Lower Hospital Costs Research Articles

Choosing the proper path: outcomes of subxiphoid vs. lateral intercostal approaches in the resection of anterior mediastinal masses

BackgroundWhile the subxiphoid approach (SA) in thoracoscopic thymectomy offers benefits in terms of fat removal and pain reduction, it remains unclear which patients with anterior mediastinal masses benefit most from the subxiphoid vs. the lateral intercostal approach (LA).MethodsThis retrospective study analyzed patients treated for anterior mediastinal masses at our center from January 2019 to December 2023. Patients were categorized into two groups based on the surgical approach: SA (35 cases) and LA (56 cases). Demographic data, clinical characteristics, perioperative metrics, and short-term outcomes were compared.ResultsNinety-one patients were included, with diagnoses including thymic cysts (43), thymomas types A, AB, and B1 (24), B2 thymomas (18), thymic carcinoma (6).No significant differences were found between the groups in terms of gender, age, tumor size, body mass index, conversion to sternotomy, or blood loss. The LA group, however, experienced shorter surgical durations (P < 0.001), less drainage (P = 0.021), shorter hospital stays (P < 0.001), and lower hospitalization costs (P = 0.024). Pain scores on the visual analogue scale were similar between groups on the day of surgery and the first postoperative day.ConclusionThe findings suggest that the lateral intercostal approach is preferable for patients with thymic cysts and Masaoka stage I–II thymomas without myasthenia gravis due to its efficiency and cost-effectiveness.

Outcomes, safety and health economics of introduction of video laryngoscopy-assisted less invasive surfactant administration.

Less invasive surfactant administration (LISA) is associated with better outcomes than InSurE (Intubation-Surfactant administration-Extubation). Video-laryngoscopy (VL) facilitates intubation in neonates, however safety and cost-effectiveness of VL-assisted LISA have not been evaluated. We compared the outcomes of infants receiving VL-assisted LISA (n = 67) with a historical cohort of infants who received InSurE (n = 52). Secondary aims were to evaluate safety and cost-effectiveness. VL-assisted LISA was associated with reduced duration of non-invasive ventilation (NIV), reduced duration of oxygen therapy, reduced composite days on NIV and mechanical ventilation (MV), and shorter NICU stay with lower hospital costs for infants ≥29 weeks GA, compared to InSurE. In the VL-assisted LISA group, 66% of the tracheal catheters were placed on the first attempt and 16% of infants displayed desaturation during placement. In infants ≥29 weeks GA, VL-assisted LISA reduced exposure to NIV, oxygen, NIV and MV combined, length of stay, and cost of care compared to InSurE.

Cost-effectiveness of faecal microbiota transplantation compared with vancomycin monotherapy for early Clostridioides difficile infection: economic evaluation alongside a randomized controlled trial

For Clostridioides difficile infection (CDI), faecal microbiota transplantation (FMT) is currently recommended for patients with three or more CDI episodes. A recent randomised controlled trial (RCT) show that FMT may be considered early, defined as intervention during the first or second CDI episode. Compared with standard care for first or second CDI, patients randomised to FMT had €1,645 lower hospital costs over 26 weeks owing to fewer admissions and hospital contacts and less medication use.

National outcomes for dementia patients undergoing cardiac surgery in a pre-structural era

ObjectiveWith an aging population and higher prevalence of dementia, there is a paucity of data regarding dementia patients undergoing cardiovascular surgery. We examined the nationwide trends and outcomes of cardiovascular surgery patients with dementia to determine its effect on morbidity, mortality, and discharge disposition.MethodsFrom 2002 to 2014, 11,414 (0.27%) of the 4,201,697 cardiac surgery patients from the Nationwide Inpatient Sample had a preoperative diagnosis of dementia. Propensity-score matching was used to balance dementia and non-dementia groups. Primary outcomes included postoperative morbidity, mortality, and discharge to skilled nursing facility (SNF).ResultsDementia patients were more often male (67%) and 65–84 years old (84%). Postoperative mortality among patients with dementia was lower compared to patients without dementia (3.4% vs. 4.6%, p < 0.05). In dementia patients, there were more complications (65% vs. 60%, p < 0.01), more blood transfusions [OR 1.3, 95%CI (1.1, 1.5), p < 0.01] and delirium [OR 3.6, 95%CI (2.9, 4.5), p < 0.0001). Dementia patients (n = 5,623, 49.8%) were twice as likely to be discharged to SNF [OR 2.1, 95%CI (1.9, 2.4), p < 0.0001]. Dementia patients discharged to SNF more often had delirium (18.2% vs. 12%, p < 0.01), renal complications (17% vs. 8%, p < 0.01), and prolonged mechanical ventilation (15% vs. 8%, p < 0.01).ConclusionsDespite an aging population with increasing prevalence of dementia, patients with dementia can undergo cardiovascular surgery with a lower in-hospital mortality and similar hospitalization costs compared to their non-dementia counterparts. Dementia patients are more likely to experience complications and require discharge to skilled nursing facility. Careful patient selection and targeted physical therapy may help mitigate some dementia associated complications.

