Cost Of Procedure Research Articles

Transcatheter closure of atrial septal defect (ASD) in adult and paediatric population without transoesophageal echocardiography/general anaesthesia

Abstract Background Transcatheter device closure is the preferred therapeutic option for ostium secundum atrial septal defect(OS-ASD). Standard practice is to perform it under transoesophageal echocardiography(TEE) guidance. However, TEE is performed under general anaesthesia (GA) and leads to increases in cost, procedural duration, ICU stay, total hospital stays, risk of oesophageal injury and complications of GA. Transthoracic echocardiography(TTE) is an excellent alternative and prior studies have shown it to be a safe alternative in paediatric population. In current study we analysed safety and efficacy of TTE-guided device closure of OS-ASD in all comer population irrespective of age, weight, defect size. Methods The study enrolled all patients who underwent device closure of OS-ASD between March 2017 and December 2023. All procedures were performed under LA for adults and conscious sedation for children. The device was placed under fluoroscopy guidance and position were confirmed on TTE. Procedural success, device, defect size ratio, procedural time, fluoroscopy time, complications, intensive care unit/hospital stay duration were analysed and compared with our own experience of 125 patients with TEE-guided closures before switching to complete TTE-guided procedure(before 2017). Results 340 patients underwent TTE-guided device closure of ASD. Procedure success was 97.4% with acceptable risk of major complications. Three(0.8%) had embolization into pulmonary artery, successfully operated surgically. Two had tamponade requiring drainage. In 9 patients, device could not be deployed despite multiple attempts and approaches. All of these had defect size of > 34mm and deficient IVC rim along with shorter (other than aortic) rim. Findings were compared with our own previous experience of TOE guided closure (practised before 2017). Compared to TOE group, TTE group had significantly lower total procedural duration (75±4 vs. 28 ±1 min; p < 0.01), intensive care unit stay (24±10 vs. 10.5±1 h; p < 0.01), and hospital (48±12 vs. 25.5±4h; p < 0.01) stay duration. Fluoroscopic time was similar in both. There was no mortality in either group. Major complications were comparable, TTE-guided group had less post-procedure complications of vomiting and headache. Additional findings of less pre-procedure fasting duration and early commencement of post procedure oral intake were noted in TTE group. Conclusion TTE-guided device closure of OS-ASD is a safe and feasible in all-comer population in experienced hands. It can definitely negate the use of TEE except in very poor echo window. The added advantages include utilization of physiological variations in PV/LV pressure during cough, Valsalva manoeuvres in awake patients. It definitely reduces the procedural duration, cost of procedure and dependence on GA and trained transoesophageal echocardiographer.

REPRODUÇÃO ASSISTIDA: DESAFIOS E AVANÇOS DAFERTILIZAÇÃO IN VITRO E INSEMINAÇÃO ARTIFICIAL COM PERSPECTIVAS ATUAIS E FUTURAS

Assisted human reproduction (AHR) is a set of medical techniques that enable human reproduction with assistance, contributing to cases of infertility, advanced age, same-sex couples, independent gestation, and family planning. The main techniques are artificial insemination and in vitro fertilization (IVF). This exploratory-descriptive study investigates the challenges faced by these couples, as well as recent advancements and future perspectives of these techniques. The analysis includes a review of recent literature, focusing on advancements such as improved ovarian stimulation protocols and embryo selection, as well as the impact of emerging technologies. The study also addresses the variable success rates, procedure costs, and ethical issues involved. It is expected that ongoing innovations will improve success rates, reduce risks, and enhance the accessibility of these treatments. Currently, the technique of intracytoplasmic sperm injection (ICSI) is widely used. Despite the challenges, AHR has enabled infertile couples to realize their dream of parenthood. With scientific and technological advancements, it is anticipated that AHR techniques will continue to evolve to benefit more and more couples wishing to have children.

