Total In-hospital Costs Research Articles

Analysis of the additional costs of clinical complications in patients undergoing transcatheter aortic valve replacement in the German Health Care System

BackgroundThis study aims at analyzing complication-induced additional costs of patients undergoing transcatheter aortic valve replacement (TAVR). MethodsIn a prospective observational study, a total of 163 consecutive patients received either transfemoral (TF-, n=97) or transapical (TA-) TAVR (n=66) between February 2009 and December 2012. Clinical endpoints were categorized according to VARC-2 definitions and in-hospital costs were determined from the hospital perspective. Finally, the additional costs of complications were estimated using multiple linear regression models. ResultsTF-TAVR patients experienced significantly more minor access site bleeding, major non-access site bleeding, minor vascular complications, stage 2 acute kidney injury (AKI) and permanent pacemaker implantation. Total in-hospital costs did not differ between groups and were on average €40,348 (SD 15,851) per patient. The average incremental cost component of a single complication was €3438 (p<0.01) and the estimated cost of a TF-TAVR without complications was €34,351. The complications associated with the highest additional costs were life-threatening non-access site bleeding (€47,494; p<0.05), stage 3 AKI (€20,468; p<0.01), implantation of a second valve (€16,767; p<0.01) and other severe cardiac dysrhythmia (€10,611 p<0.05). Overall, the presence of complication-related in-hospital mortality increased costs. ConclusionsBleeding complications, severe kidney failure, and implantation of a second valve were the most important cost drivers in our TAVR patients. Strategies and advances in device design aimed at reducing these complications have the potential to generate significant in-hospital cost reductions for the German Health Care System.

MP18-15 NATIONAL RATES OF URETERAL STENTING DURING EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY AMONG HOSPITALIZED PATIENTS IN THE UNITED STATES

You have accessJournal of UrologyStone Disease: Therapy II1 Apr 2014MP18-15 NATIONAL RATES OF URETERAL STENTING DURING EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY AMONG HOSPITALIZED PATIENTS IN THE UNITED STATES Vidit Sharma, Barry B. McGuire, Diana K. Bowen, and Robert B. Nadler Vidit SharmaVidit Sharma More articles by this author , Barry B. McGuireBarry B. McGuire More articles by this author , Diana K. BowenDiana K. Bowen More articles by this author , and Robert B. NadlerRobert B. Nadler More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.777AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The benefits of routine ureteral stenting prior to Extracorporeal Shock Wave Lithotripsy (ESWL) remains unproven and is controversial. This study aimed to explore the incidence and patterns of routine ureteral stent placement prior to ESWL among hospitalized patients in the USA. METHODS Using the Nationwide Inpatient Sample (NIS) Database, we identified patients undergoing ESWL for nephrolithiasis and/or ureterolithiasis during the years 2004 – 2010. ICD-9 codes for both ESWL and ureteral stenting were used for identification. National patterns were extrapolated for ureteral stenting in these patients, and a logistic regression model was created to identify significant predictors of ureteral stenting. A generalized linear model was also constructed to isolate the costs of ureteral stenting after adjusting for other variables impacting total hospital charges. RESULTS Of the 65,590 cases of ESWL from 2004-2010, 49.3% [95% Confidence Interval (CI) 47.3%-51.3%] were associated with ureteral stenting. Patients with nephrolithiasis and ureterolithasis were stented in 48.8% and 54.5% of cases, respectively. Logistic regression modeling predicted that stent placement was more likely in the following cases: attempted ureteroscopic stone removal [Odds Ratio (OR) 4.086, p<0.001], increasing severity of presentation [ORs for increasing severity 1.279, 1.419, 1.551 p<0.001], teaching hospital status [OR 1.412 p=0.001], acute renal failure [OR 1.446 p=0.009], urban setting [OR 1.373 p=0.024], evidence for infection [OR 1.155 p=0.029], and every 10-year increase in patient age [OR 1.076 p<0.001]. Midwestern [OR 1.359 p=0.014], Southern [OR 1.473 p<0.001], and Western [OR 1.656 p<0.001] hospitals were more likely to stent than Northeastern hospitals. Comorbid obesity was not a significant predictor of stent placement. Average total charges were $6,640 greater per stented patient (p<0.001), translating to $190,291,406 increased total costs over the study period. A generalized linear regression model predicted the total in-hospital cost of ureteral stenting to be $2,428 for stent insertion. CONCLUSIONS Extrapolating from the NIS, nearly half of inpatients undergoing ESWL are stented prior to their procedure, and this is more likely to occur in older patients and at urban teaching hospitals. Given the significant costs of ureteral stenting, further investigation into the hospital and regional variations of this practice is warranted. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e209 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Vidit Sharma More articles by this author Barry B. McGuire More articles by this author Diana K. Bowen More articles by this author Robert B. Nadler More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Comparison of Laparoscopy-Assisted and Open Donor Right Hepatectomy: a Prospective Case-Matched Study from China