Abstract 4113854: Outcomes Of Atrial Fibrillation Ablation In Elderly: A Retrospective Cohort Study

Introduction: Atrial fibrillation (Afib) is a common cardiac arrhythmia that increases in prevalence with age. Ablation has been widely used for managing Afib, but its outcomes in octogenarians have been less thoroughly investigated. Research Question: This study aims to assess the in-hospital outcomes of Afib ablation in patients aged above 80 compared to those below 80 years old. Methods: Data was obtained from the Nationwide Inpatient Sample database from January 2016 to December 2020. The study included all adult patients with a primary discharge diagnosis of Afib who underwent catheter ablation during their hospitalization. These patients were then categorized into two groups based on age: below 80 and above 80 years. In-hospital outcomes for these groups were then looked at. The primary outcome was inpatient mortality. Secondary outcomes were the length of stay, cost of hospitalization, cardiac arrest, cardiac tamponade, arrhythmias, acute respiratory failure, acute renal failure, procedural complications as well as the need for dialysis, transfusions, pressors, ventilators, and tracheostomy. Results: Out of about 35 million admissions screened, 403,247 patients had Afib as their primary discharge diagnosis, of these, 17,927 patients underwent catheter ablations during their hospitalization. Amongst them, 3,051(17%) were above the age of 80 years. The in-hospital mortality was slightly higher in the elderly compared to the younger cohort (1.1% vs 0.5%, aOR: 1.87; 95% CI: 1.20-2.92, p=0.006). They had a longer hospital stay (5.14 days vs. 3.72 days, p&lt;0.001) and lower hospitalization costs (USD 138,091 vs. USD 162,788, p&lt;0.001). Complications such as acute respiratory failure and acute renal failure were more frequent in the older age group, while no significant differences were observed in cardiac arrest, cardiac tamponade, ventricular arrhythmias, and most device-related complications. The need for new dialysis, mechanical ventilation, and pressor use was significantly less in the above-80 group. Conclusion: Afib ablation in older adults, results in slightly higher in-hospital mortality and longer hospital stays compared to younger patients. Despite these differences, the overall complication rates are comparable, suggesting that age alone should not deter the selection of patients for Afib ablation. Further studies are needed to validate these findings and optimize management strategies for the elderly population.

Abstract 4131630: Comparative Outcomes of Left Atrial Appendage Occlusion Device Implantation in Atrial Fibrillation Patients with a Lower Stroke Risk

Introduction: Current guidelines recommend oral anticoagulation in atrial fibrillation (AF) patients with a CHA 2 DS 2 -VASc score ≥ 2 for stroke prevention. Left atrial appendage occlusion (LAAO) devices serve as alternatives to reduce stroke risk in select AF patients that are unable to tolerate long-term oral anticoagulation. However, Centers for Medicare&amp;Medicaid Services reimburses left atrial appendage occlusion (LAAO) for patients with CHA 2 DS 2 -VASc score ≥ 3. Objective: To evaluate differences in outcomes and complications of LAAO therapy in AF patients with a CHA 2 DS 2 -VASc score of ≥ 3 versus &lt; 3. Methods: National Inpatient Sample and International Classification of Diseases, 10th Revision codes were used to identify AF patients who underwent LAAO device implantation in the U.S. from 2016−2020. The study population was stratified by stroke risk into two groups, CHA 2 DS 2 -VASc ≥ 3 and &lt; 3. Study endpoints assessed included procedural complications, inpatient outcomes and resource utilization. A multivariable logistic regression model was used to assess the independent association of CHA 2 DS 2 -VASc score with study outcomes. Results: A total of 73,795 and 15,500 LAAO devices were implanted in patients with CHA 2 DS 2 -VASc ≥ 3 and &lt; 3, respectively. Compared to patients with CHA 2 DS 2 -VASc score of ≥ 3, patients with CHA 2 DS 2 -VASc &lt; 3 had lower overall (6.9% vs 9.9%, P&lt; 0.01) and major (4.5% vs 6.2%, P&lt; 0.01) complications in the crude analysis. After multivariable adjustment for potential confounders, CHA 2 DS 2 -VASc &lt; 3 was associated with lower overall complications (aOR 0.84, 95% CI 0.78 – 0.91), major complications (aOR 0.90, 95% CI 0.81-0.99) and cost of hospitalization (aOR 0.95, 95% CI 0.91-0.99). Conclusions: Patients with CHA 2 DS 2 -VASc &lt; 3 had lower complications and hospitalization costs after LAAO device implantation than patients with CHA 2 DS 2 -VASc ≥ 3 . These data, if redemonstrated in a large randomized trial can have important clinical implications for stroke prevention in AF patients.

