280) were microwave ablations (MWA). Radiation doses in the group without visualisation were comparable with usual dose rates for the corresponding intervention type. The mean total radiation dose was reduced by 58.1% (11.6 versus 4.86 μSv) in the experimental group (p=0.034). The highest reduction of 78.5% (15.55 versus 3.35 μSv) was observed in radiologists with the role of assistant (p=0.002). Sub-analysis showed significant dose reduction (p<0.0001) for the use of live screen in general; considering all variables, the role "assistant" alone had a statistically significant influence (p=0.002).

CONCLUSION

The real-time visualisation of active radiation dose during CT interventions leads to a relevant reduction in radiation dose to participating radiologists.

Incidence and costs of hypoglycemia in insulin-treated diabetes in Switzerland: A health-economic analysis

AIMS

We assess the incidence and economic burden of severe and non-severe hypoglycemia in insulin-treated diabetes type 1 and 2 patients in Switzerland.

METHODS

We developed a health economic model to assess the incidence of hypoglycemia, the subsequent medical costs, and the production losses in insulin-treated diabetes patients. The model distinguishes between severity of hypoglycemia, type of diabetes, and type of medical care. We used survey data, health statistics, and health care utilization data extracted from primary studies.

RESULTS

The number of hypoglycemic events in 2017 was estimated at 1.3 million in type 1 diabetes patients and at 0.7 million in insulin-treated type 2 diabetes patients. The subsequent medical costs amount to 38 million Swiss Francs (CHF), 61 % of which occur in type 2 diabetes. Outpatient visits dominate costs in both types of diabetes. Total production losses due to hypoglycemia amount to CHF 11 million. Almost 80 % of medical costs and 39 % of production losses are due to non-severe hypoglycemia.

CONCLUSIONS

Hypoglycemia leads to substantial socio-economic burden in Switzerland. Greater attention to non-severe hypoglycemic events and to severe hypoglycemia in type 2 diabetes could have a major impact on reducing this burden.

Impact of a diabetes disease management program on guideline-adherent care, hospitalization risk and health care costs: a propensity score matching study using real-world data

OBJECTIVE

To evaluate the impact of a DMP for patients with diabetes mellitus in a Swiss primary care setting.

METHODS

In a prospective observational study, we compared diabetes patients in a DMP (intervention group; N = 538) with diabetes patients receiving usual care (control group; N = 5050) using propensity score matching with entropy balancing. Using a difference-in-difference (DiD) approach, we compared changes in outcomes from baseline (2017) to 1-year (2017/18) and to 2-year follow-up (2017/19). Outcomes included four measures for guideline-adherent diabetes care, hospitalization risk, and health care costs.

RESULTS

We identified a positive impact of the DMP on the share of patients fulfilling all measures for guideline-adherent care [DiD 2017/18: 7.2 percentage-points, p < 0.01; 2017/19: 8.4 percentage-points, p < 0.001]. The hospitalization risk was lower in the intervention group in both years, but only statistically significant in the 1-year follow-up [DiD 2017/18: - 5.7 percentage-points, p < 0.05; 2017/19: - 3.9 percentage points, n.s.]. The increase in health care costs was smaller in the intervention than in the control group [DiD 2017/18: CHF - 852; 2017/19: CHF - 909], but this effect was not statistically significant.

CONCLUSION

The DMP under evaluation seems to exert a positive impact on the quality of diabetes care, reflected in the increase in the measures for guideline-adherent care and in a reduction of the hospitalization risk in the intervention group. It also might reduce health care costs, but only a longer follow-up will show whether the observed effect persists over time.

Cost-Utility Analysis of Thumb Carpometacarpal Resection Arthroplasty: A Health Economic Study Using Real-World Data

PURPOSE

Knowledge about the costs and benefits of hand surgical interventions is important for surgeons, payers, and policy makers. Little is known about the cost-effectiveness of surgery for thumb carpometacarpal osteoarthritis. The objective of this study was to examine patients' quality of life and economic costs, with focus on the cost-utility ratio 1 year after surgery for thumb carpometacarpal osteoarthritis compared with that for continued nonsurgical management.

METHODS

Patients with thumb carpometacarpal osteoarthritis indicated for resection arthroplasty were included in a prospective study. The quality of life (using European Quality of Life-5 Dimensions-5 Level), direct medical costs, and productivity losses were assessed up to 1 year after surgery. Baseline data at recruitment and costs sustained over 1 year before surgery served as a proxy for nonsurgical management. The total costs to gain 1 extra quality-adjusted life year and the incremental cost-effectiveness ratio were calculated from a health care system and a societal perspective.

RESULTS

The mean European Quality of Life-5 Dimensions-5 Level value for 151 included patients improved significantly from 0.69 to 0.88 (after surgery). The productivity loss during the preoperative period was 47% for 49 working patients, which decreased to 26% 1 year after surgery. The total costs increased from US $20,451 in the preoperative year to US $24,374 in the postoperative year. This resulted in an incremental cost-effectiveness ratio of US $25,370 per quality-adjusted life year for surgery compared with that for simulated nonsurgical management.

CONCLUSIONS

The calculated incremental cost-effectiveness ratio was clearly below the suggested Swiss threshold of US $92,000, indicating that thumb carpometacarpal surgery is a cost-effective intervention.

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic and Decision Analyses II.

Cost-utility analysis of total shoulder arthroplasty: a prospective health economic study using real-world data

BACKGROUND

With increasing health care expenditures, knowledge about the benefit and costs of surgical interventions such as total shoulder arthroplasty (TSA) becomes important for orthopedic surgeons, social insurance programs, and health policy decision makers. We examined the impact of TSA on quality of life (QOL), direct medical costs, and productivity losses and evaluated the cost-utility ratio of TSA compared with ongoing nonoperative management using real-world data.