No reimbursement policy and implantable loop recorders in the real world setting

Abstract Background Prolonged heart rhythm evaluation is indicated in patients with suspected arrhythmias. Routine electrocardiographic Holter monitoring is often associated with poor adherence and may lead to little to no clinically relevant findings. Implantable loop recorders (ILRs) are small, subcutaneous cardiac devices providing semi-continuous electrocardiographic recording. Despite strong evidence supporting their effectiveness, ILRs are yet to be fully reimbursed by the National Health Fund- the public insurer in Poland. Purpose We aimed to investigate the feasibility, as well as the diagnostic yield of ILRs in a real world setting of a tertiary cardiovascular center. Methods We retrospectively analyzed data of consecutive patients admitted for ILR implantation between March 2013 nad November 2023. Hospitalization and procedural costs were covered by the clinic's statutory and hospital funds and not by the National Health Fund, the public payer. All patients were remotely monitored for device follow-up. Baseline demographic characteristics, as well as data regarding observation period, clinical outcomes and safety were collected. Results Data for 51 ILR implants in 50 patients was assessed. Insertion success rate was 100% on first attempt with no complications. Mean age was 54,43 ±18,56 years old. 52,94% of patients were female. Coronary artery disease was present in 21,57% patients, hypertension in 50,98%, diabetes in 13,73%. The indications for ILR implantation were unexplained syncope (n= 42; 82,35%), palpitations (n= 16; 31,37%), ischemic stroke of unknown origin (n= 6; 11,76%), monitoring of ventricular arrhythmia (n= 2; 3,92%). Mean time between occurrence of first symptoms and ILR implantation was 80,86 ±112,95 months. Mean monitoring period was 1067,62 ±668,89 days. 23 (45,1%) patients had an actionable event detected. Mean time to clinical outcome was 190,34 ±514,85 days. Based on the obtained recordings, in 13 (25,49%) patients a cardiac electronic device was implanted and 6 (11,76%) underwent an electrophysiological procedure. Time to intervention was 435,17 ± 542,9 days and 338,8 ± 273,44 days, respectively. ILR prompted medication modification in 14 (27,45%) patients. Antiarrhythmic drugs were modified in 6 (11,76%) patients. Oral anticoagulation was initiated in 3 (5,88%) patients. Mean time to any pharmacotherapy modification was 654,68 ± 604,32 days. Skin infections occurred in 2 patients, leading to early device removal. Conclusions This is the first study to present a comprehensive evaluation of ILR patients in Poland, along with a substantial observation period. We report a high prevalence of treatable cardiac conditions in patients with previous unsuccessful diagnostic work up. In the light of the upcoming favourable changes in governmental healthcare policy, demonstrating evidence supporting ILR application in everyday clinical practice is crucial for advocating their wider utilization and reimbursement.

Single centre experience using vessel Fractional Flow Reserve (vFFR) and diagnostic performance compared with invasive Fractional Flow Reserve (FFR)

Abstract Background Fractional flow reserve (FFR) is a diagnostic gold standard in the functional assessment of coronary artery stenoses (1). Alternative invasive and non-invasive methods have been developed in an attempt to avoid limitations associated with FFR including added procedural risk, patient discomfort, time and cost. Vessel fractional flow reserve (vFFR) is a novel software using two angiographic projections to generate a 3D vessel reconstruction which has shown high diagnostic accuracy in predicting a positive FFR (2-4). Methods All patients undergoing coronary angiography between 01/10/2022 and 08/03/2023, where FFR was performed, were assessed. Patients were included where images met requirements necessary to use vFFR software. vFFR measurements were taken retrospectively by a single investigator and not used to inform patient care. Data were expressed as mean +/- standard deviation and %. The correlation of vFFR to FFR was compared using Pearson’s correlation coefficient. Receiving operator characteristic (ROC) area under the curve (AUC) analysis was used to determine diagnostic performance. Statistical analysis was performed using SPSS v27. Results 28 of 37 patients and 32 of 44 vessels were included and analysed with vFFR software. Excluded vessels were unsuitable due to insufficient frame rate or projection angulation during angiography. Mean age was 63 +/- 3.8 years and 75% of patients were male. Of 32 vessels assessed, 20 were LAD, 5 RCA, 5 LCx and 2 LMS. 29 of 32 vFFR values agreed with positive or negative FFR. Positive vFFR values were seen in all 15 vessels with positive FFR. 3 vessels received a positive vFFR where FFR values were negative. Mean vFFR was 0.76 +/- 0.1 and mean FFR was 0.81 +/- 0.09. vFFR correlated significantly with FFR (R=0.777, p<0.001). vFFR demonstrated good diagnostic accuracy in discriminating "positive" (>0.8) and "negative" (≤0.8) FFR with an AUC of 0.758 (95% CI 0.61-0.91, p<0.01). Conclusion vFFR correlated significantly with FFR and all positive FFR values also received positive vFFR values. vFFR demonstrated good diagnostic accuracy in predicting a positive FFR result. Thus, these data support a strategy of using a negative vFFR to avoid further testing.Pearson correlation of vFFR to invFFRROC curve: vFFR predicting invFFR

A cost-consequence analysis comparing three distinct cardiac ablation strategies for the treatment of paroxysmal atrial fibrillation