Short-Term Efficacy of LCBDE+LC Versus ERCP/EST+LC in the Treatment of Cholelithiasis Combined with Common Bile Duct Stones: A Retrospective Cohort Study.

Background: Minimally invasive treatments for cholelithiasis have gained popularity. The complexity of diagnosing and treating choledocholithiasis offers multiple surgical options, including laparoscopic common bile duct exploration plus laparoscopic cholecystectomy (LCBDE+LC) and endoscopic retrograde cholangiopancreatography and/or endoscopic sphincterotomy plus laparoscopic cholecystectomy (ERCP/EST+LC). Objective: To compare outcomes in patients with typical signs, symptoms, laboratory, and imaging features of cholelithiasis combined with common bile duct stones, we retrospectively analyzed the short-term outcomes of LCBDE+LC and ERCP/EST+LC. Methods: We analyzed 318 patients with gallbladder stones treated between January 2022 and May 2024. Of these, 152 underwent LCBDE+LC, and 166 underwent ERCP/EST+LC. We compared patients' baseline characteristics, perioperative outcomes, and short-term complications between the two groups. The primary outcome was the effectiveness of choledochal stone removal, while secondary outcomes included length of stay, hospitalization costs, and patient satisfaction. Results: Patients' baseline characteristics were similar between the LCBDE+LC and ERCP/EST+LC groups. Stone clearance rates were comparable (97.37% versus 95.18%, P = .306), with a slight advantage in the LCBDE+LC group. The length of hospitalization was significantly shorter in the LCBDE+LC group (6.49 ± 1.18 days versus 6.77 ± 1.11 days, P < .05). The LCBDE+LC group also had lower total hospitalization costs ($5188.78 ± 861.26 versus $6498.76 ± 1190.58 P < .01). Additionally, the incidence of pancreatitis was lower in the LCBDE+LC group (0.66% versus 6.02%, P < .01). There were no significant differences between the groups in other short-term complications such as abdominal infection, cholangitis, biliary bleeding, or bile leakage. Postoperative follow-up indicated higher patient satisfaction and acceptance in the LCBDE+LC group (SSQ-8, 85.84 ± 4.31 points versus 81.20 ± 4.54 points, P < .01). Conclusion: Our findings suggest that the LCBDE+LC holds promise as a safe and efficacious approach for the management of cholelithiasis combined with common bile duct stones. However, further prospective clinical trials are essential to corroborate these results and confirm their broader applicability.

Association between volume and cost in low-resection volume regions: a population-level study on pancreatoduodenectomy for pancreatic cancer patients.

Pancreatoduodenectomy (PD) is a highly complex, invasive, and costly surgical procedure. Limited evidence on the PD volume-cost relationship in countries with a low population density exists. This study aimed to investigate this issue in Australia. This retrospective cohort study included pancreatic cancer patients who had a PD at any public hospital in New South Wales, Australia between 2016 and 2019. The primary outcome was the total hospital cost during PD admission (not including patient financial burden). Study hospitals were grouped into low-volume hospitals (LVHs; <10 PDs per annum) or high-volume hospitals (HVHs). Multivariable modelling was applied to examine the association between volume and cost. Of 443 PDs, the median total hospital cost per patient at HVHs was AU$55398; significantly lower than that at LVHs (AU$62859; P = 0.001). After adjusting for available patient and clinical factors, the total cost per patient at LVHs was 22% higher than that of HVHs (adjusted estimate: 1.22, 95% CI: 1.08-1.37; P = 0.002). Similar patterns were found in three main cost components: 24% higher employee cost at LVHs than at HVHs (1.24, 95% CI: 1.10-1.41; P < 0.001), 15% higher operating cost (1.15, 95% CI: 1.00-1.31; P = 0.047), and 31% higher other costs (1.31, 95% CI: 1.12-1.53; P < 0.001). Performance of PDs at HVHs was associated with substantially lower hospital costs. Our findings demonstrate the likely economic benefit of centralizing PDs in countries with a relatively low population density. Future studies should investigate related patient financial burdens.

