A specialty pharmacy mandate is a rule by insurance companies requiring patients to obtain "specialty" medications from specific pharmacies. This study's objective was to evaluate the impact of these mandates on patient care and the solid organ transplantation population. Two surveys were distributed to transplant professionals within the American Society of Transplantation Communities of Practice (AST COPs) and the International Transplant Nurses Society (ITNS). In total, 167 respondents were included (n=105 AST COPs, n=62 ITNS). Most of the AST COP cohort identified as pharmacists (76%), followed by physicians (13%). Most respondents from the ITNS cohort identified their role as nurse/coordinator (97%). Sixty-two percent of respondents from the AST COPs and 48% of respondents from ITNS reported delays in discharge due to specialty pharmacy mandates within the past 12months. Over 60% described delays in initiation of drug therapy related to these mandates. Additionally, 18%-34% of patients required additional outpatient visits and/or readmissions related to medication access issues in the setting of specialty pharmacy mandates. Over 50% of the time, patients paid out of pocket for medications to allow discharge if an override was not possible. Specialty pharmacy mandates delayed discharges, increased cost, and puts undue strain on the healthcare system for solid organ transplant recipients.

Abstract Aim To determine retrospectively whether ARTISS fibrin sealant decreased the incidence of postoperative seroma formation in incisional hernia repair. Methods Review of electronic patient records for all patients who underwent ARTISS fibrin sealant incisional hernia repair due to previous midline laparotomies between January 2021 and July 2024. All patients had a Reevs-Stoppa incisional hernia repair with composite mesh, which was sutured in place with 2/0 prolene. Recorded outcomes included seroma formation and length of hospital stay. Results 38 patients were analysed in the study. The patients’ mean age was 53 years (range 37-69), and 23 patients were male. All the patients were non-smokers, and the cohort’s mean BMI was 27 (range BMI <35). There were no postoperative complications, including seroma formation and no ARTISS adverse effects. The cohort’s average length of hospital stay was 4 days (range 3-6). All patients had a routine outpatient follow-up at 8-10 weeks post-surgery. There was no re-operation within 30 days or additional outpatient department visits. Conclusions This study enabled assessment of collecting necessary data and provided insight into incisional hernia repair outcomes via ARTISS fibrin sealant within a 3.5-year period at a single UK centre. ARTISS fibrin sealant is an effective strategy to help prevent post-operative seroma formation in patients with incisional hernias.

Despite guideline recommendations, many patients with chronic obstructive pulmonary disease (COPD) do not receive or persist with guideline-concordant maintenance inhaled medications. We examined patient and health system factors associated with guideline concordance and persistence. We conducted a population-based cohort study using administrative data from British Columbia, Canada (2011-2022). Patients aged ≥40 years with newly diagnosed COPD were included. Patients were classified as having high risk (≥2 outpatient or ≥1 inpatient exacerbation in the prior year) or low risk (≤1 outpatient exacerbation) of exacerbations, which we used to determine whether dispensed medications were concordant with guidelines. We used separate generalised linear models to evaluate the association between patient, clinical and health system factors and the initiation of guideline-concordant medications and subsequent persistence. We included 71 996 patients with a mean follow-up of 6.15 years (SD 2.65). 30.42% of patients initiated guideline-concordant treatment. Among those who initiated, the mean proportion of days covered (PDC) by guideline-concordant regimens was 31.93%. Patients at high risk of exacerbations initiated guideline-concordant regimens more often than those at low risk (mean 70.4% vs 13.3%) and had a higher mean PDC (57.33% vs 26.35%) per patient-year. Pulmonologist care and additional outpatient visits increased both initiation (OR 5.14, 95% CI 4.88 to 5.41 and OR 1.25, 95% CI 1.24 to 1.26, respectively) and persistence (OR 1.13, 95% CI 1.09 to 1.17 and OR 1.019, 95% CI 1.015 to 1.024, respectively) with guideline-concordant medications. Guideline-concordant use of maintenance inhaled medications is low. Increased access to outpatient and specialist care may support COPD management.