Abstract Background Cardiac ablation is a well-established treatment option for preventing atrial fibrillation (AF). While radiofrequency, cryo-energy, and laser energies are commonly employed in catheter ablation, they present the risk of potential damage to adjacent organs such as the oesophagus and phrenic nerve. To address these concerns, new technologies are being explored including pulsed field ablation (PFA), a non-thermal energy approach that employs high-voltage, short-duration pulses to selectively destroy target cells. Purpose The present analysis aims at: i) quantifying the short-term costs related to three ablation strategies for paroxysmal AF (PFA, radiofrequency ablation -RFA-, and cryo-balloon ablation -CRYO-), identify the cost drivers, and assess potential variations in resource consumption for each treatment alternative; ii) comparing the medium-term (1-year) economic implications of adopting the three alternatives, in terms of redo procedures (effectiveness) and complications (safety). Methods A cost-consequence model was developed to compare economic outcomes of the three ablation strategies for paroxysmal AF in the short- (during procedure) and medium-term (1-year). Resource consumption data during the procedure were collected by two European medical centres specialized in cardiac ablation (N=61 patients). For the medium-term analysis, costs were correlated to the effectiveness and safety of the procedures. The clinical data (i.e., redo and complication rates) considered in the model were retrieved from published literature. Costs and tariffs were collected from economic formularies of the respective hospitals. A scenario analysis was conducted to evaluate economic outcomes under various hypothetical difference in the prices of treatment kits. Results A significant difference was registered in terms of pre-procedural (mean±SD: 13.9±4.4 min for PFA, 20.1±7.6 min for CRYO and 20.5±7.7 min for RFA; ANOVA test p=0.003) and procedural time (skin-to-skin), favouring PFA over RFA and CRYO (53.6±26.8 min for PFA, 72.4±28.1 min for CRYO and 149.9±99.9 min for RFA; p<0.0001; Table 1). PFA was associated with lower procedural costs vs CRYO (-€400) and RFA (-€827). A similar economic advantage was observed in the medium-term (Table 2). The scenario analysis showed that PFA would be cost-saving vs CRYO (Δtotal costs ≤ 0) up to a price difference of +€881 (i.e., PFA kit is more expensive than CRYO kit), and similarly, up to a price difference of +€1,306 vs RFA. Above these thresholds, PFA would be considered cost-effective vs CRYO or RFA, due to its efficacy despite being more expensive. Conclusion In summary, PFA emerges as cost-effective or even cost-saving over CRYO and RFA, thanks to its faster execution, lower redo, and complications rate. Moreover, PFA time predictability would facilitate hospital planning. For a complete analysis, these benefits should be evaluated against the difference in acquisition costs among treatments.Procedural time by phase and techniqueCumulative savings per technique

Comparing procedural costs and early clinical outcomes of robotic extended totally extraperitoneal (eTEP) with intraperitoneal onlay mesh (IPOM) repair for midline ventral hernias

Comparing procedural costs and early clinical outcomes of robotic extended totally extraperitoneal (eTEP) with intraperitoneal onlay mesh (IPOM) repair for midline ventral hernias

Reduced cervical sampling of hysterectomy specimens with negative margins on conization: An opportunity to improve resource utilization.

The current recommendation for hysterectomy specimens performed for cervical cancer following conization is that the entire cervix be submitted for histologic examination. Given the high cost of medical procedures and concerns regarding difficulties with laboratory staffing, we sought to evaluate the potential for selective histologic examination in this setting. Post-conization hysterectomy cases were reviewed for the presence of residual disease in relation to the findings of the prior conization, with consideration of margin status. Residual disease was then assessed for clinical significance. The number of submitted blocks was recorded and the associated costs were estimated. Among 32 cases with invasive carcinoma, only cases with margins positive for invasive carcinoma on the conization specimen had residual invasion in the hysterectomy (n = 7), and there were no upgrades due to subtle microscopic disease; 1 case had a change in pathologic stage from pT1b1 to pT2b due to parametrial involvement in the setting of a grossly apparent lesion. Among 20 cases performed following a diagnosis of dysplasia, none were upgraded to invasive carcinoma. Based on protocol-based submission of the entire cervix, 16 blocks of cervix were submitted on average (range, 4-41). We estimate that representative sections from each cervical quadrant would save approximately 2 work hours for laboratory staff per case and up to 6 hours for larger cases, reducing costs for the laboratory accordingly. Selective cervical sampling in the setting of negative margins on conization provides an opportunity for improved resource utilization without compromising patient care; as this is a small study, confirmation of these findings in a larger number of cases may be warranted. Additional studies are necessary to determine what other contexts in surgical pathology could benefit from a similar reductive approach.

