Choice of implant filler in breast reconstruction: A study of the cost-effectiveness of saline and silicone implants

Breast reconstruction following mastectomy is increasing and implant-based breast reconstruction is the most common surgical approach. Saline and silicone implants have different cost and complication profiles and it is unclear which is the more cost-effective option. A systematic review of the literature was undertaken to summarize the quality of life data in breast reconstruction, specifically, previously published health state utility values relevant to breast reconstruction. In addition, a cost-utility analysis was undertaken from the perspective of the third-party payer, accounting for the most common complications associated with saline and silicone implants. This demonstrated that despite the increased initial cost of silicone implants, they are cost-effective with a willingness-to-pay threshold of $50,000 (ICUR$52.26/QALY). Overall, silicone implants provide improved quality of life with a marginal cost increase

Relative value to surgical patients and anesthesia providers of selected anesthesia related outcomes

BACKGROUND: Anesthesia side effects are almost inevitable in most situations. In order to optimize the anesthetic experience from the patient's viewpoint, it makes intuitive sense to attempt to avoid the side effects that the patient fears the most. METHODS: We obtained rankings and quantitative estimates of the relative importance of nine experiences that commonly occur after anesthesia and surgery from 109 patients prior to their surgery and from 30 anesthesiologists. RESULTS: Pain was the most important thing to avoid, and subjects allocated a median of $25 of an imaginary$100 to avoiding it. Next came vomiting ($20), nausea ($10), urinary retention ($5), myalgia ($2) and pruritus ($2). Avoiding blood transfusion, an awake anesthetic technique or postoperative somnolence was not given value by the group as a whole. Anesthesiologists valued perioperative experiences in the same way as patients. CONCLUSIONS: Our results are comparable with those of previous studies in the area, and suggest that patients can prioritize the perioperative experiences they wish to avoid during their perioperative care. Such data, if obtained in the appropriate fashion, would enable anesthetic techniques to be compared using decision analysis

Clinical approach to gastro-oesophageal reflux in idiopathic pulmonary fibrosis

MDIdiopathic pulmonary fibrosis is a progressive condition with limited treatment options and median survival of 3-5 years. Gastro-oesophageal reflux (GOR) has been described in up to 90% of patients. Pulmonary aspiration has been suggested to contribute to IPF, with calls for aggressive antireflux therapy. Whilst medical therapy can usually control acid reflux, surgery may be required to control non-acid refluxate, which may also be harmful if aspirated into the lung. The risks of surgery in the IPF population are significant. There is no validated technique with which to measure aspiration in this group and furthermore, patient attitudes towards the treatment of reflux and aspiration in IPF are unknown. As a result, the population that might benefit from antireflux therapy has yet to be defined. The current study comprised two main aims. The first was to characterise reflux and aspiration in an IPF cohort. The second was to evaluate patient attitudes towards the burden of IPF disease as compared to the burden of antireflux therapy. Methods Symptoms of reflux and lung health were assessed using a panel of structured questionnaires. Oesophageal function and gastro-oesophageal reflux were objectively assessed using manometry and pH-impedance monitoring. A standardised bronchoscopy and bronchoalveolar lavage, with biochemical and cytological analysis, was used to assess pulmonary aspiration. A separate group of individuals with IPF participated in an interview study. Respondents’ own health was evaluated using a visual analogue scale, the EuroQOL-5D -3L survey and a standard gamble utility analysis. Vignettes were constructed to describe mild- and moderate-severity IPF health states and adverse outcomes from medical and surgical antireflux therapy. Patient attitudes towards these four health states were assessed with a ranking exercise and a series of standard gambles. Results pH-impedance monitoring demonstrated supranormal levels of gastro-oesophageal reflux in 22 of 36 study subjects (61%). Eleven subjects had pre-existing evidence of gastro- ii oesophageal reflux and questionnaire assessment suggested GORD in 29% of subjects. Oesophageal manometry identified abnormal oesophageal function in 56%. Supranormal levels of pepsin were detected in bronchoalveolar lavage fluid in 16 subjects. The combination of pepsin quantification and oesophageal monitoring identified a subgroup of subjects with evidence of reflux and aspiration, but there was no correlation between levels of reflux and pepsin concentrations. Cytological staining results correlated poorly with gastro-oesophageal reflux. After formal multidisciplinary review, two patients who participated in the current study have undergone fundoplication. Both have enjoyed a stable disease course since surgery. In the interview study, respondents recorded mean utilities of 0.611 to 0.798 for their own health. Amongst 59 respondents, 38 regarded both IPF health states as preferable to the outcomes of either antireflux therapy outcome; the remainder disagreed. An adverse outcome from antireflux surgery was generally regarded as the worst of the health states. Discussion Oesophageal physiology and BAL fluid analysis may be combined to investigate reflux and aspiration in IPF. The current data suggest that reflux is common and frequently asymptomatic. Aspiration may only be significant in the minority of patients. Oesophageal dysmotility, a relative contra-indication to fundoplication, was evident in the majority of subjects. This is the first report of health state utilities for IPF and demonstrates a disease burden comparable to advanced lung cancer. Opinion was divided as to the relative burden associated with IPF disease and the potential outcomes of antireflux therapy. In conclusion, it remains difficult to identify the IPF patients for whom antireflux surgery might be most beneficial. For a proportion, the risks of such treatment will be prohibitive. The complexity of surgical decisions in this group suggests a requirement for a standard of care that includes a multidisciplinary team, informed by objective aerodigestive physiology and imaging.Knowledge Transfer Partnership in collaboration with Innovate UK. Funding originated largely from the Northern Oesophagogastric Unit, with additional support from the Medical Research Counci