METHODS

Patients with shoulder osteoarthritis and/or rotator cuff tear arthropathy indicated for anatomic or reverse TSA were included in this prospective study. QOL (European Quality of Life 5 Dimensions 5-Level questionnaire) and shoulder function (Constant score; Shoulder Pain and Disability Index; short version of the Disabilities of the Arm, Shoulder and Hand questionnaire; and Subjective Shoulder Value) were assessed preoperatively and up to 2 years postoperatively. Health insurance companies provided all-diagnosis direct medical costs for 2018 in Swiss francs (CHF), where 1 CHF was equivalent to US $1.02. Indirect costs were assessed using the Work Productivity and Activity Impairment Questionnaire. Baseline data at recruitment and the total costs of the preoperative year served as a proxy for nonoperative management. The incremental cost-effectiveness ratio (ICER) was calculated as the total costs to gain 1 extra quality-adjusted life-year (QALY) based on both the health care system perspective and societal perspective. The relationship between QOL and shoulder function was assessed by regression analysis.

RESULTS

The mean preoperative utility index for the European Quality of Life 5 Dimensions 5-Level questionnaire of 0.68 for a total of 150 patients (mean age, 71 years; 21% working; 58% women) increased to 0.89 and 0.87 at 1 and 2 years postoperatively, respectively. Mean direct medical costs were 11,771 CHF (preoperatively), 34,176 CHF (1 year postoperatively), and 11,763 CHF (2 years postoperatively). The ICER was 63,299 CHF/QALY (95% confidence interval, 44,391-82,206 CHF/QALY). The mean productivity losses for 29 working patients decreased from 40,574 CHF per patient (preoperatively) to 26,114 CHF at 1 year postoperatively and 10,310 CHF at 2 years postoperatively. When considering these productivity losses, the ICER was 35,549 CHF/QALY (95% confidence interval, 12,076-59,016 CHF/QALY). QOL was significantly associated with shoulder function (P < .001).

CONCLUSION

Using real-world direct medical cost data, we calculated a cost-utility ratio of 63,299 CHF/QALY for TSA in Switzerland, which clearly falls below the often-suggested 100,000-CHF/QALY threshold for acceptable cost-effectiveness. In view of productivity losses, TSA becomes highly cost-effective with an ICER of 35,546 CHF/QALY.

Comparison of contrast-enhanced videofluoroscopy to unenhanced dynamic MRI in minor patients following surgical correction of velopharyngeal dysfunction

OBJECTIVES

To compare dynamic magnetic resonance imaging (MRI) with videofluoroscopy (VFS) regarding image quality and assessment of gap size between soft palate (SP) and posterior pharyngeal wall (PPW) in children and adolescents following surgical correction of velopharyngeal dysfunction (VPD).

METHODS

Twenty-one patients undergoing unenhanced 3-T MRI and contrast-enhanced VFS were included in this IRB-approved prospective study. The MRI scan protocol comprised refocused gradient-echo sequences in transverse and sagittal planes during speech, with TE 1.97 ms, TR 3.95 ms, flip angle 8°, matrix size 128 × 128, and 5-mm slice thickness. Radial k-space sampling and sliding window reconstruction were used to achieve an image acquisition rate of 28 frames per second (fps). VFS with 30 fps was similarly performed in both planes. Closure of the velopharyngeal port during phonation was evaluated by two experienced radiologists.

RESULTS

Eleven (52.4%) patients displayed a complete closure, whereas ten (47.6%) patients showed a post-operative gap during speech. VFS and MRI equally identified the cases with persistent or recurrent VPD. Differences in SP-PPW distance between VFS (3.9 ± 1.6 mm) and MRI (4.1 ± 1.5 mm) were not statistically significant (p = 0.5). The subjective overall image quality of MRI was rated inferior (p < 0.001) compared with VFS, with almost perfect inter-rater agreement (κ = 0.90). The presence of susceptibility artifacts did not limit anatomical measurements.

CONCLUSION

Dynamic MRI is equally reliable as VFS to assess persistent or recurrent inadequate velum closure in patients following surgical treatment of VPD.

KEY POINTS

• Unenhanced 3-T dynamic MRI and contrast-enhanced videofluoroscopy are equally useful for the identification of patients with incomplete velopharyngeal closure during speech. • MRI using refocused gradient-echo acquisition with radial k-space sampling and sliding window reconstruction generates diagnostic images with 28 frames per second. • MRI can offer a radiation-free alternative to currently established videofluoroscopy for young patients.

Recent trends and variations in general practitioners' involvement in accident care in Switzerland: an analysis of claims data

Background

As in other countries, there is concern and some fragmentary evidence that GPs’ central role in the Swiss healthcare system as the primary provider of care might be changing or even be in decline. Our study gives a systematic account of GPs’ involvement in accident care from 2008 to 2016 and identifies changes in GPs’ involvement in this typical field of primary care: how frequently GPs were involved along the care pathway, to what extent they figured as initial care provider, and what their role in the care pathway was.

Methods

Using a claims dataset from the largest Swiss accident insurer with two million accident cases, we constructed individual care pathways, i.e., when and from which providers patients received care. We calculated probabilities for the involvement of various care provider groups, for initial care provision, and for the role of GPs in patients’ care pathways, adjusted for injury and patient characteristics using multinomial regression.

Results

In 2014, GPs were involved in 70% of all accident cases requiring outpatient care but no inpatient stay, and provided initial care in 56%. While involvement stayed at about the same level for accidents occurring from 2008 to 2014, the share of accidents where GPs provided initial care decreased by 4 percentage points. The share of cases where GPs acted as sole care provider decreased by 7 percentage points down to 44%. At the same time, accident cases involving care from an ED at any point in time increased from 38 to 46% and the share receiving initial care from an ED from 30 to 35 percentage points – apparently substituting for the declining involvement of GPs in initial care. GPs’ involvement in accident care is higher in rural compared to urban regions, among elderly compared to younger patients, and among Swiss compared to non-Swiss citizens.