Abstract Rationale: Maintenance inhaled medications are key to managing chronic obstructive pulmonary disease (COPD). Although clinical guidelines provide evidence-based recommendations, many patients either do not receive treatment aligned with these guidelines or have poor adherence to recommended regimens, leading to increased risk of exacerbations and medication-related adverse reactions. We examined trends in the initiation of guideline-concordant medication and adherence to such treatment after initiation, and evaluated patient and health system factors associated with each. Methods: We conducted a population-based cohort study using administrative data from British Columbia, Canada, from 2011 to 2022, which included outpatient medication dispensing records without records of drug samples. Patients aged ≥ 40 years with newly physician-diagnosed COPD were included. Outcomes were analyzed per patient-year from diagnosis. Guideline-concordant medication use was assessed by exacerbation risk, categorized as low risk (≤1 outpatient exacerbation and no hospitalization in the previous year) or high risk (≥2 outpatient exacerbations or ≥1 hospitalization in the previous year). We evaluated the factors associated with 1) the initiation of guideline-concordant maintenance inhaled medication using logistic regression and 2) adherence to guideline-concordant medication in each year after initiation, measured as proportion of days covered (PDC), using linear regression with generalized estimating equations. The initiation of treatment was defined as the first patient-year after diagnosis in which patients received guideline-concordant maintenance inhaled medication of any duration. Results: We identified 88,002 patients with COPD, with a mean follow-up of 6.22 years (SD 2.66). Of these, 37.39% never received any maintenance inhaled medication during follow-up, and 31.91% initiated guideline-concordant treatment. Among initiators, the mean PDC for guideline-concordant medication was 0.30. Patients at high risk of exacerbations initiated guideline-concordant therapy more often than those at low risk (mean 66.21% vs. 13.21%) and had a higher mean PDC (0.58 vs. 0.24) per patient-year. Overtreatment with inhaled corticosteroids in patients at low risk of exacerbation accounted for 70.33% of guideline-discordant regimens, and 68.31% of these patients had no history of asthma. Pulmonologist care and additional outpatient visits were associated with both increased initiation (OR 4.80, 95% CI: 4.58–5.03, and 1.25, 95% CI: 1.24–1.26, respectively) and adherence (PDC increase of 0.03, 95% CI: 0.02–0.03, and 0.004, 95% CI: 0.003–0.005, respectively) to guideline-concordant medications. Conclusions: Guideline-concordant use of maintenance inhaled medications is low in COPD. Addressing barriers at multiple levels of care delivery may improve evidence-based COPD management.

The increasing prevalence of chronic conditions is a significant challenge for healthcare systems worldwide, not only from a public health perspective but also for the aggregate cost that these represent. This paper estimates the additional use of healthcare services due to chronic health conditions and their associated costs in nine European countries. We analyzed inpatient and outpatient healthcare utilization using longitudinal data (Survey of Health, Ageing and Retirement in Europe [SHARE]). We implemented a difference-in-differences approach across multiple time periods. Monetary estimates were derived using WHO-CHOICE healthcare service costs. To compare countries, we calculated the healthcare cost burden of chronic conditions as a percentage of total health expenditure. People with chronic conditions require significantly more healthcare services than those without such conditions, averaging three additional outpatient visits and one extra overnight inpatient stay annually. These patterns vary across countries. In Germany, outpatient care usage is particularly high, with an average of four additional visits, while Switzerland leads in inpatient care with two extra overnight stays. The associated costs also differ widely, influenced by variations in healthcare demand, service pricing, and the prevalence of chronic conditions in each country. Chronic conditions significantly increase healthcare utilization, and demographic trends suggest this demand will continue to grow steadily. This rising pressure poses serious challenges for healthcare systems, necessitating a shift toward more efficient service delivery models.