Using single-dose liposomal amphotericin B for cryptococcal meningitis induction therapy: nurse pearls and practical perspectives

Background In Uganda where the burden of HIV-associated cryptococcal meningitis is high, conventional amphotericin B deoxycholate has been standard to manage patients with cryptococcal meningitis in research settings. However, liposomal amphotericin B (AmBisome) is now available via the efforts of UNITAID. We sought to describe our nursing experience using AmBisome within a clinical trial for cryptococcal meningitis. Methods We describe the experience of using single-dose 10mg/kg liposomal amphotericin B from the perspective of a research nurse in Uganda. Second, we described the process of preparing and administering amphotericin. Third, we assessed the nursing time required for the administration of daily amphotericin B versus single-dose liposomal amphotericin. Fourth, we discuss the major challenges faced while using liposomal amphotericin B. Results We provide estimates for the nursing time required for reconstituting, filtering, diluting and administering liposomal amphotericin B and a visual aid for nursing tasks. Based on five trained nurses, the process of reconstitution and filtration lasts an average of 52 minutes (Range: 40 to 60 minutes), to reconstitute a mean of 11 (range: 8 to 15) 50mg vials (median weight 55kg). Overall, less nursing time was required for single-dose administration than for daily amphotericin B dosing. From a nursing perspective, liposomal amphotericin B was preferable to amphotericin B deoxycholate due to its reduced infusion reactions and other toxicities. Conclusions Single-dose liposomal amphotericin B is a better alternative to daily amphotericin B. In addition to less toxicity, nosocomial infections, reduced hospital stay, and the potential for lower hospitalisation costs, the nursing implications should not be discounted. Quality nursing care is a finite resource in low- and middle-income countries, and single-dose amphotericin B reduced the nursing time required for the care of patients with cryptococcal meningitis.

Health outcomes and economic burden among patients with a COVID-19-associated hospitalization in the United States during the predominance of the XBB and JN.1 omicron lineages

Objective Conduct a comprehensive analysis of the health and economic outcomes of patients with a COVID-19-associated hospitalization in the US during the predominance of the XBB and JN.1 Omicron lineages. Methods This analysis used data from the PINC AI Healthcare Database (PHD) for all patients with a hospital admission date occurring between February 4, 2023, and February 29, 2024 with an ICD-10-CM code U07.1 “COVID-19” in any position. The data were used to estimate the mean and median length of stay (LOS), mean and median hospitalization cost, and proportion of patients that died in the hospital, by age and level of care (normal ward, intensive care [ICU], invasive mechanical ventilation [IMV]). Results LOS, hospitalization costs, and inpatient mortality increased with both the level of care and age. Patients not receiving ICU care had the shortest LOS, lowest inpatient mortality, and lowest hospitalization costs. LOS, hospitalization costs, and inpatient mortality were higher for those receiving ICU care and highest for those receiving IMV in the ICU. Within each level of care (normal ward, ICU without IMV, and ICU with IMV), the LOS, inpatient mortality, and hospitalization cost generally increased with age, indicating that older adults with COVID-19 required a longer recovery period, have a higher likelihood of death, and accrue higher costs. However, the proportion of pediatric patients with an ICU admission and/or IMV usage remained high. Limitations The PHD data may not be representative of all hospitalized patients in the US. Conclusions These findings suggest that COVID-19 continues to have severe and costly consequences in all age groups, but particularly for older adults including long LOS, ICU admission, need for IMV, mortality, and high hospital costs.

Cost-Effectiveness Ratio Analysis of LBBaP Versus BVP in Heart Failure Patients With LBBB.