Conclusions

GPs play a key role in accident care with considerable variation depending on region and patient profile. From 2008 to 2014, there is a remarkable decline in GPs’ provision of initial care after an accident. This is a strong indication that the GPs’ role in the Swiss healthcare system is changing.

Cost-Utility Analysis of Arthroscopic Rotator Cuff Repair: A Prospective Health Economic Study Using Real-World Data

Purpose

To assess the change in quality of life (QOL) and costs for patients with rotator cuff tears after arthroscopic rotator cuff repair (aRCR) compared with continued nonoperative management, using real-world evidence.

Methods

Patients indicated for aRCR were included in a prospective study and followed up to 2 years after surgery (postop) for all measurements. QOL (EQ-5D-5L) and shoulder function (Constant Score, Oxford Shoulder Score, subjective shoulder value) were assessed. Sixteen major insurance companies provided all-diagnoses direct medical costs in Swiss francs (CHF; 1 CHF = 1.03 USD). Baseline data at recruitment and costs sustained over 1 year before surgery (preop) served as a proxy for nonoperative management. Total direct medical costs to gain 1 extra quality-adjusted life year (QALY) were calculated as the incremental cost-effectiveness ratio (ICER; mean of 2 years postop compared with 1 year preop) from a societal perspective. Subgroup analyses were separately performed for traumatic (trauma-OP) and degenerative (degen-OP) rotator cuff tear patients. Sensitivity analyses for aRCR patients included more intensive nonoperative treatment with corresponding QOL gain. The relationship between QOL and shoulder function was explored using regression analysis.

Results

For 153 aRCR patients (mean age 57 years; 63% male), the mean EQ-5D index improved from 0.71 (preop) to 0.94 (1 year postop) and 0.96 (2 years postop). Mean total costs increased from 5,499 CHF (preop) to 17,116 CHF (1 year postop), then decreased to 4,226 CHF (2 years postop). The ICER for all aRCR patients was 24,924 CHF/QALY (95% confidence interval [CI] 16,742 to 33,106) and 17,357 CHF/QALY (95% CI 10,951 to 23,763) and 36,474 CHF/QALY (95% CI 16,301 to 56,648) for the trauma-OP and degen-OP groups, respectively. QOL and shoulder function were significantly associated (P < .001).

Conclusions

For RC patients treated at a specialized Swiss orthopaedic clinic, aRCR is a cost-effective intervention associated with clinically relevant improvement in QOL up to 2 years after repair compared with prior nonoperative management.

Level of Evidence

Economic Analyses - Developing an Economic Model, Level II.

Impact of osteosynthesis in fracture care: a cost comparison study

Aim: To estimate the health economic impact of osteosynthesis (OS) in fracture care over six decades in 17 high-income countries. Patients & methods: Applying a decision tree model, we assumed a hypothetical absence of OS and compared OS (intervention) with conservative treatment (CONS; comparator). We included patients with femur, tibia and radius fractures (age <65 years) and for proximal femur fractures also elderly patients (≥70 years). Results: We estimated savings in direct and indirect costs of 855 billion Swiss francs in the working age population in addition to 4.6 million years of life gained. In the elderly population, 69 billion Swiss francs were saved in direct costs of proximal femur fractures in addition to 73 million years of life gained. Conclusion: OS contributed to maximize health gains of society.

The impact of the AO Foundation on fracture care: An evaluation of 60 years AO Foundation

OBJECTIVES

Sixty years ago, the Association of Osteosynthesis (AO) was founded with the aim to improve fracture treatment and has since grown into one of the largest medical associations worldwide. Aim of this study was to evaluate AO's impact on science, education, patient care and the MedTech business.

DESIGN/METHODS

Impact evaluations were conducted as appropriate for the individual domains: Impact on science was measured by analyzing citation frequencies of publications promoted by AO. Impact on education was evaluated by analyzing the evolution of number and location of AO courses. Impact on patient care was evaluated with a health economic model analyzing cost changes and years of life gained through the introduction of osteosynthesis in 17 high-income countries (HICs). Impact on MedTech business was evaluated by analyzing sales data of AO-associated products.

RESULTS

Thirty-five AO papers and 2 major AO textbooks are cited at remarkable frequencies in high ranking journals with up to 2000 citations/year. The number of AO courses steadily increased with a total of 645'000 participants, 20'000 teaching days and 2'500 volunteer faculty members so far. The introduction of osteosynthesis saved at least 925 billion Swiss Francs [CHF] in the 17 HICs analyzed and had an impact on avoiding premature deaths comparable to the use of antihypertensive drugs. AO-associated products generated sales of 55 billion CHF.

CONCLUSION

AO's impact on science, education, patient care, and the MedTech business was significant because AO addressed hitherto unmet needs by combining activities that mutually enriched and reinforced each other.