Cancer remains one of the leading causes of mortality and financial distress worldwide. In South Korea, the government introduced a benefit extension system in 2013 aimed at mitigating the financial strain associated with cancer treatment. However, cancer patients continue to bear significant out-of-pocket (OOP) expenses. This study aims to quantify the incremental healthcare utilization and OOP expenditures incurred by cancer patients in South Korea. Utilizing data from the 2019 Korean Health Panel (KHP), we assessed cancer-related healthcare utilization and OOP expenditures. A generalized linear regression model, adjusted for demographic and socioeconomic variables, was employed. Healthcare utilization was measured by hospital admissions, outpatient visits, and emergency room (ER) visits, while OOP expenditures encompassed services including both covered and not covered by the National Health Insurance (NHI) system. Cancer patients experienced 0.39 more hospitalizations, 4.91 additional outpatient visits, and 0.11 more ER visits annually compared to non-cancer patients. Their incremental OOP expenses amounted to $482.8 per year, with $340.2 attributable to inpatient services. Notable variations in healthcare utilization and expenditures were observed across different cancer types. Despite the implementation of the benefit extension system, cancer patients continue to face considerable OOP expenses, particularly for inpatient care. With cancer incidence expected to rise, there is a pressing need for more comprehensive healthcare policies that alleviate the financial burden and prioritize cost-effective treatments for cancer patients. This study underscores the substantial economic impact of cancer on South Korean patients. Expanding the benefit extension system and promoting cost-effective care strategies are critical to easing the growing financial pressures on cancer patients.

BackgroundMost COVID-19 patients are treated in primary healthcare settings in France, where patients are typically assigned one general practitioner (GP) for the continuum of their care. The risk of progression to severe disease and death is higher in immunocompromised patients with COVID-19. We descriptively summarize the characteristics, documented clinical management and outcomes of immunocompromised patients diagnosed with COVID-19 in the outpatient setting in France.Table 1:Characteristics of immunocompromised patients diagnosed with COVID-19 in the outpatient setting, 2022-2023MethodsAdults with an immunocompromised condition and a documented diagnosis of COVID-19 in 2022-2023 were identified from The Health Improvement Network (THIN). THIN collects anonymized patient-level data from electronic health records of GPs and some specialists in the outpatient setting representative of the French population. Index was the first documented COVID-19 diagnosis, and patients with COVID-19 diagnosis the 3-months prior to index were excluded. COVID-19 treatments prescribed within1-month post-index were examined. Reinfection was defined as COVID-19 infection documented in outpatient setting at least 3 months after index.Table 2:Clinical management of immunocompromised patients diagnosed with COVID-19 in the outpatient setting, 2022-2023ResultsOverall, 13,354 immunocompromised patients with COVID-19 with a median age of 59 years (IQR:47—72), and 66% female were identified. Majority had an immunocompromised condition of active cancer diagnosed in the 3-years prior to index (76%). 64% had at least another key comorbidity documented in the 12-months prior (Table 1).Treatments prescribed included antibacterials (30%), corticosteroids (17%), nirmatrelvir/ritonavir (5%); COVID-19 was documented as the reason for antibacterial prescriptions (15% overall) and corticosteroids (8% overall) (Table 2).Post-index, 14% had at least one additional outpatient visit within 7 days, 37% within 30 days, and 54% within 60 days with an average 0.9 (SD=1.1) visits within 60 days (Table 3).Table 3:Clinical outcomes of immunocompromised patients diagnosed with COVID-19 in the outpatient setting, 2022-2023ConclusionThe use of nirmatrelvir/ritonavir was low among immunocompromised patients with COVID-19 diagnosed in outpatient visits. In contrast, inappropriate prescription of corticosteroids and antibacterials was frequent. There is a need for effective treatment options for immunocompromised patients as they face a significant healthcare burden with frequent follow-up visits and COVID-19 reinfections.DisclosuresEssy Mozaffari, PharmD, MPH, MBA, Gilead Sciences, Inc.: Employee|Gilead Sciences, Inc.: Stocks/Bonds (Public Company) Aastha Chandak, PhD, Gilead Sciences Inc.: My organization (Certara) was contracted by Gilead to conduct this study Mark Berry, PhD, Gilead Sciences, Inc.: Employee|Gilead Sciences, Inc.: Stocks/Bonds (Public Company) Gaelle gusto, PhD, Gilead Sciences Inc.: My organization (Certara) was contracted by Gilead to conduct this study Giancarlo Pesce, Sr Consultant, Gilead Sciences Inc.: My organization (Certara) was contracted by Gilead to conduct this study Agnese Restuccia, PhD, Gilead Sciences: Stocks/Bonds (Private Company) Michele Bartoletti, MD, PhD, Advan pharma: Advisor/Consultant|Advan pharma: Honoraria|Biomereux: Honoraria|Gilead: Advisor/Consultant|Gilead: Honoraria|Infectopharma: Advisor/Consultant|Msd: Advisor/Consultant|Msd: Grant/Research Support|Msd: Honoraria|Pfizer: Honoraria Paul LOUBET, MD, PhD, Astrazeneca: Advisor/Consultant|Gilead: Advisor/Consultant|Moderna: Advisor/Consultant|Pfizer: Advisor/Consultant