BackgroundLaparoscopy-assisted hepatectomy is a new minimally invasive approach for graft harvesting in living donors. Only a few liver transplant centers have introduced this surgical procedure. MethodsA prospective case-matched study was conducted on 25 consecutive donors who underwent laparoscopy-assisted donor right hepatectomy (LADRH) between July 2011 and March 2013 at our transplant center. These donors were matched 1:1 according to age, gender, and body mass index with 25 donors who underwent open donor right hepatectomy (ODRH). ResultsLADRH was successfully performed in all 25 of the donors. Donor complications, estimated blood loss, and operative time were similar between the groups. Hospital stay and periods of analgesic use were significantly shorter in the LADRH group [7.0±1.4 (LADRH) vs 8.7±2.4 (ODRH), p = 0.003, and 2.4±1.0 (LADRH) vs 3.2±1.0 (ODRH), p = 0.011, respectively). The total in-hospital cost is higher with LADRH, primarily due to the additional material costs for LADRH. Finally, there were no differences in graft size, graft survival, or recipient complications between the two groups. ConclusionThe results of this study show that LADRH is a feasible and safe procedure compared with ODRH. Although higher material costs for laparoscopic assisted procedures are inevitable, LADRH may have an advantage over ODRH by causing less pain and facilitating earlier recovery. Efforts can be made to improve the technical success of LADRH for some overweight donors.

PMS22 - Barriers of Access to Elective Orthopedic Procedures in Rio De Janeiro, Brazil

Currently, in Rio de Janeiro state, barriers to patient care who require elective surgical procedures in orthopedics are found, thus many patients remain long periods on hold until the attendance. This study aims to analyze the frequency of hospitalization procedures (HP), total inhospital cost (IC), and total number of inhospital days (ID) related to orthopedic elective procedures in Rio de Janeiro state, Brazil, from the public perspective in order to identify potential barriers of access. Orthopedic procedures that require hospitalization were selected from the public official hospital information system, for the year 2011. These procedures were separated into elective or urgent according to treatment indication, and validated by an expert panel. Costs are expressed in 2012 Brazilian Real (BRL). A public secondary database was accessed to evaluate HP, IC, and ID separated by cities. Rio de Janeiro state is composed by 92 municipalities. Total population consists of 15,989,929 inhabitants, and 6,320,446 (39.53%) live in the capital (Rio de Janeiro city). In 2011, 18,564 elective HP were performed, with a total IC of 21,977,085 BRL, and 145,295 ID. Data from the capital show 10,724 elective HP, total IC of 14,399,281 BRL, and 98,458 ID, which represent 57.77%, 65.52%, and 67.76% of the state, respectively. When only urgency procedures were analyzed, these rates fell to 43.73%, 46.46%, and 49.35%, respectively. Hospitalizations for elective orthopedic procedures in Rio de Janeiro state do not present homogeneous distribution among municipalities. The capital houses less than 40% of total population and accounts for more than 65% of costs and inhospital days. Data suggest that municipalities are able to absorb urgency occurrences, but not elective ones, creating difficulties for the treatment of patients in need of elective procedures. Decentralization of care may be able to reduce such barriers.