Extrapolating Antibiotic Sales to Number of Treated Animals: Treatments in Pigs and Calves in Switzerland, 2011-2015

To evaluate the contribution of antimicrobial use in human and veterinary medicine to the emergence and spread of resistant bacteria, the use of these substances has to be accurately monitored in each setting. Currently, various initiatives collect sales data of veterinary antimicrobials, thereby providing an overview of quantities on the market. However, sales data collected at the level of wholesalers or marketing authorization holders are of limited use to associate with the prevalence of bacterial resistances at species level. We converted sales data to the number of potential treatments of calves and pigs in Switzerland for the years 2011 to 2015 using animal course doses (ACD). For each authorized product, the number of potential therapies was derived from the sales at wholesaler's level and the ACD in mg per kg. For products registered for use in multiple species, a percentage of the sales was attributed to each authorized species according to their biomass distribution. We estimated a total of 5,914,349 therapies for pigs and 1,407,450 for calves in 2015. Using the number of slaughtered animals for that year as denominator, we calculated a treatment intensity of 2.15 therapies per pig and 5.96 per calf. Between 2011 and 2015, sales of veterinary antimicrobials decreased by 30%. The calculated number of potential therapies decreased by 30% for pigs and 15% for calves. An analysis of treatment intensity at antimicrobial class level showed a decrease of 64% for colistin used in pigs, and of 7% for macrolides used in both pigs and calves. Whereas the use of 3rd and 4th generation cephalosporins in calves decreased by 15.8%, usage of fluoroquinolones increased by 10.8% in the same period. Corresponding values for pigs were −16.4 and +0.7%. This is the first extrapolation of antimicrobial usage at product level for pigs and calves in Switzerland. It shows that calves were more frequently treated than pigs with a decreasing trend for both number of therapies and use of colistin, macrolides and cephalosporins 3rd and 4th generations. Nonetheless, we calculated an increase in the usage of fluoroquinolones. Altogether, this study's outcomes allow for trend analysis and can be used to assess the relationship between antimicrobial use and resistance at the national level.

CT-guided percutaneous biopsy of suspect pancreatic lesions: radiological and clinical outcome

AIM

To evaluate the clinical utility of computed tomography (CT)-guided percutaneous biopsies of suspect pancreatic lesions regarding safety, efficiency, radiation dose, intervention time, diagnostic yield, and complications.

MATERIALS AND METHODS

Between 2015 and 2018, 48 patients (18 female, 30 male; mean age: 64.2 years) with suspect pancreatic lesions underwent CT-guided percutaneous biopsy. Ultrasound-guided biopsy of all lesions was not possible or without any result. CT-guided interventions were compared according to the following intervention parameters: radiation dose, procedure duration, number of needle correction scans. Evaluation criteria included technical success as well as major and minor complications according to the Society of Interventional Radiology.

RESULTS

Biopsies were performed successfully in 100% of patients. No major side effects occurred during intervention. As a minor complication, 29.2% showed focal haemorrhage. Seventy-seven percent of lesions had a malignant appearance, and benign inflammatory lesions were found in 23%. The mean size of the target lesions was 2.9 cm (range: 0.7-2.3 cm). The mean target access path within the patient was 8 cm (range: 3-14 cm). The duration to completion was 12 minutes (range: 3 minutes 30 seconds to 30 minutes). The dose-length product of the intervention was 89.5 mGy·cm (range: 11-350 mGy·cm). The average number needle correction scans was 31.1 (range: 6-36).

CONCLUSION

CT-guided biopsy of suspect pancreatic lesions is an efficient and safe method. It can be performed within short intervention times and low radiation exposure for differentiation of unclear lesions.

[Imaging techniques in modern trauma diagnostics]

Modern trauma room management requires interdisciplinary teamwork and synchronous communication between a team of anaesthesists, surgeons and radiologists. As the length of stay in the trauma room influences morbidity and mortality of a severely injured person, optimizing time is one of the main targets. With the direct involvement of modern imaging techniques the injuries caused by trauma should be detected within a very short period of time in order to enable a priority-orientated treatment. Radiology influences structure and process quality, management and development of trauma room algorithms regarding the use of imaging techniques. For the individual case interventional therapy methods can be added. Based on current data and on the Frankfurt experience the current diagnostic concepts of trauma diagnostics are presented.

Health effects of micronutrient fortified dairy products and cereal food for children and adolescents: A systematic review

INTRODUCTION

Micronutrient (MN) deficiencies cause a considerable burden of disease for children in many countries. Dairy products or cereals are an important food component during adolescence. Fortification of dairy products or cereals with MN may be an effective strategy to overcome MN deficiencies, but their specific impact on health in this age group is poorly documented.

METHODS

We performed a systematic review and meta-analysis (registration number CRD42016039554) to assess the impact of MN fortified dairy products and cereal food on the health of children and adolescents (aged 5-15 years) compared with non-fortified food. We reviewed randomised controlled trials (RCT) using electronic databases (MEDLINE, EMBASE, Cochrane library; latest search: January 2018), reference list screening and citation searches. Three pairs of reviewers assessed 2048 studies for eligibility and extracted data. We assessed the risk of bias and applied GRADE to rate quality of evidence.

RESULTS

We included 24 RCT (often multi MN fortification) with 30 pair-wise comparisons mainly from low- and middle income countries. A very small and non-significant increase of haemoglobin values emerged (0.09 g/dl [95%-CI: -0.01 to 0.18]; 13 RCT with iron fortification; very low quality of evidence). No significant difference was found on anaemia risk (risk ratio 0.87 [95%-CI: 0.76 to 1.01]; 12 RCT; very low quality), but a significant difference in iron deficiency anaemia favouring fortified food was found (risk ratio 0.38 [95%-CI: 0.18 to 0.81]; 5 RCT; very low quality). Similar effects were seen for fortified dairy products and cereals and different fortification strategies (mono- vs. dual- vs. multi-MN). Follow-up periods were often short and the impact on anthropometric measures was weak (low quality of evidence) Very low quality of evidence emerged for the improvement of cognitive performance, functional measures and morbidity.

CONCLUSIONS

Fortification of dairy products and cereal food had only marginal health effects in our sample population from 5-15 years. Further evidence is needed to better understand the health impact of fortified dairy products and cereals in this age group.

SYSTEMATIC REVIEW REGISTRATION

The study protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 26 May 2016 (registration number CRD42016039554).

