Cost-effective Care Research Articles

Re-evaluating treatment thresholds in patient blood management: Female patients experience more perioperative anaemia and higher transfusion rates in major elective surgery.

By optimizing erythropoiesis, patient blood management (PBM) programmes can reduce transfusions, lower mortality and provide cost-effective care. While definitions of anaemia have historically varied by sex, for the purposes of PBM, anaemia is defined as a haemoglobin <130 g/L. Our objective was to describe whether perioperative anaemia and transfusion rates in the PBM setting vary by sex. We conducted a retrospective study of the Ontario Nurse Transfusion Coordinators Program (ONTraC) database from 2018 to 2022. ONTraC collects data from 25 Ontario hospitals which together account for >70% of Ontario's provincial blood use (~400,000 units per year). We collected data on patients undergoing elective isolated coronary artery bypass graft surgery (CABG), open heart valve replacement, CABG plus valve replacement, single-knee arthroplasty and single-hip arthroplasty. From 2018 to 2022, 17,700 patients were included in the ONTraC program; 47% were females (N = 8376). Across almost all years and procedures, females were found to have a significantly lower pre-operative, nadir and discharge haemoglobin as compared with males, irrespective of PBM interventions. Transfusion rates were significantly higher for females; this was most pronounced in cardiac surgery. Females experienced more perioperative anaemia and higher transfusion rates. Historic sex-specific definitions of anaemia may contribute to a greater tolerance of anaemia in females. Prioritizing females for multimodal PBM and consistently achieving a pre-operative haemoglobin >130 g/L may reduce the amount of red blood cell (RBC) transfusions that female patients receive.

Comparative study of neonatal hypothermia and associated factors among neonates in rural and urban areas of the Shebadino Woreda, Sidama region, Southern Ethiopia: a community-based comparative cross-sectional study

BackgroundHypothermia is one of the major causes of newborn death, particularly in low-income nations. This was due to poor thermal care in most of the rural communities. Recent studies show that there was a prevalence discrepancy between urban and rural communities where economic, educational, and life standard differences exist. Therefore, this study aimed to assess the prevalence and factors associated with neonatal hypothermia among neonates in rural and urban areas of the Shebadino woreda, Sidama region, Ethiopia.MethodA comparative community-based cross-sectional study was performed on 682 neonates in the Shebadino Woreda, Sidama Region, southern Ethiopia, in 2023. A multistage sampling technique was used, and the collected data were manually cleaned, coded, and entered into Epi Data version 4.6 before being exported to SPSS version 26 software for analysis. Variables with a p-value < 0.25 in the bivariate logistic regression were further analyzed using multivariable logistic regression. The odds ratio (OR) with 95% CI was used as a measure of association, and variables that had a p-value less than 0.05 in the multivariable logistic regression were considered significantly associated variables.ResultsThe overall prevalence of neonatal hypothermia in this study was 51.8% (95% CI: 47.2%-56.3%). It was greater among rural neonates (55.1%) than among urban neonates (48.6%). Bathing before 24 h. (AOR = 3.64, 95% CI: 1.39, 7.16), Placing a cold object near babies’ head (AOR = 2.97, 95% CI: 1.75, 5.03), Neonates who were given traditional medication (Amessa) (AOR = 1.83% CI; 1.04–3.20) and, not separated humans and animals house (AOR = 1.75, 95%, 1.05–2.91) were significantly associated with neonatal hypothermia in rural, while Night time delivery (AOR = 1.81, CI: 1.01–5.62), Neonates who were given traditional medication (Amessa) (AOR = 3.11% CI; 1.85–5.21), and Placing a cold object near babies’ head (AOR = 2.40, 95% CI: 1.37, 3.29 were significantly associated with neonatal hypothermia among urban neonates.ConclusionThe Prevalence of neonatal hypothermia in the study area was relatively greater in rural areas than in urban areas. Cost-effective thermal care such as separating humans from animal houses, teaching not to put cold objects near babies, giving special care to newborns for those delivered from women with medical problems, and giving priority to those delivered at night, is needed.