Economic burden of knee joint replacement in Iran

BackgroundThe knee is the most commonly afflicted weight-bearing joint. Osteoarthritis of the knee is regarded as one of the most commonly diagnosed causes of disability in the elderly. Knee joint replacement can be regarded as a final solution for Osteoarthritis of the knee in which the joint is worn out, accompanied by clinical symptoms such as pain, deformity, and limited movement.Aimthis study sought to estimate the economic burden of knee joint replacement procedures carried out in Iran.MethodThis cross-sectional descriptive study utilized the Incidence-based approach to assess the economic burden of knee joint replacement surgeries conducted in Iran during 2022, estimating the costs of the disease from a societal perspective. The sampling method employed was random sampling, and the sample size consisted of 300 patients. Direct costs were calculated employing the top-down approach, while indirect costs were estimated using the human capital approach. Microsoft Excel was employed for data analysis.ResultThe average direct medical costs of the knee replacement procedure per patient were $10,076.87 and $13,099.93 in the public and private sectors, respectively. The average direct non-medical costs of knee joint replacement surgery are $1123.64, with companion costs constituting most of the direct non-medical costs. Finally, the economic burden of the knee joint replacement surgery was estimated at $67340417.28.ConclusionDespite insurance coverage, knee joint replacement surgery in Iran incurs substantial costs. With the anticipated rise in the elderly population, the frequency of these procedures is expected to increase, amplifying the economic burden on the Iranian public.

A keep-it-simple embolisation approach to treat pelvic congestion syndrome without compromising clinical effectiveness.

There are two approaches to treating pelvic congestion syndrome (PCS): (i) the keep-it-simple (KIS) approach, which involves embolising only the refluxing vein(s), typically the left ovarian vein (LOV) unless the right ovarian vein (ROV) or left/right internal iliac vein (IIV) tributaries are also refluxing; and (ii) the extensive (EXT) approach, which empirically embolises almost all of the LOV, ROV, and left and right IIV tributaries. The aim of this study is to determine whether the KIS approach can effectively treat PCS while minimising the number of treated veins and coils used, without the need for injecting sclerosing agents into pelvic veins or the use of occlusion balloons. This is a single-institution retrospective cohort study. Our records identified 154 women who underwent venograms for possible PCS, with the intent to proceed with embolisation. Refluxing veins were treated using the KIS approach, deploying minimal number of coils, 'sandwiching' sclerosing foam. Short-term follow-up was conducted at 6 weeks; long-term follow-ups (between 12 and 60 months) were conducted via an electronic survey consisting of 19 questions assessing pelvic pain/pressure, leg and back pain, fatigue, and bladder and menstrual symptoms. Fifteen women had negative venogram; 139 women had one or more refluxing veins on venogram. Most women (73%) required unilateral ovarian vein (OV) embolisation, 14% required bilateral OV embolisation, and 12% underwent pelvic vein embolisation. Most cases required only four pushable coils. Clinical success was 89% at 6 weeks and 84% at 1-5 years. A visual analogue scale reduction of 5.2 points (from 7.8 to 2.7) was achieved. There were no instances of coil dislodgement or other complications. The keep-it-simple approach, embolising only the refluxing ovarian and/or iliac veins, can achieve a successful clinical outcome for pelvic congestion syndrome. The extensive approach of empirically embolising all ovarian veins and internal iliac veins may not be necessary. This carries implications for potential savings in procedure time, cost and radiation dose.

What is the True Cost of Motion Preservation? A Time-driven Activity-Based Cost Analysis of Anterior Cervical Discectomy and Fusion Versus Disc Replacement

Total disc replacement (TDR) has become a viable alternative to anterior cervical discectomy and fusion (ACDF) for select patients. Although most comparative studies have assessed outcomes, cost differences remain largely uninvestigated. This information is critical as we move towards value-based reimbursement. To address this knowledge gap, we used time-driven activity-based costing (TDABC) to compare total intraoperative costs between the two procedures. Total cost was divided into direct (personnel and supply cost) and indirect costs (administrative and overhead costs). Individual costs were determined through direct observation, electronic medical records, and through querying multiple departments (including business operations, sterile processing, plant operations, and pharmacy). Timestamps for all involved personnel and material resources were documented, in conjunction with process mapping of the intraoperative period. Total intraoperative costs were estimated for all ACDFs (n=810) and TDRs (n=54) from 2017 to 2022. Regression analyses were performed to identify factors associated with total cost. A total of 810 and 54 patients underwent one- and two-level ACDFs and TDRs, respectively. The average total intraoperative cost for an ACDF was $6,776 +/- $2,808, compared to $12,026 +/- $4,235 for TDR. Supply cost accounted for the majority of total cost for both procedures ($4,173 +/- $2,225 for ACDF and $9,532 +/- $4,010 for TDR). On multivariable linear regression analysis, TDR was associated with roughly $3,885 of additional cost compared to ACDF (p<0.001), as well as $4,072 in additional supply cost (p<0.001), most of which was driven by the higher cost of implants (p<0.001). TDABC is a highly useful methodology for estimating differences in true costs between procedures and determining cost drivers. TDRs were associated with an additional $3,885 of total intraoperative cost as compared to ACDFs, the majority of which was driven by the cost of implants.