Improved outcome for children with non‐high risk acute lymphoblastic leukaemia after using an ALL IC‐BFM 2002‐based protocol in Shanghai, China

We report the outcome of 92 non-high risk children with acute lymphoblastic leukaemia (ALL) following a Berlin-Frankfürt-Münster (BFM) Intercontinental ALL -based protocol. Compared with a matched historical control group, we found a lower incidence of treatment-related early death (1·2% vs. 10·9%, P=0·015), a higher 6-year event-free survival (75·4±4·9% vs. 58·2±6·7%, P=0·02), reduced total in-hospital costs per person (US $) (10267·0 vs. 18331·0, P<0·001) and fewer total in-hospital days (164 vs. 296, P<0·001). This ALL-BFM based protocol was quite tolerable in our institution and will be extended to high-risk patients.

Comparison of Costs of Endovascular Repair versus Open Surgical Repair for Abdominal Aortic Aneurysm in Korea

This study was designed to compare the hospital-related costs of elective abdominal aortic aneurysm (AAA) treatment and cost structure between endovascular aneurysm repair (EVAR) and open surgical repair (OSR) in Korean health care system. One hundred five primary elective AAA repairs (79 OSRs and 26 EVARs) performed in the Seoul National University Hospital from 2005 to 2009 were included. Patient characteristics were similar between two groups except for older age (P = 0.004) and more frequent history of malignancy (P = 0.031) in EVAR group. Thirty-day mortality rate was similar between two groups and there was no AAA-related mortality in both groups for 5 yr after repair. The total in-hospital costs for the index admission were significantly higher in EVAR patients (mean, KRW19,857,119) than OSR patients (mean KRW12,395,507) (P < 0.001). The reimbursement was also significantly higher in EVAR patients than OSR patients (mean, KRW14,071,081 vs KRW6,238,895, P < 0.001) while patients payments was comparable between two groups. EVAR patients showed higher follow-up cost up to 2 yr due to more frequent imaging studies and reinterventions for type II endoleaks (15.4%). In the perspective of cost-effectiveness, this study suggests that the determination of which method to be used in AAA treatment be more finely trimmed and be individualized.

Abciximab or eptifibatide in percutaneous coronary intervention: in-hospital outcomes and costs and six-month results

Inhibition of platelet aggregation with glycoprotein (GP) IIb-IIIa receptor blockers has been shown to reduce ischemic complications in patients with acute coronary syndromes (ACS) and in those undergoing percutaneous coronary intervention (PCI) in multiple placebo-controlled, randomized clinical trials. The effect of pharmacologic and cost differences between abciximab and eptifibatide, the only GP IIb-IIIa inhibitors indicated for PCI, on clinical outcomes and total hospital costs for patients undergoing PCI remain to be defined. To determine the rate of clinical events and costs associated with the use of abciximab vs eptifibatide at our centers, we retrospectively reviewed data for the cohort of 188 consecutive patients who underwent PCI and were treated with either abciximab (n = 85) or eptifibatide (n = 103) in the period between January 1998 and June 1999. The choice of a GP IIb-IIIa inhibitor was based on the preference of the interventional cardiologist. In-hospital events evaluated included death, major bleeding, minor bleeding, and hematoma. Additionally, the duration of hospital stay and total in-hospital costs were also assessed. Clinical events at 6 months included combined incidence of death, acute myocardial infarction (MI), or unstable angina (UA), as well as the incidence of hospital readmissions. In-hospital complications were generally more common with abciximab (death: 4.7% vs 0% with eptifibatide; major bleeding: 7.1% vs 4.8%, respectively; minor bleeding: 9.4% vs 5.7%, respectively; hematoma: 21.2% vs 21.4%, respectively), although none of these differences reached statistical significance. However, abciximab therapy was associated with a significantly longer mean duration of hospitalization (4.17 ± 0.48 days vs 2.85 ± 0.26 days with eptifibatide; P = 0.017) and a significantly higher mean total in-hospital costs ($31,396 ± 2,111 vs $25, 135 ± 815; P = 0.007). At six-month follow-up, the combined incidence of death, acute MI, or UA was also significantly higher in the abciximab group (32.9% vs 15.5%; P = 0.01). Additionally, hospital readmissions related to acute coronary syndromes at 6 months occurred significantly more often in the abciximab group (36.7% vs 16.5% with eptifibatide; P = 0.014). Our retrospective analysis of 188 patients undergoing PCI indicates that the use of eptifibatide instead of abciximab is associated with significantly lower in-hospital costs, significantly shorter duration of index hospitalization, and significantly reduced rates of ischemic complications and cardiovascular readmissions at 6-month follow-up. These differences were seen despite the fact that the baseline characteristics of patients in the two groups were generally similar. Therefore, eptifibatide provides a clinically effective and economically more attractive alternative to abciximab.