A randomized, embedded, pragmatic, Bayesian clinical trial examining clinical decision support for high flow nasal cannula management in children with bronchiolitis: design and statistical analysis plan

BackgroundHigh flow nasal cannula (HFNC) has been increasingly adopted in the past 2 decades as a mode of respiratory support for children hospitalized with bronchiolitis. The growing use of HFNC despite a paucity of high-quality data regarding the therapy’s efficacy has led to concerns about overutilization. We developed an electronic health record (EHR) embedded, quality improvement (QI) oriented clinical trial to determine whether standardized management of HFNC weaning guided by clinical decision support (CDS) results in a reduction in the duration of HFNC compared to usual care for children with bronchiolitis.MethodsThe design and summary of the statistical analysis plan for the REspiratory SupporT for Efficient and cost-Effective Care (REST EEC; “rest easy”) trial are presented. The investigators hypothesize that CDS-coupled, standardized HFNC weaning will reduce the duration of HFNC, the trial’s primary endpoint, for children with bronchiolitis compared to usual care. Data supporting trial design and eventual analyses are collected from the EHR and other real world data sources using existing informatics infrastructure and QI data sources. The trial workflow, including randomization and deployment of the intervention, is embedded within the EHR of a large children’s hospital using existing vendor features. Trial simulations indicate that by assuming a true hazard ratio effect size of 1.27, equivalent to a 6-h reduction in the median duration of HFNC, and enrolling a maximum of 350 children, there will be a > 0.75 probability of declaring superiority (interim analysis posterior probability of intervention effect > 0.99 or final analysis posterior probability of intervention effect > 0.9) and a > 0.85 probability of declaring superiority or the CDS intervention showing promise (final analysis posterior probability of intervention effect > 0.8). Iterative plan-do-study-act cycles are used to monitor the trial and provide targeted education to the workforce.DiscussionThrough incorporation of the trial into usual care workflows, relying on QI tools and resources to support trial conduct, and relying on Bayesian inference to determine whether the intervention is superior to usual care, REST EEC is a learning health system intervention that blends health system operations with active evidence generation to optimize the use of HFNC and associated patient outcomes.Trial registrationClinicalTrials.gov NCT05909566. Registered on June 18, 2023.

Workforce estimate to treat mental disorders in the Kingdom of Saudi Arabia

BackgroundMental, neurological, and substance abuse (MNS) disorders describe a range of conditions that affect the brain and cause distress or functional impairment. In the Middle East and North Africa (MENA), MNS disorders make up 10.88 percent of the burden of disease as measured in disability-adjusted life years. The Kingdom of Saudi Arabia (KSA) is one of the main providers of mental health services and one of the largest contributors to mental health research in the region. Within the past decade, mental health resources and services has increased.MethodsWe employ a needs-based workforce estimate as a planning exercise to arrive at the total number of psychiatrists, nurses, and psychosocial care providers needed to meet the epidemiological need of mental health conditions of the population of KSA. Estimates for a potential mental health workforce gap were calculated using five steps: Step 1—Quantify target population for priority mental health conditions. Step 2—Identify number of expected cases per year. Step 3—Set target service coverage for each condition. Step 4—Estimate cost-effective health care service resource utilization for each condition. Step 5—Estimate service resources needed for each condition.ResultsThe planning exercise indicates an epidemiologic need for a total of 17,100 full-time-equivalent (FTE) health care providers to treat priority MNS disorders. KSA appears to have a need-based shortage of 10,400 health workers to treat mental disorders. A total of 100 psychiatrists, 5700 nurses, and 4500 psychosocial care providers would be additionally needed (that is, above and beyond current levels) to address the priority mental health conditions. The shortfall is particularly severe for nurses and psychosocial workers who make up 98.9 percent of the shortfall. This shortage is substantial when compared to other high-income countries. Overall, the workforce needed to treat MNS conditions translates to 49.2 health workers per 100,000 population.ConclusionChallenges to addressing the shortfall are Saudi specific which includes awareness of cultural customs and norms in the medical setting. These challenges are compounded by the lack of Saudi nationals in the mental health workforce. Saudi nationals make up 29.5 percent of the physician workforce and 38.8 percent of the nursing workforce. Policymakers and planners supplement this shortfall with non-Saudi providers, who must be mindful of Saudi-specific cultural considerations. Potential solutions to reducing the shortfall of mental health care workers includes nurse task shifting and training of general practitioners to screen for, and treat, a subset of MNS disorders.