State of scientific research problems of judicial proceedings in civil jurisdiction

The article reveals current problems and the state of scientific research on judicial proceedings in civil proceedings. In particular, special attention is paid to the issue of justice. The definitions and content of justice given by both scientists and its normative basis are analyzed. It is established that some scientists define justice as the main function of the court, while others define it as a form of activity of the court itself. The proposed author’s definition of the concept of «justice». Issues of access to justice are highlighted. It is suggested that the issue of access to justice be classified as one of the main principles of the civil process. The availability of justice and access to court is considered in the context of the concept of basic human rights and freedoms. Access to justice is defined as a combination of such interrelated elements as unconditional freedom, state- guaranteed opportunity and equality of a person whose rights have been violated to apply for judicial protection of his rights and legitimate interests to a competent court; the duty of the court to accept the case for its proceedings, without applying formal reasons for refusal. Application of universal and unlimited court jurisdiction; guarantees of competitiveness, proper judicial procedures, which ensure reasonable terms of consideration of the case. Particular attention is paid to the main principles recommended by the Committee of Ministers of the Council of Europe to member states regarding measures that facilitate access to justice. The opinions of scientists revealing the meaning of such principles as simplification of court proceedings, acceleration of proceedings and court costs are established. The work analyzes official statistical data for 2020 - 2023, regarding the number of cases that were considered in the order of simplified legal proceedings in all courts on the territory of Ukraine. It was concluded that, in minor cases, it would be appropriate to develop and implement national standards that would allow individuals to independently fill out understandable standard forms of procedural documents and submit them to the court, without consulting legal experts. It is proposed to use a differentiated approach to determine the size of the court fee depending on the person’s income or depending on the degree of difficulty of the case, taking into account the procedural costs and time for consideration of the case.

Seismic behavior of hybrid post-tensioned special steel moment frames

Generally, conventional moment-resisting frames are prone to substantial residual displacements. To overcome this disadvantage, self-centering systems were introduced. Post-tensioned self-centering (PTSC) moment-resisting systems are a variation of conventional moment-resisting systems that drastically reduce the large residual displacements of the moment frames. However, one of the uncommon drawbacks identified in PTSC systems is their low energy dissipation. This study aims to compensate for this by innovatively combining conventional self-centering systems with special moment-resisting frames (SMRF) in various formats to retain the advantages of both systems. Another disadvantage of PTSC systems is the high cost and complexity of the structural design procedure required to maintain an elastic response in the framing beam-column elements. To address this issue, a practical and cost-effective design procedure was proposed. The study also included the influence of different dual SMRF-PTSC frame actions and base column connection types. A set of 35 structures comprising 4, 8, 12, and 16-story buildings were considered for nonlinear static/dynamic analysis and seismic response assessment. The nonlinear static analyses were carried out in a cyclic format due to the self-centering characteristics of the system. Additionally, 22 far-field records per FEMA P695 were chosen for the time history analyses. The results show that structures equipped with post-tensioned self-centering connections (PTSC) designed according to the proposed procedure are successful in drastically decreasing residual drifts. However, the total elimination of residual drifts relies on providing a self-centering connection for the base level columns and considering an overstrength factor for the base level columns' moment capacity design. The proposed value in this investigation was derived as 5, which significantly strengthens the base level columns while resulting in an overall notably cost-efficient PTSC-equipped frame. In the case of dual frames, the conventional SMRF spans should not exceed the number of PTSC-equipped spans, as doing so will diminish the self-centering characteristics of the lateral system.

Ureteric stenting outside of the operation theatre: challenges and opportunities.