For the initial treatment strategy for patients with cardiac resynchronization therapy (CRT) indications, whether to choose left bundle branch area pacing (LBBaP) or biventricular pacing (BVP) remains controversial. We aimed to investigate the cost-effectiveness ratio (CER) of LBBaP and BVP in heart failure (HF) patients with left bundle branch block (LBBB). This observational study included HF patients with LBBB who underwent successful LBBaP or BVP. The primary outcomes were echocardiographic response (left ventricular ejection fraction [LVEF] increase ≥5%), LVEF improvement, hospitalization costs, and CER (CER = cost/echocardiographic response rate). Secondary outcomes included other echocardiographic parameters, New York Heart Association (NYHA), N-terminal pro-B-type natriuretic peptide (NT-proBNP), pacemaker parameters, complications, ventricular arrhythmia (VA) events, HF hospitalization (HFH), and all-cause mortality. A total of 130 patients (85 LBBaP and 45 BVP) were included (65.6 ± 10.0 years, 70.77% men). The median follow-up period was 16(12,30), months. Compared with BVP, the LBBaP group showed a greater increase in LVEF (20.2%±11.8% vs. 10.5%±13.9%; p<0.001), higher echocardiographic response rate (86.1% vs. 57.8%; p<0.001), and lower hospitalization costs [$9707.7 (7751.2, 18,088.5) vs. $20,046.1 (18,840.1, 22,447.3); p<0.0001]. The CER was 112.7 and 346.8 in LBBaP and BVP, respectively. The incremental cost-effectiveness ratio (ICER = △cost/△echocardiographic response rate) was $-365.3/per 1% increase in effectiveness. LBBaP improved cardiac function more significantly than BVP. There were no significant differences in clinical outcomes. LBBaP-CRT is more cost-effective than BVP, offering greater LVEF improvement, higher echocardiographic response rates, lower hospitalization costs, and more significantly improved cardiac function. These findings need large randomized clinical trials for further confirmation.

Meta-analysis on Effectiveness of Palliative Care versus Conventional Care amongst Advanced Gynaecological Patients with Cancer and Caregivers.

In cancer patients, physical and psychological issues are very common. There is a need for family support and high utilisation of healthcare resources commonly. Palliative care (PC) has grown in popularity to better fulfil of needs of patients and their families and potentially lowering hospital costs. Given that the majority of patients still die in hospitals, there is a need for an effective model of PC for advanced gynaecological cancer, as well as the wise allocation of scarce resources. The main aim of this study was to compare the efficacy of PC to conventional treatment for adults with cancer, including gynaecological cancers, and their caregivers. Four randomised controlled trials (RCTs) were identified by searching PubMed, PubMed Central, Clinical Key, Embase and other grey literature from a duration of 2011-2021. Cochrane criteria were used to calculate the risk of bias, and the Grade Profiler Guideline Development Tool was used to check the quality of the included studies. Standardised mean differences (SMDs), I2 value and forest plot were prepared by using Review Manager 4.0. A total of four RCTs were extracted by following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and found to have a high risk for bias and low to poor quality of evidence. Included study sample sizes ranged from 22 to 104 participants, including 670 people in total, including 289 patients with advanced cancer patients, including gynaecological cancer and 381 unpaid caregivers. Results also showed that PC enhances patients' quality of life (SMD = 0.26; 95% confidence interval [CI] = -0.29-0.80; I2 = 76%), lowered symptom burden amongst patients (SMD = -0.75, 95% CI = -1.75-0.25; I2 = 89%), reduces patient depression (SMD = 0.08, 95% CI = -0.19-0.34; I2 = 0%) and decreases depression in unpaid caregivers (SMD = -0.16, 95% CI = -0.56-0.24; I2 = 59%). PC treatment increases patients' quality of life and lowers their symptom burden. In comparison to conventional care, it also reduces depression among patients and caregivers. We believe that the findings should be viewed with care until more recent exclusive RCTs are available.

Minimally invasive technique facilitates early extubation after cardiac surgery: a single-center retrospective study

BackgroundPostoperative time to extubation plays a role in prognosis after heart valve surgery; however, its exact impact has not been clarified. This study compared the postoperative outcomes of minimally invasive surgery and conventional sternotomy, focusing on early extubation and factors influencing prolonged mechanical ventilation.MethodsData from 744 patients who underwent heart valve surgery at the Zhejiang Provincial People’s Hospital between August 2019 and June 2022 were retrospectively analyzed. The outcomes in patients who underwent conventional median sternotomy (MS) and minimally invasive (MI) video-assisted thoracoscopic surgery were compared using inverse probability of treatment weighting (IPTW) and Kaplan–Meier curves. Clinical data, including surgical data, postoperative cardiac function, postoperative complications, and intensive care monitoring data, were analyzed.ResultsAfter propensity score matching and IPTW, 196 cases of conventional MS were compared with 196 cases of MI video-assisted thoracoscopic surgery. Compared to patients in the conventional MS group, those in the MI video-assisted thoracoscopic surgery group in the matched cohort had a higher early postoperative extubation rate (P < 0.01), reduced incidence of postoperative pleural effusion (P < 0.05), significantly shorter length of stay in the intensive care unit (P < 0.01), shorter overall length of hospital stay (P < 0.01), and lower total cost of hospitalization (P < 0.01).ConclusionsSuccessful early tracheal extubation is important for the intensive care management of patients after heart valve surgery. The advantages of MI video-assisted thoracoscopic surgery over conventional MS include significant reductions in the duration of use of mechanical ventilation support, reduced length of intensive care unit stay, reduced total length of hospitalization, and a favorable patient recovery rate.