Patients with symptomatic breast hypertrophy typically suffer from chronic back pain, recurrent skin irritation at the inframammary fold and/or low self-esteem resulting in impaired quality of life. Reduction mammaplasty has been shown to effectively treat symptomatic breast hypertrophy with high patient satisfaction. Despite the obvious benefits, reimbursement requests for reduction mammaplasty are initially often refused by the patient's health insurance company, thereby frequently resulting in additional examinations and eventually extra expenses. The study aim was to evaluate the reimbursement policy by health insurance companies for treatment costs of reduction mammaplasty in a patient cohort, to quantify the generation of additional costs due to initial refusal of reimbursement, as well as to assess back pain after surgical treatment. A retrospective cohort study was conducted in two Swiss centres. Inclusion criteria were a diagnosis of symptomatic breast hypertrophy, cost approval for reduction mammaplasty by the health insurance between October 2014 and March 2021 and informed consent for the study. The exclusion criteria were private payers for reduction mammaplasty and patients aged below 18. Primary outcome measures included median duration between the first request for reimbursement sent to the health insurance and the receipt of its approval, the number of requests needed per patient, as well as the number and type of additional outpatient visits conducted by specialists other than plastic surgeons, including the need for further diagnostic investigations and therapeutic measures. Secondary outcome measures included the additional costs generated in patients with more than one request. Finally, back pain after surgical treatment was assessed using a visual analogue scale (VAS). A total of 46 patients with symptomatic breast hypertrophy and approval for reimbursement were included in the study. The median duration to obtain cost approval for reduction mammaplasty was 9.4 weeks (ranging from 1 to 154 weeks). Reimbursement was approved after 1, 2, 3 or 4 requests in 26, 6, 11 and 3 patients, respectively. If the first request was refused, further clinical evaluation by specialists, additional imaging of the cervical spine and physiotherapy was necessary in 70%, 35% and 80% of the patients, respectively. A patient requiring more than one request to obtain cost approval for reduction mammaplasty generated additional mean costs of approximately 2400 CHF, i.e. 2181 CHF, 164 CHF and 46 CHF for ongoing physiotherapy, additional outpatient visit by a specialist doctor and complementary imaging compared to patients needing only one request for cost approval. The level of back pain could be reduced from 7.0 before surgery to 1.6 after surgery. Patients with symptomatic breast hypertrophy who needed more than one request for cost approval (43%) had to undergo further outpatient visits and/or radiological examinations, as well as physiotherapy, despite a clear indication for surgery, resulting in a prolonged symptomatology and increasing healthcare costs.