Cost–utility analysis of a palliative care program in Colombia

BackgroundThe economic assessment of health care models in palliative care promotes their global development. The purpose of the study is to assess the cost-effectiveness of a palliative care program (named Contigo) with that of conventional care from the perspective of a health benefit plan administrator company, Sanitas, in Colombia.MethodsThe incremental cost-utility ratio (ICUR) and the incremental net monetary benefit (INMB) were estimated using micro-costing in a retrospective, analytical cross-sectional study on the care of terminally ill patients enrolled in a palliative care program. A 6-month time horizon prior to death was used. The EQ-5D-3 L questionnaire (EQ-5D-3 L) and the McGill Quality of Life Questionnaire (MQOL) were used to measure the quality of life.ResultsThe study included 43 patients managed within the program and 16 patients who received conventional medical management. The program was less expensive than the conventional practice (difference of 1,924.35 US dollars (USD), P = 0.18). When compared to the last 15 days, there is a higher perception of quality of life, which yielded 0.25 in the EQ-5D-3 L (p < 0.01) and 1.55 in the MQOL (P < 0.01). The ICUR was negative and the INMB was positive.ConclusionBecause the Contigo program reduces costs while improving quality of life, it is considered to be net cost-saving and a model with value in health care. Greater availability of palliative care programs, such as Contigo, in Colombia can help reduce existing gaps in access to universal palliative care health coverage, resulting in more cost-effective care.

The effect of intestinal stoma care training on knowledge and skill levels of pediatric surgery nurses

Objectives: The study aimed to examine the effect of intestinal stoma care training on the knowledge and skill levels of pediatric surgery nurses in stoma care and to determine the factors affecting the knowledge and skill levels of pediatric surgery nurses in stoma care. Materials and methods: This quasi-experimental prospective study included 30 nurses (28 females, 2 males; mean age: 33.0±7.5 years; range, 23 to 46 years) working in pediatric surgery clinics who met the inclusion criteria between September 2023 and January 2024. A pediatric intestinal stoma care training was given to the nurses using a 20-min video prepared by the researchers. Data were collected by using a sociodemographic survey and a pediatric stoma care knowledge and skills survey developed by the researchers. The knowledge and skill levels of the nurses before and after the training and after three months were compared. Results: It was found that the pediatric intestinal stoma care training increased the knowledge and skill levels of the nurses. There was a difference between the mean number of practiced skills of nurses working only during the day and nurses working only at night before the training, and this difference was found to be statistically significant. Conclusion: Increasing the knowledge and skill levels of nurses about stoma care could decrease the risk of complications and the duration of hospitalization, ensure cost-effective care, and support the national economy in this direction.

End of life and palliative care decisions in advanced head neck cancer

The complexity of care for patients with advanced head and neck cancer is a significant issue, and current healthcare systems must focus on appropriate referral criteria, increased integration and coordination of care, and robust evaluation of specific care components. Linkage between research and service design delivery across teams, disciplines, and care settings is also important. Palliative care needs of patients with advanced head and neck cancer pose unique complexities due to the impact the illness has on eating, speaking, appearance, and breathing. Specialty palliative care consultation by trained experts helps primary teams facilitate goals of care discussions, symptom management, and medical resource navigation for the terminally ill patient. Early initiation of palliative care results in less invasive and more cost-effective patient-centered care. There is little literature on care practices in this population, and hospital-based care may increase towards the end of life to address potentially reversible conditions or uncertain prognosis. Early advanced care planning and end-of-life care options should be supported alongside continuation of therapy lines.

Update on Overactive Bladder Therapeutic Options.