[Imaging techniques in modern trauma diagnostics]

Modern trauma room management requires interdisciplinary teamwork and synchronous communication between a team of anaesthesists, surgeons and radiologists. As the length of stay in the trauma room influences morbidity and mortality of a severely injured person, optimizing time is one of the main targets. With the direct involvement of modern imaging techniques the injuries caused by trauma should be detected within a very short period of time in order to enable a priority-orientated treatment. Radiology influences structure and process quality, management and development of trauma room algorithms regarding the use of imaging techniques. For the individual case interventional therapy methods can be added. Based on current data and on the Frankfurt experience the current diagnostic concepts of trauma diagnostics are presented.

Epidemiology and costs of multiple sclerosis in Switzerland: an analysis of health-care claims data, 2011-2015

BACKGROUND

Medical therapy for multiple sclerosis (MS) is expensive. Quantifying the burden of MS is fundamental for health-care planning and the allocation of resources for the management of MS. This study provides current national estimates of prevalence, incidence, mortality, and costs of MS in Switzerland using claims data between 2011 and 2015.

METHODS

We analyzed health insurance claims of adult persons enrolled with a large health insurance group covering about 13% of the Swiss population between 2011 and 2015. The identification of patients with MS was based on prescription data of MS-specific medication using the Anatomical Therapeutic Chemical Classification system as proxy for clinical diagnosis. We estimated prevalence, mortality, and costs of basic health insurance between 2011 and 2015. Furthermore, incidence of MS was calculated for 2015. All results were weighted with census data to achieve an extrapolation to the Swiss general population level. Cost of illness was estimated as direct medical cost from the perspective of a Swiss health insurance using multivariate linear regression analysis.

RESULTS

Of the 943,639 subjects in the year 2015, 1,606 were identified as MS patients resulting in a prevalence of 190 per 100,000 (95% CI: 180-190 per 100,000). Incidence was 16 per 100,000 (95% CI: 13-19 per 100,000). According to regression analysis, the total cost of illness for basic mandatory health insurance was 26,710 Swiss Francs (CHF) (95% CI: 26,100-27,300) per person per year with the cost of medication being almost identical 26,960 CHF (95% CI: 26,170-27,800).

CONCLUSIONS

MS affects 10,000-15,000 persons in Switzerland, and the prevalence has increased over the last 22 years. These persons have high need and demand for health care. High costs are primarily due to expenses for medication. Given the imbalance of MS medication therapy from the perspective of basic health insurance on the disposable resources, it is crucial to increase transparency related to the volume, type, and allocation of expenses.

Minimally invasive screw fixation of fractures in the thoracic spine: CT-controlled pre-surgical guidewire implantation in routine clinical practice

AIM

To evaluate the feasibility and accuracy of minimally invasive, transpedicular screw placement in cervicothoracic fractures with the help of computed tomography (CT)-controlled guidewires.

MATERIALS AND METHODS

Two hundred and ninety-three guidewires were inserted in 35 patients (42.9±21.2 years) under CT fluoroscopy (286 thoracic, seven cervical). There were 28 traumatic cases, three pathological fractures, three fractures due to infectious infiltrations, and one osteoporotic fracture. In 151 pedicles, screw placement was performed in the CT room. CT images were reviewed regarding accuracy and cortical violations using the popular 2 mm increment deviation classification of Gertzbein and Robbins.

RESULTS

Guidewire implantation resulted in only 28 cortical contacts. Minor encroachments of the pedicle wall by inserted screws occurred in 39.1% (59 of 151) and in 23.8% if taking unavoidable encroachments into account (30 of 59). Pedicular isthmus width correlated to cortical guidewire contacts (r=-0.449; p=0.077) and pedicle violations (all graded "A") by the inserted screws (r=-0.581; p=0.049). Total procedural duration was 138.6±44.2 minutes, representing 14.5±11.6 minutes for each pedicle, while showing a significant correlation against higher vertebral levels (r=-0.849; p=0.0002) and the occurrence of pedicle violations (r=-0.641; p=0.027).

CONCLUSIONS

The treatment of vertebral fractures with a guidewire-based pedicle screw insertion technique under CT imaging results in very high accuracy and a low complication rate.

Implementation of a hospital-integrated general practice--a successful way to reduce the burden of inappropriate emergency-department use

PRINCIPLES

Emergency departments (EDs) are overcrowded by lower acuity patients, which might be more efficiently treated by general practitioners (GPs). This study evaluated the impact of triaging lower acuity patients to a new hospital-integrated general practice (HGP) on ED case-load and the reasons for choosing the ED/HGP.

METHODS AND RESULTS

Patients were consecutively assessed according to the emergency severity index (ESI) to triage lower acuity patients to the HGP. Consultation numbers at the emergency centre (ED and HGP) increased by 43% between 2007 (n = 16 974) and 2011 (n = 24 331) (implementation of HGP in 2009). Although self-referrals increased significantly at the emergency centre from 54% to 63% (p <0.001), the proportion of self-referrals at the ED was significantly reduced to 48% (p = 0.007). The HGP was able to reduce the burden of increasing total consultations by 36%; 4.6% were referred back to the ED after triaging to the HGP. Overall, 95% of HGP patients were self-referred, Swiss nationals (65%) and with a personal GP (82%) they attended regularly (69%). The most common reason for presenting at the emergency centre was not being able to reach the GP (60%). Diagnoses were injury- (29%) and infection- (23%) related problems affecting the musculoskeletal (27%) system and skin (21%).

CONCLUSION

The HGP succeeded in reducing the burden of inappropriate ED use: the majority of low acuity self-referred patients were conclusively treated at the HGP. The HGP does not represent competition to the GP out-of-hours care service, since the main reason for presenting at the hospital was not lacking a relationship but the GPs' inaccessibility.