PCV124 COST OF CORONARY ARTERY BYPASS GRAFT (CABG) IN ACUTE HEART FAILURE PATIENTS IN THE CZECH REPUBLIC

Coronary artery bypass graft (CABG) is one of the most costly procedures in acute heart failure patients. In our results the costs of CABG made 15.3% of total in-hospital costs althought it was carried out in less than 5% patients.

Economic Assessment of Thrombocytopenia: CATCH Registry

Thrombocytopenia is associated with increased patient risk. However, the costs of this complication are not well defined. This study assessed the impact of thrombocytopenia on in-hospital costs using results from CATCH, an observational study that examined 1988 consecutive patients receiving prolonged heparin therapy (> or =96 h). Thrombocytopenia was defined as: (group 1) an absolute reduction in platelet count to <150 x 10(9)/L; (group 2) a relative reduction in platelet count of >50% from admission levels; or (group 3) both criteria. We found that the development of thrombocytopenia was associated with significantly higher total in-hospital costs for all groups: (group 1) (difference, $8,222; 95% CI, $5,020-$11,425; P<.001); (group 2) (difference, $15,429; 95% CI, $7,472-$23,385; P<.001); and (group 3) (difference, $27,077; 95% CI, $22,901-$31,252; P<.001). However, in our adjusted model, longer lengths-of-stay and greater use of blood transfusions accounted for most incremental in-hospital cost differences.

Contrast Enhanced Magnetic Resonance Angiography Versus Intra-arterial Digital Subtraction Angiography for Treatment Planning in Patients with Peripheral Arterial Disease: A Randomised Controlled Diagnostic Trial

Objectives: To compare the diagnostic and therapeutic confidence, patient outcome and costs between MRA and DSA as the initial diagnostic imaging test, in patients with symptomatic arterial disease of the leg. Design: Randomised controlled diagnostic trial. Materials and methods: Patients were randomly allocated to MRA (n = 97) or DSA (n = 100). Primary outcomes were: ability to make treatment plan and patients satisfaction. Secondary endpoints were: type of treatment and costs. Results: A treatment plan was determined for each included patient. Additional imaging was necessary in 11% of patients in the MRA group compared to 10% in the DSA group (p = 0.5). 84% of the patients who received MRA judged the diagnostic work up as comfortable compared to 57% who had DSA (p = 0.013). Within 4 months of randomization 30 patients in the MRA group compared to 34 patients in de DSA group underwent operative procedures; 39 versus 36 patients respectively underwent angioplasty. The mean total in-hospital costs during the first 4 months were €4768,- in the MRA group compared to €4697,- in the DSA group (95% CI of difference −1331;1472). Conclusions: In patients with peripheral arterial disease of the leg an adequate treatment plan can be made with MRA. This diagnostic strategy was experienced as more comfortable and less painful compared to DSA. Total diagnostic and treatment costs of both strategies were comparable.