Millions of Americans are burdened by overactive bladder (OAB) syndrome and the psychogenic and economic hardships that accompany it. Several theories attempt to explain OAB as a neurogenic dysfunction, myogenic dysfunction, urothelial dysfunction, or decreased expression of a channel protein secondary to bladder outlet obstruction. Given that the etiology of OAB is a working theory, the management of OAB is also an evolving subject matter in medicine. There are uncertainties surrounding the pathophysiology of OAB, the strength of a clinical diagnosis, and accurate reporting because of the disease's stigma and decreased use of health care. This is a narrative review that used PubMed, Google Scholar, Medline, and ScienceDirect to review literature on current and future OAB therapies. Currently, first-line treatment for OAB is behavioral therapy that uses lifestyle modifications, bladder-control techniques, and psychotherapy. Second-line therapy includes antimuscarinic agents or beta 3 adrenergic agonists, and studies have shown that combination therapy with antimuscarinics and beta 3 adrenergic agonists provides even greater efficacy than monotherapy. Third-line therapies discussed include onabotulinumtoxinA, posterior tibial nerve stimulation, and sacral neuromodulation. OnabotulinumtoxinA has been FDA-approved as a nonpharmaceutical treatment option for refractory OAB with minimal side effects restricted to the urinary tract. Posterior tibial nerve modulation and sacral neuromodulation are successful in treating refractory OAB, but the costs and complication rates make them high-risk procedures. Therefore, surgical intervention should be a last resort. Estrogen therapy is effective in alleviating urinary incontinence in postmenopausal women, consistent with the association between estrogen deficiency and genitourinary syndrome. Potassium channel activators, voltage-gated calcium channel blockers, and phosphodiesterase inhibitors look to be promising options for the future of OAB management. As new therapies are developed, individuals with OAB can better personalize their treatment to maximize their quality of life and cost-effective care.

Vaginal Hysterectomy and Pelvic Organ Prolapse: History and Recent Developments.

Vaginal hysterectomy (VH) was described as far back as 120 CE. However, it was not till the mid-1900s when reconstructive procedures were introduced to mitigate the risk of, or treat, pelvic organ prolapse in relation to VH. Furthermore, routine hysterectomy, particularly VH, has long been advocated in prolapse surgery. However, this indication is now questionable. Literature review to provide an overview of current evidence and experts' opinion regarding the relationship between VH and pelvic organ prolapse. The review presents a historical perspective on the role of VH in the management of pelvic organ prolapse, the current debate on the usefulness of the procedure in this context, a practical guide on operative techniques used during VH and the impact of recent surgical developments on its use. Vaginal hysterectomy is a well-established technique that is still superior to laparoscopic hysterectomy for benign gynecological disease, although more surgically challenging. However, it is possible that some contemporary techniques, such as vaginal natural orifice transluminal endoscopic surgery, may overcome some of these challenges, and hence increase the number of hysterectomies performed via the vaginal route. Although patients should be counselled about uterine-sparing reconstructive surgery, vaginal hysterectomy continues to be a major surgical procedure in reconstructive pelvic floor surgery. Therefore, it is prudent to continue to train residents in vaginal surgical skills to ensure that they continue to provide safe, cost-effective, and comprehensive patient care.

Educating Our Future Medical Leaders: An Innovative Longitudinal Course Across Surgical and Medical Specialties in Graduate Education.

Increasing healthcare system complexity, multidisciplinary care delivery, and the need to deliver high-quality, cost-effective care drive a critical need for leadership development. Currently, few examples of multidisciplinary leadership development exist in the medical education literature. The Accreditation Council for Graduate Medical Education (ACGME) has identified leadership domains as essential milestones in residency education, encompassing areas such as interpersonal communication, quality improvement, and systems-based practice. Presently, published GME leadership curricula vary widely in content, delivery, and duration and rarely include multispecialty cohorts. The study authors designed and implemented a longitudinal leadership curriculum for a multispecialty cohort of senior residents and fellows from multiple hospitals within a large integrated GME program. Between July 2022-June 2023, authors delivered 12 monthly sessions on core leadership concepts. Sessions delivered relevant work-based content via large-group didactics with embedded opportunities for small-group interactive experiential and reflective practice, critical thinking, and application. Thirty GME trainees participated in the longitudinal curriculum. Interval pre-/post-session assessments demonstrated significant improvement in composite scores for 6 of 9 sessions assessed. Participants rated each module's overall importance, applicability, and acceptability highly on a summative program evaluation. This longitudinal leadership curriculum adheres to best leadership development practices, demonstrates improvement in knowledge and self-reported attitudes and behaviors related to cognitive, character, and emotional leadership domains, and develops a psychologically safe community of practice for GME participants.

Intramural Health Care Through Video Consultations and the Need for Referrals and Hospital Admissions: Retrospective Quantitative Subanalysis of an Evaluation Study.