Micronutrient Fortified Condiments and Noodles to Reduce Anemia in Children and Adults--A Literature Review and Meta-Analysis

Micronutrient deficiencies impose a considerable burden of disease on many middle and low income countries. Several strategies have been shown to be effective in improving micronutrient deficiencies. However, the impact of fortified condiments as well as fortified noodles is less well documented. We aimed to investigate existing evidence on the impact of micronutrient fortified condiments and noodles on hemoglobin, anemia, and functional outcomes in children and adults (age: 5 to 50 years). We conducted a literature review in electronic databases. In addition, we screened the homepages of relevant organizations and journals. We included randomized controlled trials (RCT). Of 1046 retrieved studies, 14 RCT provided data for the meta-analysis. Micronutrient fortification of condiments and noodles increased hemoglobin concentrations by 0.74 g/dL (95%-confidence intervals (95%-CI): 0.56 to 0.93; 12 studies) and 0.3 g/dL (95%-CI: 0.12 to 0.48; 1 study), respectively. Micronutrient fortification also led to a reduced risk of having anemia (risk ratio 0.59 (95%-CI 0.44 to 0.80)). Ferritin concentrations increased with fortified condiments. Functional outcomes were rarely assessed and showed mixed results. The use of micronutrient fortified condiments can be a strategy to reduce anemia in children and adults due to micronutrient deficiencies. The effect of fortified noodles seems to be smaller.

The health technology assessment of the compulsory accident insurance scheme of hand transplantation in Switzerland

Recently the decision-making committee of the compulsory Swiss accident insurance scheme needed to make a basic decision as to whether to fund hand transplantation under that scheme or not. A Health Technology Assessment was commissioned to inform decision-making and gain experience with applicability of the method. The following were main findings from various domains. Compared with prosthesis fitting, the outcome of hand transplantation is satisfactory for function and sensibility. Complications due to immunosuppression are frequent, sometimes severe and potentially life-shortening. The direct medical costs over the entire life span calculated for a 35-year-old unilaterally amputated base case patient were CHF 528,600 (EUR 438,500) higher than for a prosthesis. There are challenging ethical, legal and organizational issues. The committee decided not to reimburse hand transplantation for ethical reasons. The Health Technology Assessment has been shown to be a useful tool for decision-making in the context of Swiss accident insurance.

LEVEL OF EVIDENCE

IV.

Social Costs of Iron Deficiency Anemia in 6-59-Month-Old Children in India

INTRODUCTION

Inadequate nutrition has a severe impact on health in India. According to the WHO, iron deficiency is the single most important nutritional risk factor in India, accounting for more than 3% of all disability-adjusted life years (DALYs) lost. We estimate the social costs of iron deficiency anemia (IDA) in 6-59-month-old children in India in terms of intangible costs and production losses.

MATERIALS AND METHODS

We build a health economic model estimating the life-time costs of a birth cohort suffering from IDA between the ages of 6 and 59 months. The model is stratified by 2 age groups (6-23 and 24-59-months), 2 geographical areas (urban and rural), 10 socio-economic strata and 3 degrees of severity of IDA (mild, moderate and severe). Prevalence of anemia is calculated with the last available National Family Health Survey. Information on the health consequences of IDA is extracted from the literature.

RESULTS

IDA prevalence is 49.5% in 6-23-month-old and 39.9% in 24-58-month-old children. Children living in poor households in rural areas are particularly affected but prevalence is high even in wealthy urban households. The estimated yearly costs of IDA in 6-59-month-old children amount to intangible costs of 8.3 m DALYs and production losses of 24,001 m USD, equal to 1.3% of gross domestic product. Previous calculations have considerably underestimated the intangible costs of IDA as the improved WHO methodology leads to a threefold increase of DALYs due to IDA.

CONCLUSION

Despite years of iron supplementation programs and substantial economic growth, IDA remains a crucial public health issue in India and an obstacle to the economic advancement of the poor. Young children are especially vulnerable due to the irreversible effects of IDA on cognitive development. Our research may contribute to the design of new effective interventions aiming to reduce IDA in early childhood.

Radiation dose and quickness of needle CT-interventions using a laser navigation system (LNS) compared with conventional method

PURPOSE

The aim of this study was to analyse the radiation dose and quickness of needle interventions using a Laser Navigation System (LNS-group) compared with conventional method (control-group).

MATERIALS AND METHODS

In this prospective, randomized, comparative study 58 patients (19 females, 39 males; mean age, 62.9 years) were punctured either with LNS (n=29) or with conventional method with a skin mark of the puncture site (n=29). In the LNS method the puncture site was marked with laser without additional CT. Thoracic and abdominal intervention was performed in 30 and 28 patients, respectively. Radiation dose and time of the procedures were analysed. Statistical significance was calculated according to the Mann-Whitney-U-test.

RESULTS

Mean target access path in the patients of the LNS group was 6.0 cm (range, 3.0-10.1cm) and in the control group 6.0 cm (range, 1.0-10.3 cm). Time duration of complete intervention in the LNS group was 20:25 min (range, 07:00-34:00 min) and in the control group 28:00 min (range, 13:00-51:00 min). The dose-length-product (DLP) of intervention scan of the LNS group was 42.3 mGy cm (range, 10-125 mGy cm), and of the control group 59.7 mGy cm (range, 25-176.42 mGy cm).

CONCLUSION

Using the LNS for CT-guided interventions results in faster intervention time with a lower dose.

Impact evaluation of Swiss Medical Board reports on routine care in Switzerland: a case study of PSA screening and treatment for rupture of anterior cruciate ligament

QUESTIONS UNDER STUDY

Evidence-based recommendations play an important role in medical decision-making, but barriers to adherence are common. In Switzerland, the Swiss Medical Board (SMB) publishes evidence reports that conclude with recommendations. We assessed the impact of two SMB reports on service provision (2009: Recommendation of conservative treatment as first option for rupture of the anterior cruciate ligament of the knee; 2011: Recommendation against PSA screening for prostate cancer).