Impact of different stages of chronic kidney disease on in-hospital costs in patients with coronary heart disease

Chronic kidney disease (CKD) is associated with markedly increased in-hospital morbidity and mortality. Its effect on in-hospital costs for the treatment of coronary heart disease (CHD) has not been assessed that, although it is of interest due to the exponential increase in its prevalence. Clinical and costing data were retrospectively assessed from 765 consecutive patients who suffered from CHD requiring percutaneous coronary interventions. Based on their estimated glomerular filtration rate (eGFR), patients were classified in accordance with the National Kidney Foundation. Patient-level in-hospital costs for this single hospitalization were thoroughly calculated from precise in-house assessments for the national DRG database. In univariate analysis, the average total in-hospital costs increased with each stage of CKD [euro2926; euro3466; euro4208; euro9687 (stages 4 and 5 combined), P < 0.0001]. Treating patients with CKD stages 4 and 5 utilized markedly more resources than patients with ST-elevation myocardial infarction (euro4916), coronary three-vessel disease (euro4659), severely impaired left ventricular function (euro6072) or diabetes (euro4495). Multivariate analyses identified, even after adjustment for confounding comorbidities, that CKD was a significant and independent predictor of in-hospital costs; with each loss of 1 ml/min in the eGFR, the expenses for this hospitalization increased by euro18 (95% CI euro13-23). Although the absolute amount of costs may vary between different countries, this work showed, for the first time, that in all stages of CKD, there is a significant increase of in-hospital costs when treating patients with both CHD and CKD.

Contrast Enhanced Magnetic Resonance Angiography Versus Intra-arterial Digital Subtraction Angiography for Treatment Planning in Patients with Peripheral Arterial Disease: A Randomised Controlled Diagnostic Trial

To compare the diagnostic and therapeutic confidence, patient outcome and costs between MRA and DSA as the initial diagnostic imaging test, in patients with symptomatic arterial disease of the leg. Randomised controlled diagnostic trial. Patients were randomly allocated to MRA (n=97) or DSA (n=100). Primary outcomes were: ability to make treatment plan and patients satisfaction. Secondary endpoints were: type of treatment and costs. A treatment plan was determined for each included patient. Additional imaging was necessary in 11% of patients in the MRA group compared to 10% in the DSA group (p=0.5). 84% of the patients who received MRA judged the diagnostic work up as comfortable compared to 57% who had DSA (p=0.013). Within 4 months of randomization 30 patients in the MRA group compared to 34 patients in de DSA group underwent operative procedures; 39 versus 36 patients respectively underwent angioplasty. The mean total in-hospital costs during the first 4 months were euro4768,- in the MRA group compared to euro4697,- in the DSA group (95% CI of difference -1331;1472). In patients with peripheral arterial disease of the leg an adequate treatment plan can be made with MRA. This diagnostic strategy was experienced as more comfortable and less painful compared to DSA. Total diagnostic and treatment costs of both strategies were comparable.

Impact of heart failure on hospital activity and healthcare costs in Belgium

SummaryHeart failure (HF) is a serious public health problem worldwide. It has a high prevalence, affects mainly the elderly and causes high mortality or disability with high economic costs. The aim of the present study was to calculate the number of admissions for HF, the total in-hospital stay, the mean length of in-hospital stay and the in-hospital costs due to HF in Belgium.Retrospective analysis of data from the national hospital registration system provided the following results. In 2001, there were 19,398 admissions with HF as a primary diagnosis, with a total in-hospital stay of 286,938 days. The mean in-hospital stay for HF was 14.8 days. The total in-hospital cost of HF as a primary diagnosis was € 94,113,827, representing 1.8% of the total hospital expenditure.The limitations of this study are its mere focus on admissions and their characteristics in 2001, and the use of a retrospective analysis. Nevertheless, it led to the conclusion that HF was responsible for a significant number of in-hospital days, with a significant impact on healthcare costs in Belgium.

Acute Abdominal Aortic Aneurysms: Cost Analysis of Endovascular Repair and Open Surgery in Hemodynamically Stable Patients with 1-year Follow-up