In comparison to the general population, prison inmates are at a higher risk for drug abuse and psychiatric, as well as infectious, diseases. Although intramural health care has to be equivalent to extramural services, prison inmates have less access to primary and secondary care. Furthermore, not every prison is constantly staffed with a physician. Since transportation to the nearest extramural medical facility is often resource-intensive, video consultations may offer cost-effective health care for prison inmates. This study aims to quantify the need for referrals to secondary care services and hospital admissions when video consultations with family physicians and psychiatrists are offered in prison. In 5 German prisons, a mixed methods evaluation study was conducted to assess feasibility, acceptance, and reasons for conducting video consultations with family physicians and psychiatrists. This analysis uses quantitative data from these consultations (June 2018 to February 2019) in addition to data from a sixth prison added in January 2019 focusing on referral and admission rates, as well as reasons for encounters. At the initiation of the project, 2499 prisoners were detained in the 6 prisons. A total of 435 video consultations were conducted by 12 physicians (3 female and 7 male family physicians, and 2 male psychiatrists during the study period). The majority were scheduled consultations (341/435, 78%). In 68% (n=294) of all encounters, the patient was asked to consult a physician again if symptoms persisted or got worse. In 26% (n=115), a follow-up appointment with either the video consultant or prison physician was scheduled. A referral to other specialties, most often psychiatry, was necessary in 4% (n=17) of the cases. Only in 2% (n=8) of the consultations, a hospital admission was needed. Usually, hospital admissions were the result of unscheduled consultations, and the videoconferencing system was the method of communication in 88% (n=7) of these cases, while 12% (n=1) were carried out over the phone. Reasons for admissions were severe abdominal pain, hypotension, unstable angina or suspected myocardial infarction, or a suspected schizophrenic episode. Most scheduled and unscheduled consultations did not require subsequent patient transport to external health care providers. Using telemedicine services allowed a prompt patient-physician encounter with the possibility to refer patients to other specialties or to admit them to a hospital if necessary.

Multimodal Speech Biomarkers for Remote Monitoring of ALS Disease Progression.

Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease that severely impacts affected persons' speech and motor functions, yet early detection and tracking of disease progression remain challenging. The current gold standard for monitoring ALS progression, the ALS functional rating scale - revised (ALSFRS-R), is based on subjective ratings of symptom severity, and may not capture subtle but clinically meaningful changes due to a lack of granularity. Multimodal speech measures which can be automatically collected from patients in a remote fashion allow us to bridge this gap because they are continuous-valued and therefore, potentially more granular at capturing disease progression. Here we investigate the responsiveness and sensitivity of multimodal speech measures in persons with ALS (pALS) collected via a remote patient monitoring platform in an effort to quantify how long it takes to detect a clinically-meaningful change associated with disease progression. We recorded audio and video from 278 participants and automatically extracted multimodal speech biomarkers (acoustic, orofacial, linguistic) from the data. We find that the timing alignment of pALS speech relative to a canonical elicitation of the same prompt and the number of words used to describe a picture are the most responsive measures at detecting such change in both pALS with bulbar (n = 36) and non-bulbar onset (n = 107). Interestingly, the responsiveness of these measures is stable even at small sample sizes. We further found that certain speech measures are sensitive enough to track bulbar decline even when there is no patient-reported clinical change, i.e. the ALSFRS-R speech score remains unchanged at 3 out of a total possible score of 4. The findings of this study have the potential to facilitate improved, accelerated and cost-effective clinical trials and care.

Market Entry Agreements for Innovative Pharmaceuticals Subject to Indication Broadening: A Case Study for Pembrolizumab in The Netherlands

ObjectivesManaged entry agreements and especially financial-based agreements are commonly used in European countries for innovative cancer pharmaceuticals. These agreements facilitate access to innovative treatments while mitigating financial risks for payers. This study focuses on the confidential price agreement made by the Dutch government for the reimbursement of pembrolizumab, the implications of broadening indications on cost-effectiveness, and the viability or desirability of said agreement. MethodsWe selected 5 indications in which pembrolizumab was deemed effective and developed portioned survival models for each indication. Survival and progression-free survival data from the published trials were utilized to recreate individual patient data, and we extrapolated—using parametric models—to a time horizon of 30 years. Inputs for both quality of life and costs were derived from the available literature and were indexed. ResultsThe incremental cost-effectiveness ratios ranged between €35 313 and €322 349 per quality-adjusted life-year, depending on the indication. Only 1 indication fell under the €80 000 (or €100 000) cost-effectiveness threshold. When applying the average reported discount on intramural pharmaceuticals in The Netherlands, incremental cost-effectiveness ratios ranged between €20 881 and €252 934 per quality-adjusted life-year gained, and the €80 000 (or €100 000) threshold was met in 3 indications out of 5. ConclusionsOur results show that pembrolizumab could be cost-effective in some indications, depending on the confidential price agreement established. However, the possibility of reimbursing not cost-effective care when the price is anchored in 1 indication remains possible. Indication-based pricing could help align value and price for innovative pharmaceuticals that are subject to indication broadening.