Effects of integrated traditional Chinese and Western medicine for acute pancreatitis: A real-world study in a tertiary teaching hospital.

This study aimed to evaluate whether integrated traditional Chinese medicine (TCM) and Western medicine (WM) is more effective than WM for acute pancreatitis (AP). Patients with AP were enrolled and divided into the TCM and WM (TCM&WM) and WM groups according to the therapeutic protocol in real clinical settings. We applied 1:3 propensity score matching, which was to adjust confounding factors. The primary outcome was mortality, whereas the secondary outcomes were organ failure, organ supportive therapies, local complications, hospitalization cost, and length of hospital stay. Sensitivity and subgroup analyses were also performed. Of 5442 patients with AP, 4691 and 751 were included in the TCM&WM and WM groups, respectively. After PSM, patient baseline characteristics were well balanced. Compared with the WM group (n=734), the TCM&WM group (n=2096) had lower overall mortality rate (1.7%vs. 3.4%; risk ratio, 0.482; 95% confidence interval, 0.286-0.810; p=0.005). The TCM&WM group was associated with lower risk of persistent renal failure, multiple organ failure, and infection, lower utilization of organ supportive therapies, shortened lengths of hospital and intensive care unit stay, and lower hospital costs. Sensitivity analyses showed similar results. Subgroup analysis favored TCM&WM treatment for patients aged<60 years, with hypertriglyceridic etiology, and with admission interval between 24 and 48h. TCM&WM treatment can achieve lower risks of mortality and organ failure and better economic effectiveness in patients with AP than WM treatment. This study provides a promising alternative of TCM&WM treatment for AP in the real-world setting.

Intracardiac vs. transesophageal echocardiography guided transcatheter closure of patent foramen ovale and atrial septal defects

Transcatheter closure of atrial septal defects (ASD) and patent foramen ovale (PFO) can be performed with transesophageal echocardiography (TEE) or intracardiac echocardiography (ICE) guidance, but data comparing both modalities in contemporary practice is lacking. Using ICD-10 codes, patients who underwent transcatheter ASD/PFO closure between 2016 and 2020 using ICE or TEE in the Nationwide Readmissions Database (NRD) were identified. Propensity-score matching was performed to compare in-hospital adverse events, length of stay (LOS), cost, and 30-day non-elective readmissions. A total of 964 patients underwent ASD/PFO closure with ICE (38.3 %, n = 369) or TEE (61.7 %, n = 595) between 2016 and 2020. Propensity score matching yielded 327 patients in each group, which were well balanced. Median (IQR) age was 59.0 (46.0, 72.0) years and 54.7 % were female. No difference was observed in the rate of in-hospital major adverse events between groups. ICE guidance was associated with a lower median cost (ICE $20,140.1 (14,622.3, 25,027.0) vs TEE $20,740.4 (14,137.5, 33,045.3), p < 0.04). In conclusion, ICE guided ASD/PFO closure was associated with lower hospitalization cost without increasing in-hospital adverse events when compared with TEE guidance.

Comparison of Ultrasound-Guided Percutaneous Microwave Ablation and Conventional Thyroidectomy in the Treatment of Papillary Thyroid Microcarcinoma: Meta-Analysis.