To evaluate the safety, efficacy, tolerability, and cost-effectiveness of bedside or office-based ureteric stent insertion. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Protocols (PRISMA-P) and A MeaSurement Tool to Assess systematic Reviews (AMSTAR) 2 guidelines, we searched PubMed/the Medical Literature Analysis and Retrieval System Online (MEDLINE), the Excerpta Medica dataBASE (EMBASE), Google Scholar, Cochrane Central Register of Controlled Trials (CENTRAL), and Dimensions for English-language studies from 1978 to April 2023. Inclusion criteria focused on primary ureteric stent placements outside of the operating theatre (OT). A total of 15 studies involving 2072 stents were included. Success rates for correctly positioned stents in bedside or office-based insertions ranged from 60% to 95.8%, with most studies reporting ≥80% success rates. Common failure reasons included impacted stones and difficulty identifying the ureteric orifice. Pain and tolerability were assessed using various methods, with validated tools indicating moderate pain levels, but most patients would undergo the procedure again under local anaesthesia. Complication rates were generally low, with minor complications such as haematuria or postoperative fever being the most common. Procedural costs were significantly lower in non-OT settings, with estimates indicating savings of up to four-fold. Bedside or office-based ureteric stent insertion is a viable alternative to OT procedures, offering high success rates, manageable pain levels, low complication rates, and substantial cost savings. This approach is particularly advantageous in settings with limited OT access, highlighting its potential for broader adoption in urological practice. Future research should focus on standardising pain assessment methods and randomised studies.

6914 Footing the Bill: Analysis of DFU-related amputation cost expenditure in a sample of HealthFirst Insured Patients

Abstract Disclosure: M. Hashmi: None. C. Schechter: None. A. Herrera Chancay: None. H. Tabassum: None. N. Shiraliyeva: None. J. Daily: None. A.K. Myers: None. Objective Diabetes complications, especially diabetic foot ulcers (DFU), are a leading cause of health care expenditures. This study examined the total cost of amputations and subsequent procedures in Health First insured (HF) patients initially treated at Montefiore Medical Center (MMC) for DFU. Using the database of HF, a large-scale Medicaid managed insurance organization, we captured healthcare utilization beyond the scope of one hospital system, obtaining a more comprehensive understanding of expenditures. We also explored the associations of demographic and lab values with expenditures. Methods The HF data extraction covered calendar years 2021 and 2022 plus YTD 2023. Amputations were identified by CPT codes 27880, 27590, 28810, and 28820. One hundred twenty patients were included in the sample as they had HF insurance and their initial admission for DFU was at one of three hospitals at MMC. Demographic and laboratory data were extracted from the EHR. Demographics, lab values within 3 months of the index admission, and total costs were summarized, and paid amounts per capita per year were calculated. Expenditures included amputation, labs, wound care, surgery, hyperbaric therapy, interpreter services, emergency department visits, home care visits, and outpatient follow-up (in-person and telehealth). We explored demographic, comorbidity, and lab values as predictors of expenditure levels using a bivariate analysis. Results The mean age was 60.6 ± 12 years with majority being male (n=79, 65.3%) and having Type 2 Diabetes (n=103, 96.3%). A significant portion identified their race as other (n=58, 53.7%) or ethnicity as Hispanic-Latino (n=60, 56.1%). Common comorbidities in this group were current or former tobacco use (n=64, 59.2%), chronic kidney disease (n=62, 57.9%), and hypertension (n=94, 86.2%). Glycemic control was suboptimal with an average Hemoglobin A1c of 9.1% (SD 3.1%) and average admission glucose of 232.2 mg/dL. C-reactive protein 17.1 (SD 34.1) and erythrocyte sedimentation rate 88.8 (SD 36.3) were both elevated for most patients. The DFU-related amputation cost was higher for Hispanic-Latino individuals, RR 1.97 (CI 1.04, 3.71) and for those with chronic kidney disease, RR 1.36 (1, 1.86). Female sex, serum glucose and BMI were moderately associated with increased relative cost. The study was limited by not having access to subsequent visits outside our health system and the retrospective nature of the study. Conclusions Our study highlights disparities among patients who underwent a DFU related amputation, with higher costs for Hispanic-Latino individuals, those with chronic kidney disease , and women, emphasizing the need for tailored interventions for these populations to ameliorate the high cost of DFU-related care. Presentation: 6/2/2024

Benefits of Bedside Open Tracheostomy: A Safe and Cost-Effective Alternative to the Operating Room.