Evaluating dyNamic myocardial blood flow qUantitation as a Cost-effective care modeL for diabEtic patients with coronary artery diSease (NUCLEuS): A randomized controlled trial – Rationale and Design

BackgroundRecent advancements in quantifying myocardial blood flow (MBF) and coronary flow reserve using dynamic SPECT MPI have demonstrated comparable hemodynamic correlations with invasive angiography and PET. Implementation into routine practice, however, imposes attendant demands on resources. Diabetes mellitus is a rising pandemic associated with accelerated atherosclerosis, yet there is potential for under-detection of significant ischemia. ObjectivesWe postulate that quantifying myocardial blood flow (MBF) by dynamic SPECT reduces post-test resource utilization and improve economic efficiency over conventional SPECT. MethodsNUCLEuS is an ongoing prospective open-label randomized clinical trial that will enroll 300 diabetic patients without known coronary artery disease (CAD) referred clinically for SPECT MPI from March 2022 to March 2025. The aim is to determine the incremental prognostic value and post-test resource utilization of dynamic MBF over conventional SPECT in diabetic patients with suspected CAD. The primary endpoint is diagnostic failure, defined as unnecessary coronary angiography (absence of ≥50% stenosis in ≥1 coronary artery) or additional anatomical testing (e.g., coronary computed tomography angiography) within 90 days. Secondary endpoints are referrals for angiography or revascularization, escalation of anti-anginal medications, and quality-of-life scores at 12 months. Long-term endpoints are major adverse cardiovascular events (cardiac mortality, myocardial infarction, unstable angina, revascularization) within 36 months. The incremental cost-effectiveness ratio will be estimated based on cost and clinical effectiveness. ConclusionsNUCLEuS will be an imaging-directed clinical trial that will compare differences in outcomes and resource utilization of dynamic MBF over conventional SPECT MPI in the routine clinical management of CAD in diabetes mellitus.

Regional determinants for outcome and cost of status epilepticus

ObjectiveStatus epilepticus (SE) requires informed management. Since regional differences exist in practice and outcome, we aimed to characterize the epidemiology of SE and identify the factors associated with cost-effective management at the sole level IV epilepsy center of Central New York (CNY). MethodsWe searched for patients aged 18 years or older admitted at our center’s hospitals from February 2018 to November 2019 with the discharge diagnosis of SE. Seventy-seven individuals with definite SE were included. We constructed models to determine the main factors that impact the refractoriness of SE, the clinical outcome, and the estimated cost of hospitalization. ResultsThe rate of SE-related disability was 20.8% and the all-cause mortality 36.4%. Our analysis showed that initial anti-seizure medication (ASM) choice did not have a significant influence on the clinical outcome; nor did it affect the refractoriness of SE. Likewise, our anesthetic regimen did not alter the disease course or outcome. In line with prior studies, we demonstrated that age carried a negative predictive value to the SE-related disability and mortality (CI95% [-0.02, 0], p < 0.001). Interestingly, we found that use of midazolam (CI95% [-20.8, −0.08], p = 0.05) and anoxic brain injury as the underlying etiology (CI95% [-33.5, -1.59], p = 0.03) were marginally associated with shorter hospitalizations and reduced cost. The latter might reflect the rapidly-deteriorating course of anoxic brain injury, complicated by its higher likelihood of refractoriness (CI95% [0.14, 0.79], p = 0.006), and consequently, the decision to withdraw care. ConclusionTaken together, we described the demographics, management, and prognosis of SE locally and further defined the potential determinants for the cost-effective care. We found that similar to other studies, age was the main determinant factor in prognosis. We also noticed that midazolam usage was associated with shorter hospital stay, suggesting that strategic use of midazolam may reduce the direct cost of management of SE. These findings can be adopted to optimize SE management in CNY.