Purpose: In Slovenia, the transition from paper-based to electronic sick leave certificates (hereafter referred to as eBOLs) started at the beginning of 2020. While paper sick leave certificates are still widely used worldwide, many European countries are already reaping the benefits of using the eBOL system. This survey aimed to determine patients' satisfaction with the new eBOLs and highlight the most significant advantages and disadvantages from the patient's viewpoint. Methods: A quantitative cross-sectional survey was conducted in Maribor, Slovenia, and the surrounding area to collect quantitative data from family medicine outpatient clinics. Two hundred and fifty patients were randomly selected among those receiving either paper or electronic sick leave certificates. The survey was conducted online with a web survey link and consisted of two parts. The first part included eight items measuring patients’ experiences with electronic and paper sick leave certificates, rated on a five-point Likert scale. The second part consisted of two multiple-choice questions regarding the advantages and disadvantages of eBOLs. The data were analysed using bivariate statistical analysis. Results: Out of the 250 patients invited to participate in the study, 80 responded, resulting in a response rate of 32%. The mean age of the participants was 46.2 ± 11.2 years, with 56 (70%) women and 24 (30%) men. After more than a year of usage, 57 (71.3%) respondents expressed complete agreement that the eBOL system makes it easier for patients to manage their sick leave. Furthermore, 55 (68.8%) participants considered eBOLs as a good alternative to paper sick leave certificates. Most participants (76 (95%)) considered avoiding additional outpatient visits to manage their sick leave as the most significant advantage of using eBOLs. However, 64 (80%) respondents expressed uncertainty about the data sent by the eBOL system as the most significant disadvantage. Summary: The survey results showed that patients were already significantly satisfied with the eBOL system when it was first introduced and that their satisfaction increased with continued use. A broader survey including a larger number of Slovenian outpatient clinics and capturing both patients' and doctors' opinions would provide more precise and broader insights into the newly introduced IT system's advantages and disadvantages and its users' satisfaction.

Abstract Reflectance confocal microscopy (RCM) is a noninvasive technique for in vivo examination of the skin. In vivo RCM can be used to diagnose basal cell carcinoma (BCC) noninvasively. Previous studies have demonstrated that RCM is an accurate technique for the diagnosis of BCC. RCM has the advantage that it is noninvasive and provides the diagnosis within a few minutes. By contrast, the current standard of care requires an invasive biopsy, taking several days before the result is available, and is costly and can result in sampling errors. We provide a snapshot of how we have integrated RCM into our service, and how it has reduced the number of biopsies, resulting in significant cost savings and shortening patients’ pathways. Sixty-three patients with suspected BCC of the head and neck were referred to our RCM clinic in January, February and March 2023. A diagnosis of BCC was made by RCM in real time in 89% of cases (56 of 63). Confirmation of the diagnosis of BCC in clinic facilitated discussion with the patient at the same outpatient attendance with regards to treatment, without the need for an additional outpatient visit. Overall, 11% of patients (seven of 63) suspected of having a BCC, whose diagnosis could not be confirmed by RCM, required a biopsy that confirmed the diagnosis of BCC. The median turnaround time for the biopsy result was 12 days. The cost of a punch biopsy in our hospital is £330 per patient, of which £176 is attributable to histopathology costs. Following the diagnosis of BCC, 73% (46 of 63) were referred directly for Mohs surgery, 12% (eight of 63) had conventional excision, 5% (three of 63) were referred for radiotherapy, and 10% (six of 63) were managed conservatively. We have shown that integrating RCM into our dermatology service has negated the need for biopsy in 89% of head and neck BCCs referred to the RCM clinic. RCM has resulted in shortening of patients’ pathways, it has reduced the pressure on our histopathology service, it has lessened the risk of false negative biopsies due to sampling errors, and it has produced significant cost savings. The diagnosis of BCC by RCM is a simple skill to acquire and allows the clinician to make the diagnosis with a few minutes. For patients, it is a more acceptable method of diagnosing BCC without recourse to biopsy. For the wider NHS, it has the potential for significant cost savings.

BackgroundThis study investigated the incidence and clinical consequences of abnormal radiological and clinical findings during routinely performed 6-week outpatient visits in patients treated conservatively for multiple (3 or more) rib fractures.MethodsA retrospective analysis was conducted among patients with multiple rib fractures treated conservatively between 2018 and 2021 (Opvent database). The primary outcome was the incidence of abnormalities on chest X-ray (CXR) and their clinical consequences, which were categorized as requiring intervention or additional clinical/radiological examination. The secondary focus was the incidence of deviation from standard treatment in response to the findings (clinical or radiological) at the routine 6-week outpatient visit.ResultsIn total, 364 patients were included, of whom 246 had a 6-week visit with CXR. The median age was 57 years (interquartile range, 46–70 years) and the median Injury Severity Score was 17 (interquartile range, 13–22). Forty-six abnormalities (18.7%) were found on CXR. These abnormalities resulted in additional outpatient visits in 4 patients (1.5%) and in chest drain insertion in 2 (0.8%). Only 2 patients (0.8%) with an abnormality on CXR presented without symptoms. None of the 118 patients who had visits without CXR experienced problems.ConclusionRoutine 6-week outpatient visits for patients with conservatively treated multiple rib fractures infrequently revealed abnormalities requiring treatment modifications. It may be questioned whether the 6-week outpatient visit is even necessary. Instead, a more targeted approach could be adopted, providing follow-up to high-risk or high-demand patients only, or offering guidance on recognizing warning signs and providing aftercare through a smartphone application.