Tracheostomy is a commonly performed procedure in Otolaryngology and can be performed in different settings. We evaluate patient characteristics and cost efficacy of tracheostomy at the bedside versus operating room (OR). Retrospective chart review was performed for adult intensive care unit (ICU) patients who underwent tracheostomy from 2020 to 2023. Data and cost of procedures were analyzed using descriptive statistics. One hundred and sixty-five patients were included. One hundred and thirty-four (81.2%) patients underwent bedside tracheostomy. Age, sex, and BMI were not significantly different. Average time from consult to procedure and operative time was significantly shorter (p = 0.03; 0.008). There were no differences in postoperative complications, 30-day mortality, ICU length of stay (LOS), or overall LOS. Tracheostomy at the bedside offered a 73.1% cost reduction compared with performed in the OR. Advantages of bedside tracheostomy include decreased operative time, time from consult to procedure, and cost reduction for the hospital system. We advocate for consideration of bedside tracheostomy when appropriate.

Novel imaging techniques for tumor margin detection in basal cell carcinoma: a systematic scoping review of FDA and EMA-approved imaging modalities.

Mohs micrographic surgery (MMS) is the gold standard for removing basal cell carcinomas (BCCs) due to its ability to guarantee 100% margin evaluation through frozen section histopathology, offering the highest cure rate among current treatments. However, noninvasive imaging technologies have emerged as promising alternatives to clinical assessment for defining presurgical margins. This systematic scoping review examines the efficacy of these imaging modalities, focusing on those approved for clinical use by the United States Food and Drug Administration (FDA) or the European Medicines Agency (EMA). A systematic search of EMBASE, Scopus, PubMed, and the Cochrane Public Library databases identified 11 relevant studies out of 2123 records, encompassing 644 lesions across five imaging techniques. The findings suggest that dermoscopy, high-frequency ultrasound (HFUS), optical coherence tomography (OCT), line-field optical coherence tomography (LC-OCT), and reflectance confocal microscopy (RCM) show potential in detecting BCC margins, which could enhance MMS by providing better preoperative planning, informing patients of expected defect size, aiding in reconstruction decisions, and reducing overall procedure costs. This review discusses the benefits and limitations of each technique, offering insights into how these innovations could influence the future of BCC management. Emerging imaging techniques could enhance MMS by improving BCC margin assessment and reducing costs. Their adoption will depend on price and ease of use.

The Gap Between the Actual Cost and Tariffs of Global Surgical Procedures: A Retrospective Cross-sectional Study in Qazvin Province, Iran

Background: Iran’s healthcare system has a significant discrepancy between the national tariff and the cost of global surgical procedures (GSPs). This study aimed to compare the actual costs of GSPs with national tariffs in Iran’s public hospitals. Methods: This retrospective cross-sectional study was conducted in 2017. Using the census method, 6126 GSPs performed in three public hospitals were investigated in this study. Additionally, national tariffs from the Supreme Council of Health Insurance were obtained. The tariff-cost gap was the discrepancy between a GSP’s actual costs and tariff. Multiple linear regression analysis determined factors affecting the tariff-cost gap. Results: The average actual cost of GSPs was 637 USD, while the average tariff was 495 USD. The reimbursement covered only 78% of the costs. The gap was higher in older (B=1.05, 95% CI: 0.76-1.35, P&lt;0.001), females (B=26.7, 95% CI: 15.5-37.9, P&lt;0.001), patients with a longer stay (B=81.2, 95% CI: 77.5-84.8, P&lt;0.001), and procedures performed by full-time surgeons (B=67.3, 95% CI: 56.9-77.5, P&lt;0.001). Furthermore, neurosurgery had the highest effect on forecasting the gap between actual costs and tariffs among surgical specialties (B=346.9, 95% CI: 214.3-479.5, P&lt;0.001). Conclusion: Public hospitals suffer from large financial losses due to the national tariff for many GSPs not covering their actual costs. It is suggested that tariffs be increased for certain customer segments that can bear higher costs and global tariffs be adjusted to match actual service delivery costs.

Ambulatory Surgery Center versus Outpatient Hospitals: A Comparison of Reimbursements for Patients Undergoing Anterior Cervical Discectomy and Fusion