To retrospectively assess the in-hospital and 1-year follow-up costs of endovascular aneurysm repair and conventional open surgery in patients with acute infrarenal abdominal aortic aneurysm (AAA) by using a resource-use approach. Institutional Review Board approval was obtained, and informed consent was waived. In-hospital costs for all consecutive patients (61 men, six women; mean age, 72.0 years) who underwent endovascular repair (n = 32) or open surgery (n = 35) for acute infrarenal AAA from January 1, 2001, to December 31, 2004, were assessed by using a resource-use approach. Patients who did not undergo computed tomography before the procedure were excluded from analysis. One-year follow-up costs were complete for 30 patients who underwent endovascular repair and for 34 patients who underwent open surgery. Costs were assessed from a health care perspective. Mean costs were calculated for each treatment group and were compared by using the Mann-Whitney U test (alpha = .05). The influence of clinical variables on the total in-hospital cost was investigated by using univariate and multivariate analyses. Costs were expressed in euros for the year 2003. Sex, age, and comorbidity did not differ between treatment groups (P > .05). The mean total in-hospital costs were lower for patients who underwent endovascular repair than for those who underwent open surgery (euro20 767 vs euro35 470, respectively; P = .004). The total costs, including those for 1-year follow-up, were euro23 588 for patients who underwent endovascular repair and euro36 448 for those who underwent open surgery (P = .05). The results of multivariate analysis indicated that complications had a significant influence on total in-hospital cost; patients who had complications incurred total in-hospital costs that were 2.27 times higher than those for patients who had no complications. Total in-hospital costs and total overall costs, which included 1-year follow-up costs, were lower in patients with acute AAA who underwent endovascular repair than in those who underwent open surgery.

Primary Hip Arthroplasty Costs Are Greater in Low-volume Than in High-volume Canadian Hospitals

Despite the widespread success of total hip arthroplasties for treatment of arthritis of the hip, the procedure continues to be targeted for cost control. Our objective was to compare the total in-hospital cost of primary total hip arthroplasties in high-volume and low-volume hospitals. Data concerning the patient-level in-hospital costs of 940 consecutive primary total hip arthroplasties were extracted from the cost accounting system of three Canadian hospitals. Mean in-hospital costs for patients having total hip arthroplasties in a high-volume institution (> or = 300 total hip arthroplasties/year) compared with two low-volume Canadian institutions (< 300 total hip arthroplasties/year) were: overhead costs 1380 US dollars +/- 35 US dollars versus 2432 US dollars +/- 49 US dollars; direct costs 3023 US dollars +/- 93 US dollars versus 4952 US dollars +/- 91 US dollars and total costs 4403 US dollars +/- 117 US dollars versus 7385 US dollars +/- 1 US dollar 38, respectively (all comparisons in US dollars). Lower overhead and direct and total costs were found for primary total hip arthroplasties done in a high-volume Canadian hospital compared with the low-volume centers. Differences in direct costs, made up in large part by the implant cost, accounted for most of the disparity. As total hip arthroplasties continue to be scrutinized for cost containment, doing the procedure in a high-volume center seems to be an effective method of controlling costs.

Feasibility and implications of an early discharge strategy after percutaneous intervention with abciximab in acute myocardial infarction (the CADILLAC Trial)

Early complications may hamper efforts to hasten discharge after primary percutaneous coronary intervention (PCI) for myocardial infarction (MI). Glycoprotein IIb/IIIa inhibitors, by reducing early recurrent ischemia, may aid in these efforts. We examined whether adjunctive abciximab could accelerate discharge and reduce costs within a trial of primary PCI after acute MI. The CADILLAC trial randomized 2,082 patients with MI to 1 of 4 reperfusion strategies in a 2 × 2 factorial design: angioplasty, angioplasty with abciximab, stent implantation, or stenting with abciximab. Patients randomized to abciximab had postprocedural heparin withheld, and discharge scheduled for days 1.5 to 2 (low-risk patients) or days 2 to 3 (high-risk patients) after MI if they were stable. Other patients were discharged at the physician's discretion. Abciximab treatment was associated with significant reductions in the primary end points of in-hospital death, reinfarction, ischemic target vessel revascularization (TVR), or disabling stroke (5.6% vs 2.7%, p = 0.003)—largely reflecting reduced ischemic TVR (3.8% vs 1.4%, p = 0.002)—and in early subacute thrombosis (1.3% vs 0.2%, p = 0.01). Hospitalization was significantly shorter in abciximab-treated patients (median 3.1 vs 3.5 days, p <0.001), but total in-hospital costs did not differ significantly ($13,413 ± $5,309 vs $13,000 ± $6,006, p = 0.13). Rates of the composite end point did not differ significantly during the week after discharge (0.8% vs 0.2%, p = 0.10), nor did component event rates. Abciximab during primary PCI is associated with fewer early adverse outcomes, likely contributing to offset its cost. Hospitalizations after primary PCI are so short, however, that efforts to accelerate discharge with abciximab appear unfeasible, and overall costs remain unchanged.