Precision in practice: An audit study on low-flow anesthesia techniques with desflurane and sevoflurane for cost-effective and sustainable care.

In the backdrop of escalating healthcare costs and an increasing focus on resource optimization, this audit study delves into the realm of anesthesia management, specifically exploring the application of low-flow anesthesia (LFA). The primary objective was to assess adherence to hospital standards and evaluate the economic implications of LFA (<1 L/min). This retrospective audit focused on 700 adult patients undergoing elective surgeries with general anesthesia. Data sources included anesthesia records, electronic recording systems, and audits by a dedicated team. Fresh gas flow rates (FGFRs), minimum alveolar concentration (MAC), and volatile anesthetic consumption were analyzed. Cost comparisons between low-flow and high-flow anesthesia were conducted, employing specific cost per milliliter metrics. The average FGFR during the maintenance phase was found to be 0.45 ± 0.88 L/min. Adherence to hospital standards was notably high, with 94.29% of patients being maintained on low-flow gas rates. The differences in anesthetic consumption between low-flow and high-flow FGFR were statistically significant for both desflurane (12.17 ± 10.84 ml/MAC hour versus 43.12 ± 27.25 ml/MAC hour) and sevoflurane (3.48 ± 7.22 ml/MAC hour versus 5.20 ± 5.20 ml/MAC hour, P < 0.001). The calculated savings per patient with low-flow desflurane and sevoflurane anesthesia compared to high flow were found to be 109.25 AED and 6.74 AED, respectively. This audit advocates for the widespread adoption of LFA as a standard practice. Beyond aligning with hospital standards, the study highlights the multi-faceted benefits of LFA, encompassing economic savings, environmental safety, and enhanced patient care.

Clinical pathways utilization and concordance with standard of care.

e23226 Background: The rising cost and complexity of cancer care has generated interest from clinicians, healthcare institutions, and payors in creating decision-making tools to help provide consistent, high-quality, and cost-effective care. In accordance with national best practices, the Sidney Kimmel Cancer Center (SKCC) at Thomas Jefferson University Hospital began using system-based clinical pathways (Elsevier’s ClinicalPath™) in August 2019. We hypothesized that regardless of pathway utilization, our treatment decisions by subspecialists would align with clinical pathway algorithms. Methods: Chemotherapy orders for breast, genitourinary (GU), and gastrointestinal (GI) cancers between August 1, 2019 and December 31, 2022 at SKCC were identified via database review. Those ordered outside ClinicalPath were selected for chart review to identify characteristics including disease stage, line of treatment, cycles administered, and treatment response. Orders were compared to contemporaneous versions of ClinicalPath to assess if they were on- or off-pathway. Finally, off-pathway treatments were compared to the NCCN guidelines to determine if they were consistent with the national standard of care. Results: 1670 breast, GU, and GI chemotherapy ordering encounters were identified. Of these, only 105 (6.3%) were ordered outside of the clinical pathways tool and underwent chart review. 41 (39%) treatments agreed with ClinicalPath recommendations despite being ordered outside this system, and 87 (82.2%) were aligned with national guidelines. Treatment of higher stage diseases was more commonly ordered outside of ClinicalPath, with 67.7% having stage 4 disease. Of the orders, alignment with ClinicalPath decreased by stage (57.1% stage 1 vs 36.6% stage 4) and further lines of therapy (48.8% first line vs 25.0% fourth line and beyond). Discordance with national guidelines also correlated with progressive lines of therapy, though not with increasing stage. Conclusions: 93.7% of breast, GU, and GI chemotherapy orders at our institution were entered in ClinicalPath. Often, a goal of staying “on-pathway” is 80%. Of those ordered without ClinicalPath, many agreed with the ClinicalPath recommendation and more than 80% agreed with national guidelines. Differences in pathway and guideline adherence by stage and line of therapy may reflect the complexity of treatment decisions in advanced disease and suggest difficulty capturing these nuances in ClinicalPath. While only a minority of treatment decisions are made outside of ClinicalPath, those decisions largely agree with national guidelines. At a large academic center with oncology subspecialists, further investigation is needed to better understand the additional value of widespread adoption of clinical pathway tools.