Background ContextWhile some studies have demonstrated that ambulatory surgery centers (ASCs) are associated with reduced costs of orthopedic procedures, there is no consensus in the current literature as to the impact of ASCs versus hospital-based outpatient departments (HOPDs) on anterior cervical discectomies and fusions (ACDFs). PurposeThis study sought to 1) compare immediate procedure reimbursements, patient out-of-pocket expenditures, and surgeon reimbursements for ACDFs performed at ASCs versus HOPDs and 2) identify factors predicting facility utilization. Study DesignRetrospective cross-sectional study. Patient SampleWe identified ACDF procedures performed at an ASC or HOPD in commercially-insured patients aged 18-64. Outcome MeasuresPayment variables were calculated from claims within 3 days preoperatively and postoperatively. MethodsMultivariable regression models assessed a) associations between the surgery setting and payment variables and b) factors associated with the surgery setting. ResultsWe included 18,191 ACDFs (14.8% ASC, 85.2% HOPD). In multivariable analyses, ACDFs performed in an ASC (versus HOPD) were associated with 9.8% higher immediate procedure reimbursements (95% CI:7.5-12.2%), 17.2% higher patient out-of-pocket expenditures (95% CI:11.8-22.8), and 11.7% higher surgeon reimbursements (95% CI:9.18-14.2; all P<0.01) (all P<0.001). Surgery setting utilization varied by region, insurance-related factors, comorbidities, and procedural complexity. ConclusionsWe found that ASCs had significantly higher reimbursements compared to HOPDs. Regional variations in ASC utilization imply there are opportunities for standardization of care.

National Costs for Cardiovascular-related Hospitalizations and Inpatient Procedures in the United States, 2016-2021

The current economic burden of cardiovascular-related hospitalizations grouped by diagnoses and procedures in the U.S. has not been well characterized. The objective was to identify current trends in cardiovascular-related hospitalizations, procedural utilization, and health care costs, using the most recent 6 years of hospitalization data. A retrospective analysis of discharge data from the National Inpatient Sample (NIS) database was conducted to determine trends in cardiovascular-related hospitalizations, costs, and procedures for each year from 2016 to the most recent available dataset, 2021. Total cardiovascular-related costs were adjusted to and reported in 2023 dollars. In 2021, there were 4,687,370 cardiovascular-related hospitalizations at a cost of $108 billion. Heart failure hospitalizations accounted for the highest costs at $18.5 billion, followed by Non-ST-Elevation Myocardial Infarction at $11.2 billion, and stroke at $10.9 billion. Significant upward trends in costs from 2016 to 2021 were observed for heart failure, stroke, atrial fibrillation, ST-elevation myocardial infarction, chest pain, hypertensive emergency, ventricular tachycardia, aortic dissection, sudden cardiac death, pericarditis, supraventricular tachycardia, and pulmonary heart disease. Over the 6 observational years, total costs increased by over $10 billion, representing a 10 percent increase. However, the increases were not linear, as there was a significant increase of 6.5% from 2018 to 2019, then a dip of over 7% from 2019 to 2020, followed by a rise of about 6% from 2020 to 2021. By 2030, total CV-related costs are projected to reach $131.3 billion. For all years, coronary procedures were the most performed, followed by ECMO, non-bypass peripheral vascular surgery, pacemaker placement, and CABG. Both TAVR and MitraClip procedures demonstrated significant upward trends from 2016 to 2021. Overall, from the years 2016 to 2021, cardiovascular-related hospitalizations, costs, and procedures demonstrated upward trends. In conclusion, cardiovascular disease remains a high burden in the hospital setting with tremendous health care costs.

The effect of one-room CT guided brachytherapy on procedure time and cost in the treatment of cervical cancer

IntroductionBrachytherapy is associated with improved overall survival in cervical cancer patients, but the utilization seems hindered by high costs and relatively low reimbursement, particularly in the US. A one-room brachytherapy suite with CT (ORBT) could optimize the treatment workflow. By eliminating transport and waiting times, limiting applicator movement, and providing real-time applicator placement feedback, treatment time and costs could potentially be reduced. This study assesses the potential value of implementing ORBT in cervical cancer treatment. MethodsA variable cost model was developed to compare current (multi-room) brachytherapy workflows (MBRT) to ORBT, taking into account staff utilization, staff, equipment and consumables costs and room expenses. Two current care scenarios were simulated; applicator placement performed in the operating room (S1), and applicator placement performed in a brachytherapy suite (S2). For both scenarios literature reported fraction times of MBRT were compared to a range of ORBT times. Sensitivity analyses were performed to determine the influence of input parameters. ResultsIn scenario one, the results showed yearly savings of $45,572 up to $339,439 (USD), assuming a 5% and 20% reduction in fraction duration, respectively, in ORBT compared to MRBT. In scenario two, ORBT does not result in costs savings at 5% to 15% improvement. Therefore, only when ORBT results in a >20% improvement of fraction time, cost will be saved. DiscussionThe results indicate that reducing procedure time (using ORBT) can lead to cost savings, depending on the current workflow. Savings appear to depend mostly on applicator placement location, number of patients per year, and involved personnel.