METHODS

We performed an observational study and assessed quantitative data over time via interrupted times series analyses. The primary outcome was the quarterly number of performed prostate-specific antigen (PSA) tests and the annual rates of surgical ACL repair in patients with ACL rupture. Data were adjusted for time trends and relevant confounders.

RESULTS

We analysed PSA tests in 662,874 outpatients from 2005-2013 and treatment data in 101,737 patients with knee injury from 1990-2011. For the number of PSA tests, the secular trend before the intervention showed a continuous but diminishing increase over time. A statistically significant reduction in tests was estimated immediately after the intervention, but a later return to the trend before the intervention cannot be ruled out. The rate of surgical ACL repair had already declined after the late 1990s to about 55% in 2009. No relevant additional change emerged in this secular trend after the intervention.

CONCLUSIONS

Despite some evidence of a possible change, we did not find a sustained and significant impact of SMB recommendations in our case study. Further monitoring is needed to confirm or refute these findings.

Health technology assessment in Switzerland: a descriptive analysis of "Coverage with Evidence Development" decisions from 1996 to 2013

OBJECTIVES

To identify factors associated with the decisions of the Federal Department of Home Affairs concerning coverage with evidence development (CED) for contested novel medical technologies in Switzerland.

DESIGN

Quantitative, retrospective, descriptive analysis of publicly available material and prospective, structured, qualitative interviews with key stakeholders.

SETTING

All 152 controversial medical services decided on by the Federal Commission on Health Insurance Benefits within the framework of the new federal law on health insurance in Switzerland from 1997 to 2013, with focus on 33 technologies assigned initially to CED and 33 to evidence development without coverage.

MAIN OUTCOME MEASURES

Factors associated with numbers and type of contested services assigned to CED per year, the duration and final outcome of the evaluations and perceptions of key stakeholders.

RESULTS

The rate of CED decisions (82 total; median 1.5/year; range 0-9/year), the time to final decision (4.5 years median; 0.75 to +11 years) and the probability of a final 'yes' varied over time. In logistic regression models, the change of office of the commission provided the best explanation for the observed outcomes. Good intentions but absence of scientific criteria for decisions were reported as major comments by the stakeholders.

CONCLUSIONS

The introduction of CED enabled access to some promising technologies early in their life cycle, and might have triggered establishment of registries and research. Impact on patients' outcome and costs remain unknown. The primary association of institutional changes with measured end points illustrates the need for evaluation of the current health technology assessment (HTA) system.

Magnetic resonance imaging evaluation of lipodystrophy in HIV-positive patients receiving highly active antiretroviral therapy

We evaluated retrospectively an automated method for the separate detection of subcutaneous and visceral fat in the abdominal region by magnetic resonance studies in HIV-positive patients on highly active antiretroviral therapy. The patients were divided into four different groups: lipoatrophy, lipohypertrophy, mixed and the control group. The use of software for the automated detection of abdominal compartment visceral adipose tissue (VAT), total adipose tissue (TAT) and subcutaneous adipose tissue (SAT) was compared to manual evaluation methods (fuzzy C-mean). The results of ROC analysis showed that the parameters, particularly the VAT, are better than the VAT/TAT and at identifying patients with the symptoms of abdominal fat accumulation. A sensitivity of 80.3% and a specificity of 79.5% resulted from a threshold VAT value of >87 cm(2). Moreover, the manual evaluation method was shown to provide greater values for VAT and the VAT/TAT ratio than those given by the automated method. In the present study, a rapid MRI protocol for the detection and assessment of the course of lipodystrophy was presented and tested on a group of patients with signs of HALS, as well as on an antiretroviral naïve control group.

MR-guided laser-induced thermotherapy (LITT) in patients with liver metastases of uveal melanoma

PURPOSE

Evaluation of the local tumour control rate and survival data for magnetic resonance (MR) imaging-guided laser ablation of uveal malignant melanoma liver metastases by using laser-induced interstitial thermotherapy (LITT).

MATERIALS AND METHODS

The LITT was performed in 18 patients with liver metastases (n = 44) from uveal malignant melanoma. All patients tolerated this intervention well. With the Kaplan-Meier method, the survival rates were calculated. Indications for the procedure were defined for patients with no more than five metastases, none of which were larger than 5 cm in diameter: The Indication for LITT treatment were recurrent liver metastases after partial liver resection (22%), locally non-resectable tumours (17%) or metastases in both liver lobes (61%).

RESULTS

The mean survival rate for all treated patients was 3.6 years (95% CI: 2.19, 5.06). We started the calculation on the date of diagnosis of the metastases treated with LITT. The median survival was 1.83 years; 1-year survival, 88%; 3-year survival 47%, 5-year survival 17%. Calculated after the first LITT treatment the median survival was 2.8 years (95% CI: 1.0, 5.0). 10 patients were treated by transarterial chemoembolization before LITT.

CONCLUSION

MR-guided LITT treatment shows a high local tumour control and survival rates in patients with liver metastases of uveal malignant melanoma.

Hospital-integrated general practice: a promising way to manage walk-in patients in emergency departments

RATIONALE, AIMS AND OBJECTIVES

The inappropriate use and overcrowding of emergency departments (EDs) by walk-in patients are well-known problems in many countries. The current study aimed to determine whether ambulatory walk-in patients could be treated more efficiently in a new hospital-integrated general practice (HGP) for emergency care services compared to a traditional ED.

METHODS

We conducted a pre-post comparison before and after the implementation of a new HGP. Participants were walk-in patients attending the ED of a city hospital in Zurich. Main outcome measures were differences in total process time, time intervals between stages of care and diagnostic resources used.