We estimated healthcare resource utilization (HRU) and costs in patients with generalized myasthenia gravis (gMG) in Taiwan. This retrospective population-based, matched cohort study used the National Health Insurance Research Database to identify prevalent patients with gMG (cases) in 2019. In total, 2537 cases were matched (1:4) by age, sex, and urbanization level to 10148 randomly selected patients without gMG (comparators). A generalized linear regression model predicted the frequency of HRU and costs among service users. Costs attributable to gMG were obtained by subtracting all-cause HRU costs incurred by comparators from cases. The mean age of all patients was 54.99 years and 55.97% were female. Compared with comparators, cases had significantly higher rates of hypertension (33.03%/24.26%), diabetes mellitus (18.92%/11.37%), malignancies (16.00%/4.08%), cardiovascular disease (11.35%/8.12%), thyroid-related conditions (5.99%/1.16%), respiratory illness/disorders (4.38%/1.22%), and neurotic disorders (4.65%/2.6%). Amongst users of healthcare resources, cases had a mean 10 additional outpatient visits, 0.62 inpatient stays, and 0.49 emergency room visits in 2019 compared with comparators (p < 0.0001 for all). The mean (standard deviation) difference in all-cause healthcare costs between cases and comparators was NT$ 94997 (76431) [US$ 3133 (2521)], and was significantly higher for all categories (outpatient, inpatient, emergency room, drugs; p < 0.0001 for all). Among employed persons, 13.18%/7.59% of cases/comparators changed employment status during the study (p < 0.0001). gMG presents a substantial burden on HRU and healthcare costs in Taiwan. A high attrition rate from full-time employment suggests additional societal costs. Improved treatments are needed to alleviate the burden of disease on individuals, healthcare systems, and economies.

Purpose: Axillary lymph node dissection (ALND) is performed to treat locoregional metastatic disease in breast cancer and melanoma patients. However, it is notorious for its complications, most commonly seroma formation and its sequelae. Ample research has been done to evaluate seroma formation after ALND; these results, however, have not been conclusive. Hence, this pilot study aimed to evaluate a readily available haemostatic patch, Hemopatch®, to assess its effect on seroma formation following ALND. Methods: In this pilot study, a prospective cohort of 20 patients receiving Hemopatch® following ALND was compared to a retrospective cohort of patients who underwent ALND between 2014 and 2019. The primary outcome measure was the number of patients developing clinically significant seroma (CSS) after ALND. Additionally, the number of wound complications, subsequent interventions, additional outpatient clinic visits, and drain output was assessed. Differences between groups were deemed clinically relevant if the proportions differed >50% between groups. Results: In total, 20 prospective and 42 retrospective patients were included. In the Hemopatch® group, 30% of the patients developed CSS, compared to 43% in the control group. Three patients in both groups developed a surgical site infection . Thirty-five percent of patients in the Hemopatch® group required additional unscheduled visits versus 62% of patients in the control group. Conclusion: The application of Hemopatch® after ALND did not lead to a clinically relevant reduction of CSS and wound complications. However, fewer Hemopatch® patients required additional outpatient clinic visits. Due to the limited amount of participants, the true value of Hemopatch® in ALND remains unclear.