Economic impact of diabetic ketoacidosis in a multiethnic indigent population: analysis of costs based on the precipitating cause.

Diabetic ketoacidosis (DKA) is a common complication of diabetes. We analyzed the inpatient costs of treating DKA in a multiethnic, indigent population in Houston, Texas. We measured the cost of resources utilized for all patients admitted to our hospital with DKA from 1 January to 31 December 1998. We also analyzed their medical records to determine the factors that precipitated the episode of DKA and then grouped them into three categories: acute illnesses, noncompliance with diabetes treatment, and new-onset diabetes. The data were analyzed by one-way ANOVA. The Tukey-Kramer procedure was used for post hoc multiple comparisons. There were 167 admissions for DKA. The mean age was 40 +/- 13 years. The ethnic distribution was 49% African American, 32% Hispanic American, and 18% white. The total inhospital cost of treating DKA was $1,816,255. The mean cost per hospitalization was $10, 876 +/- 11,024. The frequency distribution by category of DKA-precipitating factor was 18% acute illness, 59% noncompliance, and 23% new onset. There were differences in mean cost of DKA associated with the three categories: $20,864 +/- 17,910 for acute illness, $11,863 +/- 8,701 for new onset, and $7,470 +/- 6,300 for noncompliance (P < 0.0001). The total cost for each category was $671,375 for acute illness, $694,082 for noncompliance, and $450,798 for new onset. DKA is an expensive complication among indigent, multiethnic diabetic patients. Although the mean cost per admission was lowest for DKA precipitated by noncompliance, this causal category was responsible in sum for the greatest portion of the economic burden.

Duration of cardiopulmonary bypass and risk of perioperative stroke in coronary artery bypass surgery operations

reductions cn the composite endpoint of death, repeat MI. ischemic target vessel revascularization (TVR), and disabling stroke (3.0% vs. 1.3%, p=O.Ol), largely due to a decrease in ischemic TVR (2.4% vs. 0.6%, p=O.O025). Abciximab also reduced early subacute thrombosis (1 .O% vs. O.l%, p=O.O06). Among 1703 pts in the U.S., mean times of hospital D/C in abcx and non-abcx treated pts were 4.9 + 2.7 days vs. 5.4+ 3.5 days respectively, p<O.OOl, and total mean in-hospital costs for the 2 groups were $13,413 (abcx) vs. $13,000 (no abcx), p=O.13. In the first 7 days following hospital D/C, there were no significant differences relative to abcx treatment regarding the composite endpoint (0.8% vs. 0.3%, p=NS) or its individual elements, nor were differences in major or minor bleeding observed. ConclusionsAdjunctive abciximab therapy during primary PCI is associated with reduced early adverse ischemic outcomes that may facilitate early hospital D/C and effect cost sawngs. However, standard times to D/C after primary PCI are now so short that efforts to further accelerate DIG with abciximab were for the most part not feasible, and cost savings were not realized.

Cost-effectiveness of intracoronary ultrasound for percutaneous coronary interventions

The Strategy for Intravascular Ultrasound (IVUS) guided PTCA and Stenting trial included a prospectively designed economic analysis to investigate whether routine IVUS guidance intervention is cost-effective. Consecutive patients (n = 269) with 356 lesions were randomly assigned to receive provisional stenting with angiographic guidance only (ANGIO) or with IVUS guidance. The 2-year major adverse cardiac event-free survival (effectiveness) was significantly higher in the IVUS-guided group (80% vs 69%, p <0.04). In-hospital costs for procedural personnel, capital equipment, and disposable equipment were higher in the IVUS group. This was offset by lower costs for inpatient care and urgent target vessel revascularization in the IVUS group. Therefore, the total in-hospital cost was only slightly higher with IVUS (5,245 ± $2,256 [IVUS] vs 4,776 ± $2,961 [ANGIO], $/patient, p = 0.15). During a 2-year follow-up, costs for cardiac hospitalizations were slightly lower in the IVUS group, whereas costs for medication and indirect costs were similar. This resulted in identical total costs over the 2-year period (15,947 ± $8,545 [IVUS] vs 16,103 ± $9,954 [ANGIO], $/patient, p = 0.89). The incremental cost-effectiveness ratio for IVUS guidance calculated to −$1,417/major adverse cardiac event-free survival gained. In 55.3% of bootstrapping replications, IVUS was less expensive and more effective. In conclusion, when used in a provisional stenting strategy, routine IVUS imaging is cost-saving half the time.