COST-EFFECTIVENESS OF AIRLINE DEFIBRILLATORS: IS PEACE OF MIND MORE IMPORTANT THAN SAVING LIVES?

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/74922/1/j.1524-4733.2001.40201-5.x.pd

Surgical Approach in Total Hip Arthroplasty: Patient Outcomes and Impact on Costs

Total hip arthroplasty is often renowned as one of the most important surgical advances of the past century. Orthopaedic surgeons must choose a surgical approach to gain access to the hip joint in order to perform the reconstruction. There is debate in the literature as to which surgical approach optimizes patient outcomes, minimizes complications, and reduces costs to hospitals as a high volume procedure. In the current studies, patient reported outcomes were compared at short-term follow-up using a prospective study design across the anterior, posterior, and lateral approach. A micro-costing method was used to acquire costs related to each procedure, as well as compare hospital metrics such as operating room time and hospital length of stay. The anterior approach demonstrated superior functional outcomes at short-term follow-up, and significantly reduced costs from a hospital perspective. Further studies should compare objective assessments of function such as gait analysis, and cost-effectiveness from a societal perspective

Using economic evaluation and preference elicitation methods to inform decisions about how best to reorganise services :a case study of the redesign of emergency medical services

PhD ThesisThe aim of this thesis was to evaluate the centralisation of emergency medical services (EMS) in different local hospitals into a single specialised emergency care hospital in terms of costs and quality of care. It also aimed to investigate preferences and trade-offs that individuals’ were willing to make to receive treatment at the centralised specialised emergency hospital. The economic evaluation method builds upon a systematic review of economic evaluation methods and types of economic evaluation that have been used to assess the performance of centralised healthcare specialities. A discrete choice experiment (DCE) was used to investigate preferences for centralised EMS and the trade-offs individuals were willing to make to receive treatment at the centralised hospital. The DCE identified preferences for: shorter travel times to the hospital; shorter waiting times; fewer days in hospital; low risk of death; low risk of readmission; and outpatient follow-up care in local hospitals. However, people were willing to trade-off increased travel time and waiting time for higher quality of specialised emergency medical care in the centralised hospital. A Markov model was developed to evaluate the costs and effectiveness of centralisation of EMS compared with non-centralised care. Multiple sensitivity analyses were carried out to assess whether centralisation had an impact on cost, quality and cost-effectiveness over the short and longer term. The incremental cost per QALY at one year (deterministic estimate £1,004 per QALY) and 10 years (deterministic estimate £636 per QALY) were both well below the threshold used by the National Institute for Health and Care Health Excellence (£20,000-£30,000 per QALY). There were fewer deaths in the centralised EMS compared with noncentralised services (deterministic estimate: 31.47 fewer deaths at 1 year, 31.57 fewer deaths at 10 years). Discounting the costs and outcomes at different rates did not alter conclusions. The economic evaluation suggested that centralisation of EMS into fewer more specialised units could be cost-effective, although cost-effectiveness may vary in specific population sub-groups. Sub-group analyses suggest that centralised EMS would be more cost-effective for elderly patients, the most economically deprived patients and those presenting with diseases of the circulatory system. These findings ii support the recommendations to centralise urgent and EMS in England. However, a cost benefit analysis that incorporated the results of the DCE into the economic evaluation suggested that centralised EMS could have negative societal value when compared with services provided in local hospitals. The implications of these findings, potential limitations of the methods used in this thesis and recommendations for future research are discussed.Health Foundation Londo