RESULTS

The median process time from admission to discharge was 120 minutes in the ED [interquartile range (IQR): 80-165] versus 60 minutes in the HGP (IQR: 40-90) (P < 0.001). The adjusted odds ratio of receiving any additional diagnostics was 1.86 (95% confidence interval 1.06-3.27; P = 0.032) for ED doctors versus general practitioners (GPs) when controlling for patients' age, sex and injury-related medical problems.

CONCLUSION

The HGP is an efficient way to manage walk-in patients with regard to process time and utilization of additional diagnostic resources. The involvement of GPs in the HGPs should be considered as a promising model to overcome the inappropriate use of resources in EDs for walk-in patients who can be treated by ambulatory care.

Burden of micronutrient deficiencies by socio-economic strata in children aged 6 months to 5 years in the Philippines

Background

Micronutrient deficiencies (MNDs) are a chronic lack of vitamins and minerals and constitute a huge public health problem. MNDs have severe health consequences and are particularly harmful during early childhood due to their impact on the physical and cognitive development. We estimate the costs of illness due to iron deficiency (IDA), vitamin A deficiency (VAD) and zinc deficiency (ZnD) in 2 age groups (6–23 and 24–59 months) of Filipino children by socio-economic strata in 2008.

Methods

We build a health economic model simulating the consequences of MNDs in childhood over the entire lifetime. The model is based on a health survey and a nutrition survey carried out in 2008. The sample populations are first structured into 10 socio-economic strata (SES) and 2 age groups. Health consequences of MNDs are modelled based on information extracted from literature. Direct medical costs, production losses and intangible costs are computed and long term costs are discounted to present value.

Results

Total lifetime costs of IDA, VAD and ZnD amounted to direct medical costs of 30 million dollars, production losses of 618 million dollars and intangible costs of 122,138 disability adjusted life years (DALYs). These costs can be interpreted as the lifetime costs of a 1-year cohort affected by MNDs between the age of 6–59 months. Direct medical costs are dominated by costs due to ZnD (89% of total), production losses by losses in future lifetime (90% of total) and intangible costs by premature death (47% of total DALY losses) and losses in future lifetime (43%). Costs of MNDs differ considerably between SES as costs in the poorest third of the households are 5 times higher than in the wealthiest third.

Conclusions

MNDs lead to substantial costs in 6-59-month-old children in the Philippines. Costs are highly concentrated in the lower SES and in children 6–23 months old. These results may have important implications for the design, evaluation and choice of the most effective and cost-effective policies aimed at the reduction of MNDs.

Intraoperative PEEP-ventilation during PMMA-injection for augmented pedicle screws: improvement of leakage rate in spinal surgery

BACKGROUND

Within the last two decades the use of polymethylmethacrylate (PMMA) in the treatment of osteoporotic vertebral fractures has been established widely. Several techniques of cement application in spinal surgery have been described. Besides classical vertebroplasty, kyphoplasty and related techniques that reinforce stability of the fractured vertebral body itself, augmentation of pedicle screws became an issue in the past 10 years. Aim of this technique is strengthening of the implant-bone-interface and the prevention of loosening and failure of posterior instrumentation in limited bone quality due to osteoporosis. PMMA use in spinal surgery always bears the risk of cement leakage and cement embolism. There are only few publications dealing with cement leakage in pedicle screw augmentation. We examined our cohort concerning incidence and type of leakage in comparison to the literature. In particular, we evaluated a possible role of intrathoracic pressure during cementation procedure.

PATIENTS AND METHODS

In this retrospective study 42 patients were included. Mean age was 74 (57-89) years. 311 fenestrated, augmented screws were analyzed postoperatively concerning leakage and subsequent pulmonary embolism of cement particles. Overall, there was a leakage rate of 38.3 %, and 28.6 % of patients showed pulmonary embolism of PMMA. During surgery, patients were in part ventilated with a positive end-expiratory pressure (PEEP) of 15 cmH2O during cement injection. These individuals showed significantly less leakage locally as well as less PMMA-emboli in the pulmonary circulation in contrast to patients ventilated without increased PEEP.

CONCLUSION

PEEP elevation during administration of PMMA via fenestrated pedicle screws is reducing the leakage rate in spinal surgery. These beneficial effects warrant further evaluation in prospective studies.

Sustained health-economic effects after reorganisation of a Swiss hospital emergency centre: a cost comparison study

Background

Emergency departments (EDs) are increasingly overcrowded by walk-in patients. However, little is known about health-economic consequences resulting from long waiting times and inefficient use of specialised resources. We have evaluated a quality improvement project of a Swiss urban hospital: In 2009, a triage system and a hospital-associated primary care unit with General Practitioners (H-GP-unit) were implemented beside the conventional hospital ED. This resulted in improved medical service provision with reduced process times and more efficient diagnostic testing. We now report on health-economic effects.

Methods

From the hospital perspective, we performed a cost comparison study analysing treatment costs in the old emergency model (ED, only) versus treatment costs in the new emergency model (triage plus ED plus H-GP-unit) from 2007 to 2011. Hospital cost accounting data were applied. All consecutive outpatient emergency contacts were included for 1 month in each follow-up year.

Results

The annual number of outpatient emergency contacts increased from n=10 440 (2007; baseline) to n=16 326 (2011; after intervention), reflecting a general trend. In 2007, mean treatment costs per outpatient were €358 (95% CI 342 to 375). Until 2011, costs increased in the ED (€423 (396 to 454)), but considerably decreased in the H-GP-unit (€235 (221 to 250)). Compared with 2007, the annual local budget spent for treatment of 16 326 patients in 2011 showed cost reductions of €417 600 (27 200 to 493 600) after adjustment for increasing patient numbers.

Conclusions

From the health-economic point of view, our new service model shows ‘dominance’ over the old model: While quality of service provision improved (reduced waiting times; more efficient resource use in the H-GP-unit), treatment costs sustainably decreased against the secular trend of increase.