Purpose: To perform a meta-analysis of clinical trials comparing percutaneous microwave ablation (PMWA) guided by ultrasound with conventional thyroidectomy for the management of papillary thyroid microcarcinoma (PTMC), analyzing feasibility, safety, and long-term efficacy, and to provide clinical guidance for the treatment selection of PTMC. Methods: Embase, PubMed, Cochrane Library, Web of Science, CNKI, VIP Database, and Wanfang Database were systematically searched to identify clinical studies of PMWA or thyroidectomy for PTMC up to December 2023. The relevant data from the articles were extracted, and the data analysis was performed using RevMan 5.4 software. Results: A total of 442 articles were identified and subsequently screened based on the inclusion and exclusion criteria, 9 clinical studies involving a total of 1577 patients were included, with 788 patients in the PMWA group and 789 patients in the surgery group. Following data extraction and statistical analysis, in comparison to the surgery group, the PMWA group had shorter operation time [mean differences (MD) = -36.36; 95% CI -55.66 to -17.06; P = .0002], shorter hospital stay (MD = -3.93; 95% CI -5.55 to -2.30; P < .00001), less intraoperative bleeding (MD = -21.25; 95% CI -27.36 to -15.15; P < .00001), and lower hospital costs (MD = -1.00; 95% CI -1.33 to -0.66; P < .00001), all with statistical significance. The comparison of postoperative complications revealed a lower incidence of complications in the PMWA group compared to the surgery group [relative risk (RR) = 0.29; 95% CI 0.21 to 0.40; P < .00001], with statistical significance. Thyroid-related hormone analysis showed that the free triiodothyronine (MD = 0.61; 95% CI 0.33 to 0.90; P < .00001) and free thyroxine (MD = 1.81; 95% CI 0.94 to 2.68; P < .0001) levels in the PMWA group were higher than those in the traditional surgery group, while the levels of thyroid-stimulating hormone were lower than those in the traditional surgery group (MD = -7.63; 95% CI -10.25 to -5.01; P < .00001), with statistically significant differences, indicating that PMWA had a smaller impact on thyroid function. In 2 studies, there were no statistically significant disparities in postoperative recurrence or lymph node metastasis (LNM) between the 2 cohorts (RR = 0.70; 95% CI 0.33 to 1.50; P = .36). There were no statistically significant differences in physiological health score between different groups and different time points before and after treatment (P > .05); However, the mental component score and the total score of the Medical Outcomes Study (MOS) item short-form health survey were significantly elevated in the ablation group compared to the excision group post-treatment (P < .05). Conclusion: For patients with low-risk PTMC with definitive diagnosis and precise risk stratification, PMWA can be selected. PMWA treatment for patients with PTMC is comparable to conventional surgical treatment and has the advantages of minimal trauma, rapid recovery, no scarring, and fewer complications, which are superior to open surgery to a certain extent. For patients with ambiguous preoperative diagnosis and uncertainty regarding LNM status, surgical intervention is the optimal choice.

Estimating the value of new antibiotic treatment strategies in Zhejiang province, China: cost-effectiveness analysis based on a validated dynamic model

ObjectivesThis analysis aims to better reflect the value of new antibiotic treatment strategies, thereby informing clinical antibiotic use, antimicrobial reimbursement and/or hospital formulary decision-making in China.DesignWe adapted a published and...

Palliative care consultation in patients hospitalized with out-of-hospital cardiac arrest: Impact on invasive procedures, do-not-resuscitate orders, and healthcare costs

BackgroundThe impact of palliative care consultation on the management and outcomes of patients hospitalized with out-of-hospital cardiac arrest (OHCA) remains poorly understood. This study examined associations between palliative care consultation and in-hospital outcomes of patients hospitalized with OHCA, stratified by survival status. MethodThis cross-sectional study used data from the National Inpatient Sample (2016–2021). Adult patients hospitalized with OHCA who received cardiopulmonary resuscitation were included. Multivariable analyses assessed associations between palliative care consultation and outcomes in non-terminal and terminal OHCA hospitalizations, adjusting for demographics, hospital characteristics, and comorbidities. ResultsAmong 488,700 OHCA hospitalizations, palliative care consultation was associated with lower odds of invasive procedures in non-terminal hospitalizations, including percutaneous coronary intervention (PCI) (aOR 0.30, 95 % CI 0.25–0.36), mechanical circulatory support (aOR 0.54, 95 % CI 0.44–0.68), permanent pacemaker (aOR 0.27, 95 % CI 0.20–0.37) and implantable cardioverter defibrillator insertion (aOR 0.22, 95 % CI 0.16–0.31), and cardioversion (aOR 0.62, 95 % CI 0.55–0.70). In terminal hospitalizations, palliative care was associated with lower odds of PCI (aOR 0.78, 95 % CI 0.70–0.87) and cardioversion (aOR 0.91, 95 % CI 0.85–0.97), but higher odds of therapeutic hypothermia (aOR 3.12, 95 % CI 2.72–3.59), gastrostomy (aOR 1.22, 95 % CI 1.05–1.41), and renal replacement therapy (aOR 1.19, 95 % CI 1.12–1.26). Palliative care was associated with higher DNR utilization in both subgroups and lower hospital costs in non-terminal hospitalizations but higher costs in terminal hospitalizations. ConclusionPalliative care consultation in OHCA is associated with differences in invasive procedures, DNR utilization, and hospital costs, varying by survival status.