TREATMENT OF HIGH ENERGY LIMB THREATENING LOWER EXTREMITY TRAUMA: AN ETHICAL ARGUMENT FOR AMPUTATION

High-energy lower extremity trauma is a limb and sometimes life-threatening injury. These injuries permanently and irrevocably change a patient’s body and life. They can be treated with immediate amputation, reconstruction or delayed amputation after failure of reconstruction. In this paper, I explore the evidence concerning the treatment of mangled extremities, and I identify gaps in the evidence. Based on what is currently known, I argue that physicians not only have an obligation to reframe amputation as a treatment choice rather than a procedure for when all else fails, but also that they have an obligation to promote amputation as the preferred treatment option for these injuries, due to the significant harms and limited benefit of limb reconstruction

Economic evaluation of end-stage renal disease treatment

One of the main functions of the human kidney is the clarification of blood from human waste products, such as ureum and creatinine. Failure of functioning of the kidneys may ultimately lead to death. When the stage of very limited kidney functioning (5 to 10% of norm-al) is reached, renal replacement therapy becomes essential to survive. Chronic renal replacement therapy has been available since the 1960s. At present, three major types of renal :replacement therapy are available: haemodialysis, peritoneal dialysis and kidney transplantation. With haemodialysis, the body is connected to an extracorporeal filter or dialyser, consisting of a semipermeable membrane to which blood is taken and returned. This requires a permanent artificial access to the body (a shunt, fistula or synthetic graft), that usually is created in the forearm. Dialysis fluid, resembling blood plasma, is passed in the opposite direction across the outside of the membrane. Waste products and excess water from the blood diffuse into this dialysis fluid. Several forms of haemodialysis are available in the Netherlands. Most patients receive full care centre haemodialysis which requires the patient to travel to a dialysis centre, usually 3 times a week. The patient is attached to a dialysis machine for 3-4 hours. Limited care or active centre haemodialysis is similar to full care centre haemodialysis, but the patient takes active responsibility for the treatment, implying that the majority of the (nursing) tasks involved are performed by the patient him/herself. Another modality is home haemodialysis whereby the patient has all the necessary equipment at home and takes active responsibility for the treatment; some help from a partner, family member or nursing assistant is usually necessary

Minimally invasive treatment of venous insufficiency using endovenous laser ablation