Abstract BACKGROUND AND AIMS In Japan, &amp;gt; 97% of patients with end-stage kidney disease (ESKD) select hemodialysis as a renal replacement therapy (RRT). Hemodialysis (HD) and peritoneal dialysis (PD) have been provided at our hospital for many years, and kidney transplantation (KT) has been available here since 2015. In January 2018, we introduced the option of RRT for outpatients based on the shared decision-making (SDM) method, which was recently shown to be useful for patients. METHOD Patients receive ∼1-h explanation of the SDM method by a nurse in the outpatient department. If patients desire additional outpatient visits, they receive as many as they want; a decision about RRT is not required after a single visit and patients can change their decision at any time. We conducted a prospective observational study to investigate patients’ selection of RRT and the influence of the SDM method on the selection of RRT. The data were examined by Fisher's exact test and significance was accepted at P &amp;lt; 0.05. RESULTS During the period from January 2018 to December 2021, 116 patients visited our outpatient department and 69 patients underwent RRT. Only 53% of the patients initially requested hemodialysis (Figure 1), but &amp;gt; 80% of the patients eventually underwent hemodialysis (Figure 2). From 2018 to 2021, 156 patients started RRT; 58 of them (37%) had visited the outpatient department before starting RRT. The number of patients who visited the outpatient department has increased year by year. The emergency initiation of dialysis decreased significantly after the outpatient use of the SDM method began [odds ratio (OR) 0.44, P = 0.024]. CONCLUSION There was a tendency for patients’ satisfaction regarding their own selection of RRT via the SDM method in the outpatient department. Patients can obtain the information they need and select a better treatment for themselves via an explanation of the SDM method. The SDM method is thus very effective for both patients and medical staff when considering RRT.

Seroma is a common complication after mastectomy, with an incidence of 3% to 85%. Seroma is associated with pain, delayed wound healing, and additional outpatient clinic visits, leading potentially to repeated seroma aspiration or even surgical interventions. This study aimed to assess the effect of flap fixation using sutures or tissue glue in preventing seroma formation and its sequelae. Between June 2014 and July 2018, 339 patients with an indication for mastectomy or modified radical mastectomy were enrolled in this randomized controlled trial in the Netherlands. Patients were randomly allocated to one of the three following arms: conventional wound closure (CON, n = 115), flap fixation using sutures (FFS, n = 111) or flap fixation using tissue glue (FFG, n = 113). The primary outcome was the need for seroma aspiration. The secondary outcomes were additional outpatient department visits, surgical-site infection, shoulder function and mobility, cosmesis, skin-dimpling, and postoperative pain scores. Flap fixation after mastectomy leads to fewer seroma aspirations than conventional wound closure (CON 17.5% vs FFS 7.3% vs FFG 10.8%; p = 0.057), with a significant difference between flap fixation with sutures and conventional wound closure (odds ratio [OR], 0.37; 95% confidence interval [CI], 0.16-0.89; p = 0.025). Flap fixation has no significant negative effect on surgical-site infections, shoulder function and mobility, cosmesis, skin-dimpling, or postoperative pain. Flap fixation using sutures leads to a significant reduction in aspirations of post-mastectomy seromas. The authors strongly advise surgeons to use sutures for flap fixation in patients undergoing mastectomy. (ClinicalTrials.gov no. NCT03305757). The trial was registered after enrollment of the first participant. However, no specific explanation exists for this except that through the years more importance has been given to central trial registration. Our research team can ensure that after enrollment of the first participant, no changes were made to the trial, analysis plan, and/or study design.

Potential Value of Haptic Feedback in Minimally Invasive Surgery for Deep Endometriosis