Dialectical behavior therapy (DBT) in an assertive community treatment structure (ACT): testing integrated care borderline (ICB) in a randomized controlled trial (RECOVER)

BackgroundThough Dialectical Behavior Therapy (DBT) and other treatment models for individuals with Borderline Personality Disorder (BPD) have shown to be efficient in inpatient and outpatient settings, there is a general shortage of these treatments. In Germany, most resources are spent on inpatient treatments and unspecific crisis interventions, while it is difficult to implement the necessary team structures in an outpatient setting. This study is testing an alternative approach focussing on outpatient treatment: Integrated Care Borderline (ICB) provides DBT for persons with severe BPD within the structures of an Assertive Community Treatment (ACT). ICB is team-based, integrating psychiatric and social support as well as crisis interventions into a DBT-strategy.MethodsICB was compared to TAU in a prospective, randomized controlled trial. This study is part of RECOVER, a comprehensive stepped care approach in Germany, which enrolled a total of 891 participants. 146 persons were diagnosed with BPD as main diagnosis. Of these, 100 were allocated to the highest level of severe mental illness (SMI) and randomly assigned to either ICB (n = 50) or TAU (n = 50). Data were collected at baseline and 12 months later. The main outcomes were psychosocial functioning (GAF), severity of BPD (BSL-23) and other mental symptoms (BSI, PHQ-9, GAD-7, self-harm), employment status (VILI), as well as hospital days and associated costs.ResultsData show a significant increase of psychosocial functioning and a significant decrease of BPD and other psychiatric symptoms in both groups (r = .28 – .64), without any significant differences between the groups. The proportion of self-harming persons decreased in both groups without statistical significance. Patients were significantly more likely to be employed after a year of treatment in ICB (p = .001), but not in the TAU group (p = .454). Analyses showed a significant difference between the groups (p = .032). Moreover, psychiatric hospital days were significantly reduced in ICB (-89%, p < .001, r = .61), but not in TAU (-41%, p = .276, r = .15), resulting in a significant difference between the groups (p = .016) and in lower annual hospital costs in ICB (5,546€ vs. 10,726€, -48%, p = .011) compared to TAU.ConclusionOur results replicate earlier studies, showing that DBT can be efficient in outpatient settings. Furthermore, they indicate additional effects on employment and hospital days. The ICB-approach seems to offer a viable framework for multiprofessional outpatient DBT-teams. Future research will have to test whether the additional effects are brought about by the additional features of ICB compared to standard outpatient DBT.Trial registrationRegistration number with ClinicalTrials.gov (NCT03459664), RECOVER.

Palliative Care Utilization Among Hospitalized Patients With Hepatocellular Cancer: A Nationwide Study in the Pandemic Era (2019-2021).

Background: Palliative care addresses a range of needs, from symptom management to providing support to patients with hepatocellular cancer (HCC) and their families throughout the illness. However, research on palliative care in HCC remains limited, particularly during the COVID-19 pandemic. This study investigates the healthcare utilization associated with palliative care referral among patients with HCC. Methods: This is a retrospective cross-sectional analysis conducted using the National Inpatient Sample (NIS) database from 2019 to 2021 among patients with HCC age ≥18 years. Results: Among the 35,220 hospitalizations with HCC as the principal diagnosis, 18.7% received inpatient palliative care referrals. Factors associated with increased palliative care referrals included age ≥65 years, Midwest region, Charlson Comorbidity Index (CCI) score ≥3, and end-of-life care, as reflected by discharge resulting in death. No racial or insurance disparities were observed. Palliative care consultations were associated with lower total hospital costs ($20,573 vs $26,035, <0.0001). A higher prevalence of "do-not-resuscitate" status was also found among patients with palliative care referrals. Conclusion: The study provides an understanding of palliative care utilization across pre-pandemic and pandemic periods. Factors such as advanced age, hospital region, and underlying comorbidities influenced the likelihood of referral, with no discernible racial or insurance disparities identified. Palliative care involvement has also been shown to provide cost-effective supportive care with lower hospital costs. These findings provide invaluable guidance for optimizing the integration of palliative care alongside HCC management.