Abciximab: an updated review of its therapeutic use in patients with ischaemic heart disease undergoing percutaneous coronary revascularisation.

Abciximab (Reopro) is an antibody fragment that dose-dependently inhibits platelet aggregation and leucocyte adhesion by binding to the glycoprotein (GP) IIb/IIIa, vitronectin and Mac-1 receptors. Abciximab (0.25 mg/kg bolus plus infusion of 0.125 micro g/kg/min for 12 hours) showed greater efficacy than tirofiban in reducing the 30-day composite endpoint of death, nonfatal myocardial infarction (MI) or urgent target-vessel revascularisation in the randomised, double-blind TARGET study in patients scheduled for stent placement. In addition, the beneficial effects of treatment with abciximab previously observed in the randomised, multicentre, placebo-controlled EPILOG and EPISTENT studies have been maintained to 1 year, with a significantly reduced incidence of ischaemic complications relative to placebo consistently observed across a range of subgroups including age, sex, bodyweight and indication for revascularisation. The incidence of the composite endpoint was reduced in patients presenting with acute MI of <48 hours' duration in comparison with either fibrinolytic therapy or stenting alone in the randomised STOPAMI and ADMIRAL trials, primarily because of a reduced requirement for urgent repeat revascularisation and reduced incidence of mortality. In the randomised, nonblind, multicentre CADILLAC trial in patients with acute myocardial infarction (MI), stenting alone was superior to percutaneous transluminal coronary angioplasty (PTCA) and stenting alone was not inferior to PTCA plus abciximab. Recent large randomised, multicentre studies (ASSENT-3 and GUSTO-V) have shown higher efficacy (on various ischaemic endpoints) of abciximab in combination with either a reduced dose of tenecteplase or reteplase compared with the fibrinolytic drug alone. TIMI grade 3 flow rates at 60 and 90 minutes in the TIMI-14 and SPEED trials were higher in patients who received abciximab in combination with either alteplase or reteplase than abciximab alone and were similar to that seen with the full-dose fibrinolytic alone. In the randomised, multicentre GUSTO IV-ACS study, no significant differences in any of the ischaemic endpoints at either 7 or 30 days in patients with acute coronary syndromes who were not scheduled to undergo early revascularisation (within 12 hours of end of infusion) were apparent between those who received abciximab (bolus and either 24- or 48-hour infusion) and those who received placebo in addition to aspirin and heparin. The most common adverse events associated with the use of abciximab are bleeding complications and thrombocytopenia, although the risk of major bleeding can be limited through adhering to current administration protocols. Treatment costs are generally higher in both stent plus abciximab and angioplasty plus abciximab groups than stent plus placebo, primarily because of the acquisition cost of abciximab. Abciximab appeared most cost beneficial in high-risk patients undergoing elective percutaneous coronary revascularisation; among lower risk patients, abciximab therapy has been associated with higher total in-hospital and 6-month medical costs than eptifibatide. The GP IIb/IIIa receptor antagonist abciximab, when used with aspirin and heparin, has demonstrated efficacy in reducing the short- and long-term risk of ischaemic complications in patients with ischaemic heart disease undergoing percutaneous coronary intervention, when used with aspirin and heparin. High-risk patients (including those with diabetes mellitus) derive particular benefits from abciximab treatment. Abciximab remains an important therapeutic option for the prevention of complications in patients with ischaemic heart disease.