Obesity is a major risk factor for many chronic diseases and disabilities, with severe implications on morbidity and mortality among older adults. With an increasing prevalence of obesity among older adults in Ghana, it has become necessary to develop cost-effective strategies for its management and prevention. However, developing such strategies is challenging as body mass index (BMI)-specific utilization and costs required for cost-effectiveness analysis are not available in this population. Therefore, this study examines the associations between health services utilization as well as direct healthcare costs and overweight (BMI ≥25.00 and <30.00 kg/m2) and obesity (BMI ≥30.00 kg/m2) among older adults in Ghana. Data were used from a nationally representative, multistage sample of 3350 people aged 50+ years from the World Health Organization's Study on global AGEing and adult health (WHO-SAGE; 2014/15). Health service utilization was measured by the number of health facility visits over a 12-month period. Direct costs (2017 US dollars) included out-of-pocket payments and the National Health Insurance Scheme (NHIS) claims. Associations between utilization and BMI were examined using multivariable zero-inflated negative binomial regressions; and between costs and BMI using multivariable two-part regressions. Twenty-three percent were overweight and 13% were obese. Compared with normal-weight participants, overweight and obesity were associated with 75% and 159% more inpatient admissions, respectively. Obesity was also associated with 53% additional outpatient visits. One in five of the overweight and obese population had at least one chronic disease, and having chronic disease was associated with increased outpatient utilization. The average per person total costs for overweight was $78 and obesity was $132 compared with $35 for normal weight. The NHIS bore approximately 60% of the average total costs per person expended in 2014/15. Overweight and obese groups had significantly higher total direct healthcare costs burden of $121 million compared with $64 million for normal weight in the entire older adult Ghanaian population. Compared with normal weight, the total costs per person associated with overweight increased by 73% and more than doubled for obesity. Even though the total prevalence of overweight and obesity was about half of that of normal weight, the sum of their cost burden was almost doubled. Implementing weight reduction measures could reduce health service utilization and costs in this population.

Evidence-based adoption of purse-string skin closure for stoma wounds

Despite recent studies suggesting arthroscopic partial meniscectomy (APM) is not more effective than physical therapy (PT), the procedure is still frequently performed in patients with meniscal tears. To assess whether PT is noninferior to APM for improving patient-reported knee function in patients with meniscal tears. Noninferiority, multicenter, randomized clinical trial conducted in 9 hospitals in the Netherlands. Participants were aged 45 to 70 years with nonobstructive meniscal tears (ie, no locking of the knee joint). Patients with knee instability, severe osteoarthritis, and body mass index greater than 35 were excluded. Recruitment took place between July 17, 2013, and November 4, 2015. Participants were followed up for 24 months (final participant follow-up, October 11, 2017). Three hundred twenty-one participants were randomly assigned to APM (n = 159) or a predefined PT protocol (n = 162). The PT protocol consisted of 16 sessions of exercise therapy over 8 weeks focused on coordination and closed kinetic chain strength exercises. The primary outcome was change in patient-reported knee function on the International Knee Documentation Committee Subjective Knee Form (range, 0 to 100; from worse to best) from baseline over a 24-month follow-up period. The noninferiority margin was defined as a difference between treatment groups of 8 points and was assessed with a 1-sided α of .025. The primary analysis followed the intention-to-treat principle. Among 321 patients who were randomized (mean [SD] age, 58 [6.6] years; 161 women [50%]), 289 (90%) completed the trial (161 women and 158 men). In the PT group, 47 participants (29%) had APM during the 24-month follow-up period, and 8 participants randomized to APM (5%) did not have APM. Over a 24-month follow-up period, knee function improved in the APM group by 26.2 points (from 44.8 to 71.5) and in the PT group by 20.4 points (from 46.5 to 67.7). The overall between-group difference was 3.6 points (97.5% CI, -∞ to 6.5; P value for noninferiority = .001). Adverse events occurred in 18 participants in the APM group and 12 in the PT group. Repeat surgery (3 in the APM group and 1 in the PT group) and additional outpatient visits for knee pain (6 in the APM group and 2 in the PT group) were the most frequent adverse events. Among patients with nonobstructive meniscal tears, PT was noninferior to APM for improving patient-reported knee function over a 24-month follow-up period. Based on these results, PT may be considered an alternative to surgery for patients with nonobstructive meniscal tears. ClinicalTrials.gov Identifier: NCT01850719.

Internal drainage of the upper urinary tract by stenting is a common urological procedure. The use of stenting in modern urological practice is on the rise due to widespread adoption of modern endourological, laparoscopic, percutaneous and high-tech robotic interventions. The presence of a stent in the patients body may cause stent-related symptoms and negatively affect the quality of life, resulting in additional outpatient visits and hospitalizations. The review provides an analysis of the causes, diagnostic evaluation, prevention and treatment of stent-related symptoms. The authors describe the management options including -blockers, anticholinergics, and their combinations.