The Effectiveness of Albumin-to-Globulin Ratio as a Prognostic Biomarker in Primary Gastrointestinal Cancer: A Systematic Review and Meta-Analysis.

Albumin-to-globulin ratio (AGR) is a cheap, widely accessible component of common blood work that has been implicated in the prognosis of various cancers. This effect is attributed to the cooperative relationship between albumin reflecting the body's nutritional status and globulin serving as an indicator of immune status. With the high morbidity and mortality associated with gastrointestinal cancer and the increasing necessity for cost-effective health care, research into AGR's potential as an indicator of prognosis is warranted. A database search, including key terms between AGR and gastrointestinal cancer, was performed. Random-effects meta-analysis was completed on extracted hazard ratios with two-sided p-values <0.05 being deemed significant. A total of 8,384 patients with gastrointestinal cancer were included. A low AGR was found to be associated with increased risk for reduced overall survival incancer of the primary GI tract (HR: 1.82, 1.35-2.45, p < 0.001), esophageal cancer (HR: 1.57, 1.19-2.06, p < 0.001), colon cancer (HR: 3.36, 2.02-5.58, p < 0.001), and colorectal cancer (HR: 2.27, 1.15-4.48, p = 0.02) populations. A low AGR is significantly associated with increased risk for reduced overall survival in primary gastrointestinal cancer. Due to the ease of access and low cost to physicians and patients, incorporation of AGR into clinical evaluation of prognosis in these cancers should prove beneficial to patient outcomes.

Health Care Digital Strategy: Designing the New Norm

The time has arrived when oral and maxillofacial surgery (OMS) teams must redesign patient care by offering high-quality, easy, and cost-effective virtual care services through digital tools and telemedicine. Only a few pilot programs have been established to date, but now, the new norm requests large-scale routine services. The healthcare institutions should build this strategy based on their long-term goals. A prime example of its successful implementation is our unit at the National Institute of Children's Diseases (Bratislava, Slovak Republic), where a reliable telemedicine program was implemented for the outpatient follow-up visits of patients operated on for craniosynostosis. This program was instrumental in maintaining the long-lasting and high-impact character of craniosynostosis care during the coronavirus disease 2019 (COVID-19) crisis. The parents of the children were surveyed to evaluate the new program's effectiveness. The results were overwhelmingly positive, with an overall parental satisfaction rate of 72.3% and a 67.2% convenience rate for the services. The returned questionnaires revealed that 79.3% of parents were satisfied with physicians' communication, and 88.7% agreed that the virtual meetings adequately addressed their clinical needs. Moving forward, healthcare centers and physicians should organize their time and resources to experiment with the rapidly growing list of digital tools. The organizations should prioritize adapting their clinical information technology (IT) systems for optimal telemedicine practices. With the rapid technological advancements, new digital clinical systems should incorporate the capabilities of generative artificial intelligence (AI) in sophisticated virtual systems. This will require an even closer collaboration between clinicians, scholars, allied healthcare providers, healthcare leaders, and digital system designers. It is clear that in today´s complex healthcare ecosystem, the present and future of care delivery is digital. Will modern OMS teams adopt these strategies? It is something that all of us anticipate with huge interest.

Traumaplasty: When and How to Perform Acute Arthroplasty for Fractures Around the Hip in the Elderly Patient

Acute fractures around the hip are prevalent injuries associated with potentially devastating outcomes. The growing utilization of arthroplasty for femoral neck fractures in the elderly is likely a result of improvements in reoperation rates and postoperative function. Compared to hemiarthroplasty, total hip arthroplasty is associated with a slight functional benefit that is unlikely noticeable for many patients, as well as minimal differences in complications and patient reported outcome measures. However, the evidence supporting cement use in femoral stem fixation is robust. Multiple high power randomized controlled trial-based studies indicate cement fixation brings more predictable outcomes and fewer reoperations. In the setting of acute acetabular fracture, total hip arthroplasty is a favorable approach for elderly patients and fracture patterns associated with increased risk of revision after open reduction and internal fixation. Variations in patient characteristics and fracture patterns demand careful consideration whenever selecting the optimal treatment. In fracture patient populations, comanagement is an important consideration when seeking to reduce complications and promote cost-effective quality care.