Background Venous insufficiency is very common and causes significant quality of life (QoL) impairment. Conventional open surgery featuring junction ligation, stripping of the axial vein and phlebectomy is known to offer significant benefits over conservative management; resulting in improved QoL. Additionally this treatment has been shown to be highly cost-effective. Despite these advantages, surgery is associated with significant post-operative morbidity; in the form of pain and immobility, even in the absence of complications. Additionally, in the long term; high recurrence rates have marred these promising early results, eventually returning patients to their pre-operative state. Unsurprisingly recurrence is unpopular with patients and patient satisfaction has been observed to be disappointingly low. At the end of the 20th century, new minimally invasive endovenous interventions were developed. Rapidly gaining popularity; it was hoped that they could address some of the limitations of surgery. Following initial cases series; the endothermal technique of endovenous laser ablation (EVLA) appeared to have the highest technical efficacy with a good safety record. Objectives Three studies were performed with the aim of perfecting the ablative procedure and evaluating it against the gold standard of conventional surgery. Study 1 was designed to establish the optimal management of saphenous tributaries and perforators following ablation of the saphenous axis. Study 2 was designed to directly compare the outcomes of EVLA with surgery to establish whether EVLA can match the effectiveness of surgery, whilst addressing its limitations. Study 3 was designed to explore the association between the magnitude of energy delivered during EVLA, procedural safety and periprocedural morbidity; in the context of evidence suggesting lower recanalisation rates following more aggressive use of laser energy. Methods Studies 1 and 2 were randomised clinical trials. Participants had primary, symptomatic, unilateral venous insufficiency, with isolated saphenofemoral junction incompetence, leading to reflux into the great saphenous vein (GSV). Study 1 randomised 50 patients to EVLA alone (Control) or EVLA with concomitant ambulatory phlebectomies (EVLTAP). Study 2 randomised 280 patients equally into groups receiving either surgery or EVLA. Outcomes were: QoL, Venous Clinical Severity Score (VCSS), technical success, requirement for secondary procedures, pain scores, time taken to return to normal function, recurrent varicose veins on clinical examination, patterns of reflux on duplex ultrasound examination, and the effect of recurrence on quality of life. Assessments were at 1, 6, 12 and 52 weeks after the procedure. Study 3 used linear and logistic regression models to study the effect of energy delivery on outcome. The models controlled for age, gender, BMI, pre-operative QoL and vein dimension. The outcomes were QoL, complications, recovery time, pain scores and analgesia requirements. The sample size calculation established that 115 patients would be required to detect any significant relationship. Results Study 1: EVLTAP took longer, but significantly decreased the requirement for subsequent interventions. There was no impairment in immediate post-procedural pain or QoL with EVLTAP. Median (IQR) Venous Clinical Severity Score (VCSS) at 3 months was lower (better) for EVLTAP than for Control (0 (0-1) versus 2 (0-2); P < 0.001), with lower (better) disease specific QoL (Aberdeen Varicose Vein Questionnaire (AVVQ) scores) at 6 weeks (7.9 (4.1-10.7) versus 13.5 (10.9-18.1); P < 0.001) and 3 months (2.0 (0.4-7.7) versus 9.6 (2.2-13.8); P = 0.015). At 1 year, there were no differences in VCSS or AVVQ scores. Study 2: Both groups had significant improvements in VCSS after treatment (P < 0.001), which resulted in improved disease-specific QoL (AVVQ, P < 0.001) and quality-adjusted life year (QALY) gain (P < 0.001). The pain and disability following surgery impaired normal function, with a significant decline in five of eight SF-36 domains (P < 0.001 to P = 0.029). Periprocedural QoL was relatively preserved following EVLA, leading to a significant difference between the two treatments in pain scores (P < 0.001), six of eight SF-36 domains (P = 0.004 to P = 0.049) and QALYs (P = 0.003). As a result, surgical patients took longer to return to work and normal activity (14 versus 3 days; P < 0.001). Complications were rare. Initial technical success was greater following EVLA: 99.3 versus 92.4% (P = 0.005). Surgical failures related mainly to an inability to strip the above-knee GSV. The clinical recurrence rate at 1 year was lower after EVLA: 4.0 versus 20.4% (P < 0.001). The number of patients needed to treat with EVLA rather than surgery to avoid one recurrence at 1 year was 6.3 (95 per cent confidence interval 4.0 to 12.5). 12 of 23 surgical recurrences were related to an incompetent below-knee GSV and ten to neovascularisation. Of five recurrences after EVLA, two were related to neoreflux in the groin tributaries and one to recanalisation. Clinical recurrence was associated with worse QoL (AVVQ scores) (P < 0.001). Study 3: 232 patients were included. The mean (range) age was 50 (18-83) years. 63% were women. The mean (range) energy delivery was 89.8 (44.5-158.4) Jcm-1. There was no significant effect on any outcome related to increasing energy delivery. Conclusions Concomitant phlebectomy with EVLA prolonged the procedure, but reduced the need for secondary procedures and significantly improved quality of life and the severity of venous disease. This supports a recommendation that phlebectomy is performed routinely in conjunction with EVLA. EVLA was as effective as surgery for varicose veins, but importantly had lower periprocedural morbidity as evidenced by less negative impact on early post-intervention QoL and furthermore clinical recurrence rates were also significantly lower than observed following conventional surgery. This suggests that EVLA with phlebectomy is superior to conventional surgery in the management of primary superficial venous insufficiency. Study 3 clearly confirms that EVLA is a safe procedure and that for the range of energies studied, there was no evidence demonstrating an increase in complication rates or the periprocedural morbidity of EVLA. These findings support the adoption of EVLA and concomitant phlebectomy as the gold standard treatment for primary superficial venous insufficiency